Bridging dermatology and psychology

Shriyal Sethumadhavan journeys into the world of psychodermatology and holistic patient care as she gathers expert perspectives from renowned dermatologists.

Psychodermatology, the interdisciplinary field that explores the intricate relationship between skin health and mental well-being, is gaining significant traction in India. With a population marked by diverse cultural, social, and environmental influences, the intersection of dermatology and psychology presents unique challenges and opportunities. This emerging field not only sheds light on the psychological impact of skin disorders but also offers innovative approaches to patient care that address both physical symptoms and emotional well-being. As dermatologists increasingly recognise the significance of incorporating psychosocial considerations into their practice, the insights shared by experts in this burgeoning field serve as invaluable resources, offering perspectives, strategies, and examples of successful collaborations that underscore the holistic nature of patient care. In the pages to follow, through their experiences and anecdotes, these professionals highlight the vital role of empathy, personalised treatment approaches, and multidisciplinary collaboration in promoting overall wellness for individuals grappling with hair, body, and skin concerns in India.

From doctor-centric to patient-centric care

Through insightful anecdotes and professional experiences, Dr Rupali Pavaskar, Dermatologist, Cosmetic Dermatologist, Trichologist, Dr Rupali Pavaskar ’s Clinic & Transforme Dermo-Cosmetic Center, Thane, emphasises the critical role of empathy and personalised treatment approaches.

I am from a generation where patients would state their complaints, get a prescription, and leave, trusting the doctor completely. But Google changed everything.

“What’s happening to me? What are my treatment options?”

Our practice has shifted to being more patient-driven. Patients prefer to make decisions themselves rather than relying solely on our judgment. Most often, their consulting partner is Google.

Our workload and stress levels have significantly increased. Why? Because there is no fixed approach for every patient. For some, stating the disease name in a regional language suffices. Others seek reassurance that they do not have skin cancer and are grateful. Some respond to medical jargon and quickly leave. However, trouble arises when patients look at you as if you are a zombie and ask you to speak in their language. That’s when I rely on my most trustworthy and reliable communication skills.

I use flow charts with a dash of genuine empathy and round it up with one of these statements: 1. This is how I would take it further, but the final call is yours! 2. Stress is the triggering factor for your immunity to misbehave. You need to decide whether to keep on suffering for life or nip the problem in the bud (when they insist upon the cause of an idiopathic condition, which you will see later how truthful this is).

3. Skin treatments could go on for life but if you decide to change your lifestyle or deal with your stress levels in a better way, we could write a different story!

Example of Insulin Resistance

“Good stuff needs to be oft-repeated; bad stuff is effective even once!” That is the irony of life! Hence reinforcing the last statement is of supreme importance for better patient outcomes and a satisfactory practice.

Stress! Stress! Stress! From a point where doctors could not see any sense in discussing mental health issues and organic diseases connection until today when ‘psychodermatology’ is a well- established branch and ‘emodermatology’ has been so well taken up by doctors like Dr Pradnya Manwatkar, we have come a long way!

After 22 years of practice, I have come to this stage where I can see the past life baggage on patients’ shoulders right from their first step into the OPD, and a majority of the time, Iam correct when I can tell whether:

1. They are aware of their extra luggage but are not aware of the extra price they are paying for it at the check-in counter of life.

2. They are aware of the luggage as well as the price that they are paying to carry that stuff around. 3. They are blissfully unaware and just paying the price for it.

Only 50 per cent of these patients would be willing to offload for fear of revisiting the place from where they picked up this stuff. Only 25 per cent of these willing patients would land up at a Shrink’s clinic, out of which only 10 per cent will continue offloading or debulking, and others will state compatibility issues with their shrink. Wow! How?

I still remember that patient of mine who walked into the OPD with sunken shoulders and a downward gaze (you start seeing the straps of the extra baggage). She brings in a huge file (strings of the bag) with multi-specialty complaints, totally irrelevant to each other (buckles), totally unresolved despite the best of the specialists (side pockets), learning to tolerate the complaints (zips of the sack), and finally the statement, “Doctor! You are my last trial (not even hope) (the entire bag!)”

I gave her a long hard look, noticeably kept away the prescription pad, and said, “Tell me your problem!”

“Doctor! Did I not just tell you?” She looked irritated. “Tell me your actual problem! What’s bugging you in life?” She gave me that halfunbelievable half-relieved kind of look and the story just flowed out. Unhealthy interpersonal relationships, especially with in-laws. The husband is a good friend but without any physical intimacy and without any help in resolving her problems. She is okay if he has his interests elsewhere since he deserves to be happy. Her only daughter is her world, who is the only person who gets her. Lack of selfconfidence or rather self-worth reflected heavily in her monologue.

‘Where did all this start? Wonder how are her relations with her parents and siblings?’ (I thought I was thinking internally until she replied)

“When I was born, my parents distributed Samosas instead of sweets to express their displeasure over the birth of a girl child.”

I was like, people killed her self-worth by telling her this story again and again, which she possibly would not have known otherwise. Doomed, she was! Beyond repair? Possibly! Hopeless? May not be! Rescue? Removal from hostile conditions, which she was planning anyways with her daughter for her education. Respite?

“Is there anything that you like doing from the bottom of your heart?” I enquired! “Oh yes! I am a writer! Once I move out after a year, I will start doing it!”

I said: “Well! Dear, you have already wasted half of your life’s work! Do you want to wait for one more year?”

She looked at me with a… blank look, which I so very much wanted to fill in. What did that blank look mean? Realisation, shock, disbelief, or something else? This time I ensured that my thoughts were not verbalised. I handed over the prescription, gave her my number for any emergency assistance or something like that and she left!

“Did I trade into deep waters unnecessarily? Am I a psychologist? For God’s sake, why can’t I practice mindless dermatology? Why do I waste so much time? “These thoughts hounded me until I received a message from her… “Thank you Doctor! For making me realise the connection between my mind and body. Nobody had ever enlightened me like this before. My unbearable pain is fading away. I have started writing, and believe me, when I say that my world is changing within me since Iam undergoing regular counseling sessions. Thank you once again!”

“Hmmm!” I said to myself while manually settling down the goosebumps! Is this the cure that our patients are longing for?

Please note: Not all cases are open and shut like these. If I have 100 stories of emodermatology, only 10 per cent have an ending. Others fade into oblivion. Not everyone decides to take their life head-on. Not everyone cares to write feedback. Yet, we have not wasted our time. What goes out cores around. How else do you think we get those referrals who believe in us from day one? How else do we think scores us above any other money-making profession that also satisfies our souls? Most importantly, with time, experience, and additional knowledge about psychology, we internalise this process so well that it is over before we even realise what good we have done!

Addressing patient struggles

Dr Nirja Sheth, MBBS, DV&D, DCA Hypnotherapy, Maharaja Sayajirao University of Baroda, and Consultant Dermatologist and Clinical Hypnotherapist, Vadodara, explains in her inter view with Shriyal Sethumadhavan, how dermatological conditions can profoundly impact patients’ psychological well-being, leading to emotional struggles that require empathetic understanding and a holistic approach to treatment.

It has been extensively studied that beautiful people attract more attention from everyone. They are perceived as wealthier, healthier, more intelligent, successful, honest, trustworthy and confident, says Dr Nirja Sheth. “It has been observed that small children too are attracted to beauty. Beauty stimulates a part of the brain to produce hormones like dopamine, serotonin and oxytocin which in turn produce emotions like pleasure, desire, trust and connection.”

Those who follow the prevailing standards of beauty are given special attention, preferential treatment and merit social advantage.

How do hair, body, and skin concerns impact the psychological well-being of your patients?

The impact is profound. Individuals with features like a beautiful face, thick and shiny hair, and a well-proportioned body tend to feel more confident and happier. The sight of oneself in the mirror can elevate happiness levels, akin to the boost experienced when wearing new, brightly coloured clothes or dressing well. Moreover, individuals who are perceived as beautiful or attractive often exhibit higher self-esteem, leading to more social connections, friendships, and professional opportunities, as well as increased chances of finding a suitable matrimonial match.

What are some common emotions or mental health issues that patients with dermatological conditions experience?

On the other hand, patients with visible skin diseases in exposed areas or experiencing symptoms like itching often suffer from severe anxiety, depression, sleeplessness, insecurity, and low self-esteem. They feel embarrassed when they have to scratch in the presence of others and regret being unable to wear trendy, short clothes. Consequently, they may have fewer friends, become introverted, and avoid attending official meetings and social gatherings such as parties and get-togethers. Another issue is the expense of treatment. In chronic cases, treatment may be prolonged, requiring more medications and thus, more money. Financial constraints can lead to stress, resulting in fewer visits to doctors and neglect of the condition. Patients may have to compromise on finding a suitable life partner and lucrative employment, leading to a sense of helplessness and prompting them to question, the “Why Me?” syndrome.

How do you approach understanding and empathising with your patients’ psychological struggles?

When a patient with an aesthetic problem comes to me, after assessing the disease, the first thing I do is tell the truth. I talk to the patient, relatives, parents, or whoever is concerned and explain the gravity of the disease and the chances of improvement of the condition. I do a lot of counseling to help the patient accept the condition if it is untreatable. If treatable, then I tell them it is not the end of the world and assure them that everything will be fine. It is a matter of time. I show the patients “before and after” treatment images of patients who have undergone treatment. It strengthens their confidence in me and the therapy. It makes the patient more optimistic and reduces the fear that their condition is never going to improve. I give examples of popular, successful, and well-known personalities like Lata Mangeshkar, Amitabh Bachchan, Ghulam Ali ji, Om Puri, and sportswomen like PT Usha and Mary Kom who are not the most beautiful people. Ghulam Ali and Om Puri had severe acne and pox scars on the face and still, they were adored by people. I explain to them that when one develops a skill that is appreciated, then people do not see the flaws in looks and appearance.

In patients who are very anxious and have bouts of crying and insomnia, anxiolytics like Clonazepam 0.25 to 0.50 mg may be required. As Iam a clinical hypnotherapist, I also give relaxation sessions and guide them on how to do it at home by themselves. Relaxation reduces anxiety and helps with insomnia. Skin diseases like psoriasis and eczema are aggravated by stress, so relaxation also takes care of that factor. I advise them to do Yoga, meditate, pray and focus more on self-development, engage in a hobby, and meet friends and people with confidence. If the patient has clinical depression affecting his or her day-to-day work, I refer them to a psychiatrist.

Empowering self-care

Dr Avina Jain, MBBS MD Dermatology, Founder, Auro Skin Clinic, Mumbai, advocates for a holistic approach, considering both physical and psychological aspects to promote overall health and skin care. As she shared in this inter view with Shriyal Sethumadhavan, Dr Jain emphasises the integration of self-care recommendations tailored to individual concerns in dermatological treatment plans.

How do you incorporate self-care recommendations into your treatment plans for patients with hair, body, and skin concerns?

As a dermatologist, I integrate self-care recommendations into treatment plans by emphasising the importance of a consistent skincare routine tailored to the patient’s specific concerns.

This includes:

• Understanding their daily schedule and where they can fit the skin care routine. For example: Their sun exposure hours, their work shifts, and commute method to work.

• Correct products: By discussing in depth the type of skin they have in different seasons and their outdoor exposure and then guiding correct cleanser, moisturiser and sunscreen which suits them in varied weathers and seasons.

• Sunscreen: For better compliance, I make patients try different sunscreen in the clinic and whatever suits them best is prescribed to them.

• Education: On correct shower methods including water temperature, soap usage, moisturising the whole body, caring about nails, and toe web spaces.

• Pamphlets: I provide pamphlets on dry skin, acne care and hair care. All the basic do’s and don’ts are written so that they can follow it up.

• Teaching about DIYs and what is okay for their skin, hair and nails and what is not. Along with it, salon procedures and how to be sure they don’t damage any parts of skin/hair/nail.

• I also recommend the correct diet as priority then oral supplements, or in-clinic procedures, depending on the individual’s needs and goals. Also making a full-year plan and booking appointments in advance helps a lot.

• Explaining the science behind procedures and lasers and clearing the apprehensions about the same helps in inculcating them in their skin/hair care journey.

What self-care practices do you recommend to patients to promote overall well-being?

There are five crux points – diet, sleep, stress, water, exercise. Taking care of each point makes the foundation of healthy skin and overall well-being:

1. Diet: I write an in-depth nutrition plan on their prescription about healthy eating and fitting according to their routine, age, work, cultural and economic background. By this, there are no cheat meals, and outside food can be enjoyed without guilt. Also teaching about inflammatory food and food-producing glucose spikes. Where to place nuts, seeds, fruits, and salads in a day is also important.

2. Sleep: An unhealthy relationship with sleep is one of the biggest issues we see in practice. An in-depth discussion on their sleep pattern including less usage of gadgets at night, regular sleep timings, avoiding caffeine post evening and finally having a healthy relation to sleep.

3. Stress check: In one’s crazy fast-moving life, practicing stress-reduction techniques such as mindfulness, meditation, yoga, or deep breathing exercises is crucial and how to easily inculcate it in one’s daily routine is an important part of my consultation. Work-life balance is also crucial for overall well-being and as a preventive step for chronic diseases.

4. Water: The elixir of life. As simple as an alarm on the phone helps, especially for people who forget to drink water.

5. Exercise: Inculcating and making them understand Atomic Habits. To start with only 1 minute per day and upgrading gradually and finally imbibing exercising as a daily activity. It improves blood circulation, boosts mood, and supports healthy skin.

Guidance on blood investigations and other routine check-ups: I ensure this as per the patient’s age, comorbid conditions, and family history investigations are needed.

How do you support patients in developing self-care routines that prioritise their mental and emotional health?

It involves a holistic approach that considers both the physical and psychological aspects of skincare.

• Being an active listener and giving them the space to discuss their personal and professional issues which are leading to stress.

• Understanding their schedule, family structure and work environment and how they can fit a healthy routine in it.

• Discussing their diet, cultural stigmas and systems followed at home, and aligning them towards better health overall.

• Education on the mind-skin connection, explaining how stress, anxiety, and other emotional factors can influence skin health.

• In-depth discussion on their sleep pattern and less usage of gadgets at night and having a healthy relation to sleep.

• Limiting alcohol and smoking, and ideally cutting down completely. The negative effects of both are huge on the body and the skin and hair.

I also involve family members when needed especially with adolescents and clearing their fixations too about their children’s health.

Transforming body image

Dr Vaishali Janawade-Kanthi, Director, Luvayaa Skin Clinic, emphasises the importance of listening, empathising, and counseling to help patients accept their condition and achieve positive outcomes, in her inter view with Shriyal Sethumadhavan.

How do you approach addressing body image concerns in patients with hair, body, and skin conditions?

We often encounter patients who have body image concerns. While most skin conditions may not be life-threatening, they cannot be easily hidden from the public eye. Therefore, patients with skin conditions such as psoriasis, vitiligo, alopecia areata, or even common baldness experience a tremendous impact on their psychosocial life. People often fear stigmatisation or labelling due to their skin conditions. The younger generation is particularly concerned about acne, as they have a certain standard of beauty in mind and find it difficult to accept spots, bumps, or pigmentation on their skin. Men with androgenetic alopecia are often ridiculed for their bald heads and rejected by partners. This has a significant psychological impact on individuals as it affects their body image.

What strategies do you use to help patients develop a positive body image and improve their self-esteem?

To achieve better outcomes for patients, I often address and strategise their body image issues. I believe the most important aspect is listening to them with a patient ear. Giving them time to talk about their problems and fears regarding the condition is helpful. The next important aspect is empathising with the patient and understanding the emotions involved. This helps in building trust with the patient.

Finally, counselling them about the likely causes and the best treatment options that can be offered. I believe that we have to look at them as humans and not just as money – procuring subjects. It is important at times to help them accept their condition. A polite and empathetic approach is of utmost importance in patient care.

Have you encountered any challenges in addressing body image issues, and how did you overcome them?

I have encountered many such challenges in patients. To quote: there was a patient who was rejected by six girls just due to his baldness. He had lost all hope and finally approached me for help. I counselled him and offered to do a hair transplant. I was able to build trust by listening, understanding his issues, and counselling him about the procedure. His post-surgery outcomes were extremely good, and within six months, he was married. The patient had invited me to his wedding and was very grateful. His happiness brought tremendous satisfaction to my work. Another interesting case was a 65-year-old patient who had been suffering from psoriasis for the past 20 years. He was frustrated with the treatment outcomes as nothing had worked before. When he sought my help, I listened to him carefully, and during that entire visit, I addressed his health issues and his emotions. For the first time, he had a doctor who had listened to him and addressed his emotions. I counselled him to get his diabetes under control and work on his weight loss. Infact, I had prescribed minimal medications. Although the patient had disappeared for a while, he returned one day with a lot of positive changes in his health. He had reduced weight; his blood sugars were under control, and thus even his psoriasis had come under control. He had brought his daughter and son to me for treatment. This was indeed a satisfying experience as a doctor. All I had done here was empathise with the patient and help him bring a positive change in his life. Sometimes, all it takes is one gesture, one word, to change the course of someone’s life..

Enhancing patient well-being

Dr. Ishan Pandya, MBBS, MD (Dermatology, Venereology, Leprosy), MSc (Psychology), and Consulting Dermatologist and Psychologist, Lumos Skinic, Ahmedabad, in his inter view with Shir yal Sethumadhavan, talks about how he employs a multidisciplinar y approach to address psychological aspects alongside dermatological concerns, resulting in improved patient outcomes.

How do you collaborate with mental health professionals to address the psychological aspects of hair, body, and skin concerns?

When I consult patients and discover that they have mental health issues, I assess the severity of their symptoms. Being both a qualified psychologist and dermatologist aids me in this assessment, helping to establish rapport and providing a solid foundation for therapy. Patients are generally receptive to the idea of addressing both their dermatological and mental health concerns in one place, if not simultaneously. I often feel the need to initiate psychotropic medications and refer patients to specialised psychologists, for which I explain my rationale about these referrals (to psychiatrists and psychologists). However, the stigma associated with mental health and misinformation regarding psychotropic medicines often makes it challenging for me to refer patients. I have a network of mental health professionals who understand the kind of work I do, and they have been helpful.

I speak to them in front of the patients to foster transparency between us, and this approach usually proves effective. In cases where patients are resistant, I may ask them to wait while I consult with a psychiatrist and explain the case. Fortunately, psychiatrists are usually understanding and I guide them on treatment, side effects, and the extent to which I can prescribe medications.

What benefits do you see in taking a multidisciplinary and holistic approach to patient care?

A multidisciplinary and holistic approach helps in better patient compliance, resulting in improved treatment and care. Viewing patients through a psychodermatological lens creates a unique perspective for each individual, even among those with the same diagnosis, allowing for personalised treatment. Patients feel heard, cared for, and recognised as individuals rather than just another case among many. This approach breaks down barriers between health professionals and patients. While there are numerous benefits to the multidisciplinary and holistic approach, I will highlight a common detail often encountered in my practice. One may not require extensive psychological expertise to implement this approach, but simply being aware of it can lead to better treatment outcomes and patient satisfaction. A common issue observed among health professionals is blaming patients for non-compliance and subsequent lack of improvement in their condition. I firmly believe that behind every non-compliant patient lies unwavering beliefs and concerns that need addressing. A holistic approach compassionately addresses these sensitive issues, asking questions such as, “Why is the patient not taking medication regularly?” and identifying any barriers to adherence. Additionally, a multidisciplinary and holistic approach addresses the effects of diseases triggered or exacerbated by stress, which may not adequately respond to prescribed treatments.

Can you share examples of successful collaborations that have resulted in improved patient outcomes?

Acne excoriee is one of the most frequently seen psychodermatological disorders. A detailed evaluation in such cases often reveals mental stressors and how picking the skin helps the patients relieve that stress. While evaluating the patients and taking a proper history, patients themselves realise what is actually going on. This realisation motivates them to start therapy. I start with the standard habit reversal therapy for such patients, which has resulted in the successful control of the disease in many cases. I also recall several cases of urticaria, psoriasis, vitiligo, and eczema, where mental health consultation proved very helpful and resulted in better treatment outcomes.