Hyperpigmentation and belief systems: are tHey linked?

Dr PRADNYA MANWATKAR explains how hyperpigmentation can be tackled beyond medicines.

P atient: My family has told me that my skin has become darker!

Me: How long do you think this is happening?

Patient: Its been a few months; and I have gone to four dermatologists. I even tired herbal medicines and now I only pray.

All of us have been in this situation and I am forced to think that I will be the patient’s fifth dermatologist who will probably give the same cocktail of medicines that is available - maybe even add in a monoclonal antibody and pray that it works.

As dermatologists, one of the biggest challenges we face in our country of colour is colour! By this I mean, the changes in the pigment of the skin – in medical terms it is hyperpigmentation, which can be a great ordeal not only for the patient but for the dermatologist.

From tanning to melasma to lichen planus pigmentosus, we all face such patients daily.

Although we have been taught that stress can directly affect the hypothalamic pituitary adrenal axis (HPA axis) and the secretion of corticotropin-releasing hormone (CRH) from the hypothalamus increases the synthesis of proopiomelanocortin (POMC) in the pituitary lobe, which is the precursor for adrenocorticotropic hormone (ACTH) and melanocyte stimulating hormone (MSH), which have numerous physical actions including acting as regulators of immune response and melanogenesis – it is a task convincing a patient that it is related, isn’t it? How many times have we heard our patients say, “But I don’t have stress”, or ask us the famous rhetorical question, “Stress is normal, isn’t it?”

Here is where emodermatology comes into practice: Applying Rational Emotive Behaviour Therapy (REBT) to dermatology.

I remember having a discussion with one of my dermatologist friends about the one simple formula that could help our patients bring their attention to the “normal” stress that they talk about. A+B=C -- a simple formula! Any disease brings into play the need to apply this simple formula that REBT offers. ‘A’ stands for activating factors, ‘B’ for belief systems, and ‘C’ for consequences.

Activating factors are the stresses that all of us face: a bad boss, nagging family, failure, guilt of not doing enough, lack over control of a situation. They can be anything that trigger stress hormones.

Consequences fall under three categories: psychological, behavioural and physical.

I want to dwell on the above three categories before I explain the ‘B’ category.

Once stress is activated, consequences can be manifested in a psychological manner where a patient experiences more stress and a higher-than-normal level of emotions. A common example would be panic attack, or a nervous breakdown.

Behavioural consequences tend to be more severe and can be seen as obsessions, compulsions, and delusions; making a patient seek a psychiatrist.

Physical consequences are where specialists like us come into the picture. These consequences are usually seen in one of the systems of our bodies like irritable bowel disease in the GI system, asthma or repeated infections in the pulmonary system, and eczema, psoriasis, vitiligo, and the infamous hyperpigmentation on the skin.

Why do people manifest specific diseases? Why doesn’t stress or activating factors trigger only a certain part of the system? I suppose that would need further studies at a psychophysiological level. However, it is not only the activating factors (A) that cause the consequences (C). It is only when belief systems (B) is added to the A that we get the consequences.

It is the belief system that needs to be targeted to achieve better treatment outcomes in hyperpigmentation cases. A belief system is a thought or a firm concept or an ideology that we carry about people, places, situations, animals, global warming, and wars. It is developed in the mind through nurture and culture that we are exposed to during our growing years and later on as adults. Not to forget that our own nature (the one we are born with) also helps shaping these beliefs. These may change over time. Confused? Let me try to simplify it: Any statement that holds ‘must’ or ‘should’ is a belief system.

Common examples are: ‘I must look pretty in order to be married’, ‘I should be able to earn enough money to take care of my family’, ‘I must not hit back if my husband hits me as it is against a woman’s demeanour’, and ‘I must be fair-skinned to be accepted by people around me’. The list is endless.

These ‘musts’ or ‘should be’ either are a part of our conscious thinking or a part of our subconscious mind. They play a big role in our reactions to people and situations. Stress happens when we cannot identify these beliefs, not because we were triggered with the activating factors. A is not equal to C A plus B = C. Get it? It may seem complicated and timeconsuming to apply the formula in our daily life. However, it takes a simple question to start the conversation for the patient to realise that maybe it is their thoughts or beliefs that are aggravating the pigmentation.

“What is the question?” asked my dermatologist friend.

I looked at her and said, “I start out with: ‘What do you stress about?’”

“Come on, Pradnya! No patient will admit that they have stress. Half of them don’t even know what stress is!” she replied with gusto.

“And that’s precisely the answer I expect,” I said adding, “When they say that I ask my next question: ‘Can you define stress for me?’”

My patients, almost always, never have an answer. It is here where I have achieved my first step of emodermatology -- to make the patient think.

Counselling is not about changing a person’s thoughts in one session: It is a beautiful art to instigate thoughts and make patients ponder over what exactly could be bothering them. If they knew what was bothering them, they wouldn’t end up at our clinic, but would have gone to the psychologist instead. As a matter of fact, they wouldn’t have developed hyperpigmentation in the first place! They would just change their belief systems (B) and heal themselves!

Easier said than done. While the process is slow, A+B=C needs patience on our part. The aim is to start a process of change, and not to get a 100 per cent result on the first day of examination. Even our traditional creams and lasers take time, don’t they? We take the first step nonetheless.

A+B=C is the additional step. Take it.

About the author: DR PRADNyA MANWATkAR, Consultant Dermatologist and Cosmetologist, Skin Matra, is based in Mumbai and author of the book “How To Tell your Skin To Heal Itself”. She has completed her training hours in REBT-Rational Emotive Behavioural Therapy, and actively counsels her patients to ensure better treatment outcomes. Her expertise lies in emodermatology, and latest treatments along with counselling that ensure long lasting treatment outcomes.