Clinicians examine mind-body connection of urticaria, stress

June 1, 2012  |  By Jane Schwanke

San Francisco — Although the expression “I was so stressed I broke out in hives” is quite common, it can be a challenge for dermatologists to identify the psychosocial precipitants of chronic urticaria, according to Josie Howard, M.D., a psychiatrist in private practice, and clinical instructor departments of psychiatry and dermatology, University of California, San Francisco. But that is beginning to change, she says.

“There is a growing appreciation of the link between the mind, the immune system, and the skin,” Dr. Howard says. “The skin and the nervous system are derived from the same embryologic layer, and we are only just beginning to appreciate the implications of this link.”

The missing link

Today, more research is being conducted on the connections between urticaria and stress. For example, some research is focusing on the relationship between stressful life events and the onset or exacerbation of chronic idiopathic urticaria; others are looking at ways to improve chronic urticaria using hypnosis and relaxation techniques. And new research is even looking at the relationship between post-traumatic stress disorder and the incidence and severity of chronic idiopathic urticaria.

The patients most likely to be diagnosed with chronic urticaria due to stress include a subset of patients in whom no cause can be found, Dr. Howard says.

“This subset — about 30 percent of patients who have been diagnosed with idiopathic urticaria — is the group in which we most often look to psychological factors for an explanation,” she says. “Many dermatologists will agree that it is not uncommon to see chronic idiopathic urticaria arising after a major life stressor, or for patients who are most impaired by urticaria to be those with more limited stress management skills.”

With many of these patients, there is an opportunity for dermatologists to help them with their skin conditions as well as their quality of life.

“Sometimes, it’s just a matter of planting a seed that somatic symptoms respond to stress reduction techniques that can motivate a patient to pursue treatment,” Dr. Howard says. “This can also lead to diagnosis and treatment of previously unidentified psychiatric comorbidities such as mood and anxiety disorders.

“The patient who presents with relatively minor dermatological symptoms and a seemingly disproportionate amount of distress about these symptoms is telling you something,” she says. “They are telling you that they are experiencing significant distress but may not have the capacity to recognize the psychological contribution to their suffering.”

Dr. Howard suggests dermatologists take time to educate patients about the link between stress, anxiety and the skin. “The one-on-one time gives dermatologists the opportunity to direct patients toward interventions that can improve their overall quality of life,” she says.

Dr. Howard does caution dermatologists against starting patients on antidepressants without first educating themselves.

“There is more and more evidence that antidepressants may be less useful than psychotherapy and cognitive behavioral therapy in treating mild-to-moderate depression,” Dr. Howard says. “Any patient who starts an antidepressant needs to be followed closely and monitored for the emergence of manic or hypomanic symptoms.”

Analyzing immunity

Psychological stress exacerbates chronic urticaria through a variety of mechanisms, including heightened basophil response to corticotrophin releasing factor and adrenocorticotropic hormone (ACTH) and a derangement of the hypothalamic-pituitary-adrenal (HPA) axis (Dyke SM, Carey BS, Kaminski ER. Clin Exp Allergy. 2008;38(1):86-92).

Interactions between the central nervous system and the immune system are complex and bidirectional, and there is evidence supporting an intimate structural and functional relationship between peripheral nerves and mast cells, as well as for the local secretion of mast cell influencing neuropeptides by nerves, Dr. Howard says. In the subset of patients who are termed stress responders, increased histamine release mediated by neuropeptides can be seen.

“So, on the flip side of this, we can ask, ‘How can psychological interventions bolster the immune system and relieve somatic symptoms?’ Buffet in 2003 showed improvement in urticarial wheals after subcutaneous injection with histamine when treated with hypnosis and relaxation techniques (Buffet M. Ann Dermatol Venereol. 2003;130(1):S145-S159),” she says.

Simply put, external stressors plus cognitive, behavioral and social stressors have been shown to play a significant role in the intensity of itch, often providing an ever greater correlation than the actual dermatologic disease severity, according to Dr. Howard.

Perhaps the best patient outcomes in the future will come as a result of a growing appreciation of the link between the mind, the immune system and the skin, she says.

“My hope is that we will be able to move towards a more integrated approach to treating patients which incorporates attention to the multifactorial nature of so many dermatologic conditions, both in their etiology as well as the experience of living with these conditions, whether it is chronic urticaria, psoriasis, acne or delusions of parasitosis,” she says.



American Board of Psychiatry and Neurology

Clinical Faculty,

University of California San Francisco, Departments of Psychiatry and Dermatology

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