Hypnosis in Dermatology FREE

THE HYPNOTIC phenomenon has been used since ancient times in the form of trance induction to assist healing. Each of us goes into spontaneous mild trances daily while engrossed in watching television or a movie, reading a book or magazine, or otherwise being absorbed in some activity or meditation. With proper training, an individual can intensify this trance state in himself or herself or in another individual, and use this heightened focus to induce mind-body interactions that help alleviate suffering or promote healing. The state of altered consciousness known as a "trance state" may be induced using guided imagery, relaxation, deep breathing, meditation techniques, self-hypnosis, or hypnosis-induction techniques. Some individuals are more highly hypnotizable than others, but most can obtain some benefit from hypnosis. In dermatologic practice, hypnosis may help reduce skin pain and pruritus, ameliorate psychosomatic aspects of skin diseases, and hasten the resolution of some skin diseases, including verruca vulgaris. Even suggestion, without formal trance induction, can be effective in some patients. Early articles on the use of suggestion to treat verrucae include those by Bloch¹ and Sulzberger and Wolf.²

The precise definition of hypnosis has proven to be slippery. Marmer³ defined hypnosis as a psychophysiological tetrad of altered consciousness consisting of narrowed awareness, restricted and focused attentiveness, selective wakefulness, and heightened suggestibility. For more detailed discussion of the definitions of hypnosis, see Crasilneck and Hall⁴ or Watkins.⁵ Many myths exist regarding hypnosis—too numerous to enumerate and refute here—that overrate, underrate, and distort the true capabilities of hypnosis.

A MEDLINE search was conducted from January 1966 through December 1998 on key words related to hypnosis and skin disorders. Hypnosis was searched as a MeSH category, and "hypnosis" and "hypnotic" as title and abstract words. Names of specific skin diseases were searched as MeSH categories, and as title and abstract words. Boolean "and" combinations of hypnosis and hypnotic with names of specific skin diseases produced relevant references. References earlier than 1966 and book references were obtained from the reference lists that were included in articles. Preference was given to articles based on controlled trials when available. Case reports were included to cover the use of hypnosis in treating skin diseases when controlled trials had not yet been reported.

To what degree hypnosis can affect physiological factors such as blood flow and release of chemical mediators, as opposed to a purely psychological response, is often difficult to measure reliably. Nonetheless, many patients note subjective improvement of symptoms and, in some cases, objective reductions in the size, number, or intensity of skin lesions. The exact psychophysiologic mechanisms by which hypnosis induces improvement are not fully elucidated. Hypnosis is known to be able to regulate blood flow and other autonomic functions not usually under conscious control. The relaxation response that occurs with hypnosis also affects the neurohormonal systems that in turn, regulate many body functions (see the discussion and references in the remainder of this section).

Results of studies^{6 - 8} of the effect of hypnosis on immediate immune responses show the ability of hypnotized volunteers to significantly decrease the flare reaction to the histamine prick test (P<.02). The effect of hypnotic suggestion on delayed cellular immune responses was significant on erythema size (P<.02) and palpable induration (P<.01) in one study,⁶ but not in others.^{9 - 10} However, even simple suggestion has been shown¹¹ to induce contact dermatitis in an area not touched by lacquer tree allergen but believed by sensitized individuals to have been so touched; the same individuals did not react when actually touched by lacquer tree allergen but believed that they had not been so touched (P<.01). Similarly, using hypnosis, volunteers in a double-masked protocol¹² who were told to increase their sensitization to 1 of 2 experimental allergens—dinitrochlorobenzene and diphenylcyclopropenone—while decreasing it to the other showed a significant difference in reactions between allergens they were told under hypnosis to enhance and those they were told to diminish (P<.01).

Results of a study¹³ of persons with multiple personality disorder (now called dissociative identity disorder) and different allergic responses; dermatologic reactions; and effects on seizure disorders, pain control, and healing in the same individual, depending on the personality present, show how much influence the mind can have on physiological reactions and disease processes. This study cited similar related differences in physiological responses and disease conditions for some individuals under hypnosis vs in their normal waking state.

Treatment strategies that include hypnosis may be used to improve healthful behaviors, diminish situational stress, alleviate phobias (eg, to needles or bugs), control harmful habits such as scratching, provide immediate and long-term analgesia, reduce symptoms related to disease such as pruritus, improve recovery from surgery, and facilitate the mind-body connection to promote healing. Hypnosis can be an especially useful tool for treating skin diseases that have a psychosomatic aspect. Griesemer¹⁴ and Griesemer and Nadelson¹⁵ recorded the incidence of emotional triggering of dermatoses in 4576 patients during 1 year (Table 1).

Good reference sources for skin disease response to hypnosis are found in the somewhat outdated book by Scott,¹⁶ and in a chapter on the use of hypnosis in dermatologic problems in the book by Crasilneck and Hall.⁴ Koblenzer¹⁷ also mentions the use of hypnosis in common dermatologic problems. An excellent book for patients by Grossbart and Sherman¹⁸ discusses mind-body interactions in skin diseases, and includes hypnosis as recommended therapy for a variety of skin conditions. Some dermatoses that have responded to hypnotherapy are discussed in the following subsections.

Hypnosis is a tool, analogous to a scalpel, that is used to cut through psychological and behavioral roadblocks to healing. It is not a therapy in and of itself. The therapies that can be facilitated by hypnosis include supportive (ego strengthening), direct suggestion, symptom substitution, and hypnoanalysis.^{16 ,19 - 21}

Induction of the hypnotic state in adults can be achieved by a variety of methods that focus attention, soothe, or produce monotony or confusion.^{4 - 5} In children, the hypnotic state is often induced by having the child pretend that he or she is watching television, a movie, or a play, or by using some other distractive process that uses the imagination.²²

Supportive (ego-strengthening) therapies during a hypnotic state include positive suggestions for self-worth and effectiveness. Posthypnotic suggestion is often used, and further strengthening of the effect can often be obtained by making an audiocassette tape that the patient can use repeatedly for self-hypnosis. The strengthened ego is then better able to repress or confront discordant elements that block healing.

Direct suggestion while in the hypnotic state is the most commonly used method of decreasing discomfort from pain, pruritus, burning sensations, anxiety, and insomnia. Posthypnotic suggestion and repeated use by the patient of an audiocassette tape for self-hypnosis helps reinforce the effectiveness of direct suggestion. For deeply hypnotizable individuals, direct suggestion may produce a sufficiently deep anesthesia to permit cutaneous surgery. Direct suggestion can also be used to reduce compulsive acts such as skin scratching or picking, nail biting or manipulating, and hair pulling or twisting.¹⁶ Psychophysiologic responses such as hyperhidrosis, blushing, and some forms of urticaria can also be controlled by direct suggestion. Some types of skin lesions can even be induced to resolve themselves by using direct suggestion, the classic example being verrucae (see the "Verruca Vulgaris" subsection).

Symptom substitution is a method of retraining the subconscious through hypnosis to replace a destructive habit pattern with a more constructive one.^{13 ,16} For example, scratching can be replaced by some other physical activity, such as grabbing onto something and holding it so tightly for half a minute so that it almost hurts. Other outlets for stress that can substitute for scratching include athletic activities, artwork, verbal expression of feelings, and meditation.

Hypnoanalysis may prove useful in patients with chronic psychosomatic dermatoses that are nonresponsive to other, simpler approaches. Results may occur more quickly than with standard psychoanalysis.¹⁶

Many older studies of the effectiveness of hypnosis on specific dermatologic conditions are based on 1 or a few uncontrolled cases. Although these findings are included in the following subsections, they await further confirmation. The word may is used to qualify recommendations that are based on skimpy evidence. This weakness should be kept in mind when evaluating the information and recommendations presented. In recent years, the trend toward more controlled trials has produced more reliable information.²³ However, randomized controlled trial results are still not available for most disease categories. Although this list of dermatologic conditions is not all-inclusive, it includes most of the dermatologic conditions for which hypnosis has been found to be reasonably helpful in reducing symptoms or improving aspects of the condition (Table 2).

Hollander²⁴ reported success in controlling acne excoriée in 2 patients by using posthypnotic suggestion. Under hypnosis, the patient was instructed to remember the word scar whenever she wanted to pick her face and to refrain from picking by saying scar instead. The excoriations resolved, whereas the underlying acne did not. Therefore, hypnosis may be an appropriate primary alternative treatment for the excoriation aspect of acne excoriée, with standard acne treatments for the acneiform aspects.

Gupta et al²⁵ found a strong correlation between high stress reactivity and depression in patients with alopecia areata (P<.001). Hypnosis can be used to teach patients to control high stress reactivity. Although there are anecdotal reports of hypnotherapy improving alopecia areata, results of a small clinical trial²⁶ of medical hypnotherapy with 5 patients who had extensive alopecia areata showed a significant increase in hair growth in only 1 patient; 3 had a slight increase in hair growth, and 1 had no change. Hypnosis improved psychological variables in these 5 patients.²⁶ It seems that hypnosis may be more appropriate as a complementary therapy than as a primary alternative treatment for alopecia areata.

There are numerous anecdotal articles²⁷ in the literature of improved atopic dermatitis in children and adults as a result of hypnotherapy. In a clinical trial, Stewart and Thomas²⁸ treated 18 adults with extensive atopic dermatitis who had been resistant to conventional treatment with hypnotherapy. They used relaxation, stress management, direct suggestion for nonscratching behavior, direct suggestion for skin comfort and coolness, ego strengthening, posthypnotic suggestions, and instruction in self-hypnosis. Their results were statistically significant (P<.01) for reduction in itch, scratching, sleep disturbance, and tension. Reported topical corticosteroid use decreased by 40% at 4 weeks, 50% at 8 weeks, and 60% at 16 weeks. For milder cases of atopic dermatitis, hypnosis along with moisturization can suffice as a primary alternative treatment. For more extensive or resistant atopic dermatitis, hypnosis can be a useful complementary therapy that reduces the amounts required of other conventional treatments.

Mason²⁹ described remarkable resolution of congenital ichthyosiform erythroderma of Brocq in a 16-year-old boy after direct suggestion for resolution under hypnosis. Similar yet less spectacular results were confirmed by Wink³⁰ in 2 sisters aged 8 and 6 years, by Schneck³¹ in a 20-year-old woman, and by Kidd³² in a 34-year-old father and his 4-year-old son. In light of these case reports, hypnosis may be potentially useful as a complementary therapy to emollients.

Reduction in severity of dyshidrotic dermatitis has been reported with the use of hypnosis as a complementary treatment.³³ Data from Griesemer¹⁴ (Table 1) indicate a significant psychosomatic component for dyshidrosis, so hypnosis may be useful as a complementary therapy.

In one case report³⁴ of successful treatment of erythromelalgia in an 18-year-old woman using hypnosis alone followed by self-hypnosis, permanent resolution occurred.

Jabush³⁵ described a 33-year-old man with recurrent multiple Staphylococcus aureus–containing furuncles since age 17 years that were unresponsive to multiple treatment modalities. He had a negative self-image. Hypnosis and self-hypnosis with imagined sensations of warmth, cold, tingling, and heaviness brought about dramatic improvement in 5 weeks, with full resolution of the recurrent furuncles. The patient also improved substantially from a mental standpoint. Presumably, the hypnosis helped normalize his immune response to the bacteria. Conventional antibiotic therapy is the first line of treatment for furuncles, but in unusually resistant cases with significant psychosomatic overlay, complementary use of hypnosis may help end the long-term susceptibility to recurrent infection.

When oral pain has a psychogenic component, hypnosis may be effective as a primary treatment.³⁶ Even with organic disease, hypnosis may give temporary relief from pain.

Onset of herpes labialis was intentionally triggered by hypnotic suggestion in a patient.³⁷ Ameliorization of discomfort from herpes simplex eruptions is similar to that for postherpetic neuralgia (see the "Postherapeutic Neuralgia" subsection). Reduction in the frequency of recurrences of herpes simplex after hypnosis has also been reported.³⁸ In cases with an apparent emotional trigger factor, hypnotic suggestion may be useful as a complementary therapy for reducing the frequency of recurrence.

Hypnosis or autogenic training may be useful as adjunctive therapies for hyperhidrosis.³⁹

A 33-year-old man with lifelong ichthyosis vulgaris that was better in summer and worse in winter began hypnotic suggestion therapy in the summer and was able to maintain the summer improvement throughout the fall, winter, and spring.⁴⁰ Hypnosis may thus be useful as a complementary therapy for ichthyosis.

Pruritus and the accompanying lesions may be reduced in selected patients using hypnosis as a complementary therapy for lichen planus.^{16 ,33}

Several cases of neurodermatitis have resolved using hypnosis as an alternative therapy,^{41 - 44} and stayed resolved for up to 4 years of follow-up. Hypnosis may be useful as a complementary or even alternative therapy for neurodermatitis.

Reduction of pruritus and resolution of lesions has been reported,^{16 ,33} with use of hypnotic suggestion as a complementary therapy for nummular dermatitis.

The pain of acute herpes zoster and of postherpetic neuralgia can be reduced by hypnosis.^{16 ,38} Hypnosis may have a place as a complementary therapy for postherpetic neuralgia.

The intensity of pruritus may be modified and improved by hypnosis.¹⁶ An example⁴⁵ is that of a man with chronic myelogenous leukemia whose intractable pruritus was much improved with hypnotic suggestion. Hypnosis may be used as a complementary therapy for intractable pruritus.

Stress plays an important role in the onset, exacerbation, and prolongation of psoriasis. Hypnosis and suggestion have been shown to have a positive effect on psoriasis.^{46 - 48} In a typical case report,⁴⁹ 75% resolution of psoriasis was reported using a hypnotic sensory-imagery technique. Another case⁵⁰ of extensive severe psoriasis of 20 years' duration showed marked improvement using sensory-imagery to replicate feelings in the patient's skin that he had experienced during sunbathing. Yet another case⁵¹ of severe psoriasis of 20 years' duration resolved fully with use of a hypnoanalytic technique. Tausk and Whitmore⁵² performed a small, randomized double-masked controlled trial using hypnosis as adjunctive therapy in psoriasis, with significant improvement in highly hypnotizable patients. Hypnosis can be useful as a complementary therapy for resistant psoriasis, especially if there is a significant emotional factor in its triggering.

Improvement of rosacea, especially the vascular blush component, has been described in selected cases of resistant rosacea in which hypnosis has been added as complementary therapy.^{16 ,33}

Several cases of successful adjunctive treatment of trichotillomania have been described.^{53 - 55} It seems that hypnosis may be a useful complementary therapy for trichotillomania.

Inhibition of immediate-type hypersensitivity response by direct suggestion under hypnosis was described for 8 of 12 patients.⁵⁶ In another study,⁵⁷ flare but not wheal sizes were significantly reduced after hypnosis compared with sessions without hypnosis. Two patients with urticaria that responded to hypnotic suggestion were described in another study,⁵⁸ including an 11-year-old boy whose urticarial reaction to chocolate could be blocked by hypnotic suggestion, so that hives appeared on one side of his face but not the other in response to that hypnotic suggestion. In a study⁵⁹ of hypnosis with relaxation therapy on 15 patients with chronic urticaria of 7.8 years' average duration, within 14 months, 6 patients had resolved and another 8 improved, with decreased medication requirements reported by 80% of patients. In selected individuals, it seems that hypnosis may be useful as complementary or even alternative therapy for chronic urticaria.

Results of the early studies by Bloch¹ and Sulzberger and Wolf² on the efficacy of suggestion in treating warts have since been confirmed numerous times to a greater or lesser degree,^{60 - 63} as well as not confirmed in a few studies.^{64 - 65} A recent study⁶⁶ with negative results was criticized for using a negative suggestion about not feeding warts rather than a positive suggestion about having the warts resolve. Numerous studies^{67 - 82} attest to the efficacy of hypnosis in treating warts, but this was not confirmed in a study⁸³ that tried to replicate the success reported by Sinclair-Gieben and Chalmers⁸⁴ of using hypnotic suggestion to cause warts to disappear from one hand but not the other in persons with bilateral hand warts. In a well-conducted study⁸⁵ that serves as a typical example, 53% of the experimental group had improvement of their warts 3 months after the first of 5 hypnotherapy sessions, whereas none of the control group had improvement. In summary, it seems that hypnosis can be helpful as complementary or alternative therapy for warts.

Hautmann and Panconesi⁸⁶ described in detail the psychoneuroendocrinimmunologic aspects and mechanisms of vitiligo. Occasionally, patients with vitiligo have improved using hypnotic suggestion as complementary therapy.^{16 ,33}

Hypnosis currently is underused as an alternative or complementary therapy in dermatologic practice. For selected skin diseases in appropriately selected patients, it can decrease or eliminate symptoms and, in some cases, induce lasting remissions or cures. Discussing this option with patients will allow the dermatologist to gauge the patient's receptiveness to this treatment modality. Time requirements for screening patients, educating them about realistic expectations for results from hypnosis, and actually performing the hypnotherapy are generally no greater than for screening, preparing, and educating patients about cutaneous surgery and then actually performing it. Just as many dermatologists choose to refer patients with complex cutaneous surgical problems to competent specialists in dermatologic surgery, many dermatologists would choose to refer patients with complex psychosomatic dermatologic problems to competent specialists in hypnosis-assisted therapy. Dermatologists who prefer to refer patients to hypnotherapists or who desire further information about training in hypnotherapy can obtain referrals and information from the American Society of Clinical Hypnosis or similar professional organizations.

Advantages of medical hypnotherapy for skin diseases include nontoxicity, cost-effectiveness, ability to obtain a response when other treatment modalities fail, ability to reduce relapses, and ability of patients to self-treat and gain a sense of control when taught self-hypnosis reinforced by using audiocassette tapes. Adding this treatment capability can result in pleased and grateful patients.

Disadvantages of medical hypnotherapy in dermatologic practice include the extensive practitioner training required, the low hypnotizability of some patients, the negative social attitudes still prevalent about hypnosis, and the lower reimbursement rates for cognitive therapies such as hypnosis compared with procedural therapies such as cutaneous surgery. The training requirements for hypnosis are no more extensive than those required for cutaneous surgery. Social attitudes and reimbursement policies can be changed with time. The low hypnotizability of some individuals is, to a large extent, "hard-wired" into their brains and tends to be consistent over time, as measured by the Hypnotic Induction Profile.⁸⁷

Patient selection is an important aspect of successful medical hypnotherapy in dermatologic practice. Part of the art of being a dermatologist is being able to choose appropriate therapeutic modalities for specific patients. Hypnosis-assisted therapy works best in moderately to highly hypnotizable patients who are appropriately motivated, and who have dermatoses with a large psychosomatic component or that are otherwise known to be responsive to intervention with hypnosis. As with any therapy, it is best to start with simple cases, referring the more complex cases to those more experienced. As the practitioner gains experience, more difficult cases may be added.

Hypnosis, like any other tool, can be effective and gratifying in many cases, when appropriately applied. Like any other tool, hypnosis is not a panacea. It seems to work miracles for some and yet, to fail completely for others; most results lie somewhere in between. The specific type of therapy chosen to be assisted by hypnosis is also a key factor in producing positive results. With proper selection of disease process, patient, and provider, hypnosis can decrease suffering and morbidity from skin disorders with minimal adverse effects.

Accepted for publication June 24, 1999.

Reprints: Philip D. Shenefelt, MD, MS, Division of Dermatology and Cutaneous Surgery, Department of Internal Medicine, Mailstop MDC 019, College of Medicine, University of South Florida, 12901 Bruce B Downs Blvd, Tampa, FL 33612 (e-mail: pshenefe@hsc.usf.edu).