May 6, 2024 • 24 mins
If there is one thing we want you to take away from this episode, it’s a sense of EMPOWERMENT.
For this discussion, Dr George Moncrieff and Dr Roger Henderson are joined by a world authority in how mental health and the skin are linked, Professor Anthony Bewley. The trio chat about the huge impact skin conditions can have on someone's quality of life, as well as diving into:
- Why you should talk to your GP about your mental health
- Psychodermatology (the medical term for addressing the mind and the skin) resources in the UK
- Guidance on how managing the physical symptoms of your dry skin condition (for example, itchiness) can help relieve the impact this may be having on your mental wellbeing.
Thank you to our kind sponsor AproDerm, who provide a range of emollients designed for the management of dry skin conditions, including eczema, psoriasis and ichthyosis.
Everyone’s skin is unique and what works for one person, may not work for another. That’s why AproDerm has developed the AproDerm Emollient Starter Pack. This pack contains all four of their emollients varying in their formulation, consistency and hydration, giving you the choice to find a routine that suits you.
Find out more here:
IG: https://www.instagram.com/aproderm/
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We hope you find this podcast interesting and helpful. Please leave us a review or email info@aproderm.com with any feedback on this episode or suggestions on dermatology topics that you would like to hear about in future podcasts.
The views expressed in this podcast are of Dr George Moncrieff and Dr Roger Henderson. Fontus Health has not influenced, participated, or been involved in the programme, materials, or delivery of educational content.
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Transcript
Episode Transcript
Available transcripts are automatically generated. Complete accuracy is not guaranteed.
Dr Roger Henderson (00:06):
Hello and welcome to this Skin Deep podcast
where we look at skin relatedissues, conditions, and treatments
in an interesting and informed way.
I'm Dr Roger Henderson, I'm a GPwith a long-standing interest in
this particular area of health.
Dr George Moncrieff (00:20):
And I'm Dr George Moncrieff.
I was also a GP, although I've now retiredfrom my practice, and I'm a former Chair
of the Dermatology Council for England.
Dr Roger Henderson (00:32):
And in this podcast, George and I will be looking
at the impact that skin diseases canhave on someone's mental wellbeing.
And this is the first of twopodcasts on this topic, and we're
delighted to be joined by ourvery special guest and expert in
this area, Professor Tony Bewley.
Now George, we both know just how muchsomeone's mental and physical health
(00:55):
is intrinsically linked, and being bothvisible and a very large organ, skin
diseases can have a massive impact onsomeone's quality of life, especially when
areas such as the face, the hair, or eventhe genitals can be involved, can't they?
(01:20):
So I suppose if someone is listening,with a skin condition that they feel
is impacting on their mental health,and one of the things that George and I
really hope you're going to get out ofthis podcast is a sense of empowerment.
We want you to feel that you can approachyour healthcare professional and explain
just how your skin condition is impactingon you, and not be afraid to do so.
(01:46):
And we hope that what we can tellyou in this podcast will give you
the confidence to go and do that, andmove your care forwards, rather than
being stuck in a rut, if you feelthat's where you are at the moment.
Dr George Moncrieff (02:01):
Yeah, because what we have come to realise,
very clearly, is that healthcareprofessionals often underestimate
and underappreciate, and don't evenrecognise, that there's a problem here.
So unless you tell them, unlessyou make that the purpose of going
to see your doctor, they won'tknow and they can help a lot.
(02:23):
They can help to signpostand they need to be involved.
So don't be backward aboutcoming forward with these issues.
Tony, one of the things we've beendiscussing is that the medical
profession is not always alert to theseconcerns and can easily miss things,
especially during a busy consultation.
And so, one of the messages I'd liketo get out there, is to encourage
(02:46):
our patients to actually make thisthe purpose of coming to see us.
Have you got any particularthoughts on that idea?
Professor Anthony Bewley (02:55):
Well, I think that's right George, I mean, I always
say, when I'm talking to patients or tohealthcare professionals, "Don't suffer in
silence, there is always help out there."
There are treatments availableand there are treatments which are
being developed day in, day out.
So what was a possible set of treatmentsa year ago will have changed by now.
(03:20):
And also healthcare professionals arebecoming increasingly aware of what
it is to live with a skin condition.
So we know from research from theAll-Party Parliamentary Group on
Skin report, which was in 2020,which showed that a massive 98%
of patients who live with a skincondition have psychological distress
(03:44):
from living with that skin condition.
And sadly, 82% of patients arenot signposted via healthcare
professionals to psychological support,or they just simply didn't ask.
Over half of patients simplydidn't ask about, "well, I
feel a bit dreadful right now.
(04:05):
What, what's available totry and help support me?"
So we as healthcare professionals needto get a little bit better about that.
And there are reasons why healthcareprofessionals tend to be a bit
more reticent about embracing thataspect of patient's wellbeing.
(04:25):
Things like time and fear about what canof worms they might think they're opening
up, and that's why really we love it whenpatients come to us and say, "Look, you
know, I'm really struggling with this.
Please can you help?"
You know, "What can I do?"
So, well prepared patients who comealong with an idea of what they want
(04:49):
from the consultation really helpsthem, but certainly it really helps
us as healthcare professionals.
Dr George Moncrieff (04:55):
Yes, and what I say is actually, look, make that the
reason for coming to see your doctor.
Not just to discuss what we're going todo for your skin, but make the reason
for coming to see us that you want us tobe aware of how this is affecting you.
And for the doctor, you haven'tgot to sort it out in that
consultation, just acknowledgingit and maybe signposting them.
Professor Anthony Bewley: Yeah, I think that's right. (05:17):
undefined
I think just, from what I hearfrom patients, providing a patient
feels heard and listened to,that for them is half the battle.
What they don't want is to have somekind of resistance from healthcare
professionals, or even worse, dismissalfrom healthcare professionals where it's
not weighted or taken seriously enough.
(05:41):
That can feel incredibly disempowering.
Dr George Moncrieff (05:45):
Having said all that, the report, which actually you
chaired, highlighted that there arequite limited mental health resources.
Professor Anthony Bewley (05:53):
Yeah sadly, there are few dedicated psychodermatology
healthcare units around the UK,and mental health services are
stretched, especially post COVID.
But there are services around, andas I say, if a patient feels heard,
(06:14):
that really is half the battle, andI think that healthcare professionals
are getting better and better at this.
We still have an awfully long way togo, but I think we are getting better.
I think the message is, in medicalschool and in postgraduate training
for younger doctors, making surethat the patient is at the centre
(06:34):
of a decision and that the patientgets heard, is really very important.
And I do think the UK, becauseof the NHS and socialised
medicine, is not so bad at this.
When I do training schools abroad,in Europe or outside of Europe,
there are other factors whichmean that healthcare professionals
(06:56):
do not embrace the whole patientcentricity, quite as eagerly as we do.
So we have got some reasonsto, to champion what has been
good advances in the UK, butwe still have a long way to go.
Dr George Moncrieff (07:11):
`Yeah, absolutely.
That's nice to hear.
Another thing that you highlighted inthis report was that children need special
attention and we really do need dedicatedpaediatric psychodermatology resources.
Because children have the wholeof their life ahead of them.
Any particular thoughts there?
Professor Anthony Bewley: Yeah, I think that's right. (07:29):
undefined
And, and paediatric mental healthis so crucial, and a lot of, in
psychodermatology units, a lot of thepsychosocial support that we have,
professionally, is from adult trainedpsychiatrists and psychologists.
So, accessing CAMHS, or Child andAdolescent Mental Health Services, can
(07:51):
be quite a challenge because they're evenmore stretched than the adult services.
However, as I say, dermatologistsare, all dermatologists are
paediatric dermatologists.
We are all trained to be able to managepatients from the age of zero to whenever,
and that's the same in general practicetoo, so, so we do have some training.
(08:14):
It might not be as specific as welike, but we can listen, and we can
hear and we can signpost, and thereare places to which we can signpost.
I did want to mention as well,the concept of the cumulative life
course impairment, CLCI, which isabout disease modification really.
So we're increasingly aware indermatology, that if you live with
(08:38):
a skin condition, that carriesits own psychological burden.
And if you start living with thatskin condition aged ten, then you
have many decades in which you'recarrying the psychological burden.
And that becomes the cumulative, in otherwords, the year by year addition, of the
(08:59):
psychological burden throughout that life.
And so these days, dermatologists anddermatology healthcare professionals,
are talking about disease modification.
In other words, reducing thatcumulative life course impairment.
In other words, treating the skin andthe psychological problems as early and
(09:23):
as comprehensively as you can, so thatwe try not to build up that burden that
the patient may carry throughout life.
Dr George Moncrieff (09:32):
Indeed.
For example, a disturbance of someone'sself-esteem, self-confidence, can
affect relationships, it can affectwhether you join a team, it can affect
your sporting activities therefore.
It can affect your choice of subjects youdo, it may affect important relationships
and intimate relationships, that canaffect your future partner, your career.
(09:53):
So something quite minor, relativelyminor, to us perhaps, not necessarily
to the patient, early in life can goon to have really pretty devastating
longer term consequences, on whatyour achievements are in life.
Whether you're going to become thePrime Minister, simply because you had
skin disease when you were a teenager,that affected your self-confidence.
(10:15):
So, this concept of the cumulativelife course impairment, which
is so much more devastatingfor a younger person, isn't it?
Professor Anthony Bewley (10:24):
Yeah, and I think that, I think you alluded to a
point there, which is quite important aswell George, and that is that it doesn't
really matter the extent of the disease.
We know from research that patients withminor disease can have quite significant
psychological burdens associatedwith that limited skin condition.
(10:45):
And some patients who have quiteextensive disease cope quite well.
So, I think that patients need toknow that we will take seriously
any skin condition, and we won'tdismiss it as being, well, it's
only affecting X part of your body.
We will, and we should, take anydisease burden, however insignificant
(11:09):
it might seem compared to lotsof patients, we need to take that
seriously, and the patient needs toknow that we will take that seriously.
Dr George Moncrieff (11:16):
These are all such critically important issues, aren't they?
But I'm just aware that there weretwo previous All-Party Parliamentary
reports for this, in this field, oneI think, was in 2003 and one in 2013.
And I feel that the recommendationsfrom those two reports haven't really
been implemented by policymakersor service commissioners.
(11:40):
Have you got any confidence that thisreport, is going to make a difference?
Professor Anthony Bewley (11:45):
I think it's slow, steady progress, so you're
absolutely right, the progress from adecade or so ago has not been as explosive
or as comprehensive as I would have liked.
And there are some parts of the UK,especially in the devolved nations
of the UK, where psychodermatologyprovision is really not very good at all.
(12:11):
But, the message of making surethat we have, at least regional
psychodermatology units across theUK, is steadily improving in momentum.
And as I said before, Ithink, but we do okay.
We don't do brilliantly by anymeans, in the UK, but we do okay.
And we're probably doing better than alot of Europe or the rest of the globe.
(12:36):
That's not a good reason to be complacent,and that's the reason why we published
the All-Party Parliamentary Group on Skin.
We do need to make sure thatwe do have, at least, regional
psychodermatology units across the UK.
Interestingly as well, in Europe, there'san organisation called ESDaP, European
Society for Dermatology and Psychiatry,and we are a member of ESDaP, and we
(13:00):
have mirrored the UK message acrossEurope, with a white paper published
in 2023, to say that we are, in Europe,we also agree that there should be,
at least, regional psychodermatologyunits across the whole of Europe.
And there are plenty of statesin Europe where there is no
dedicated psychodermatology unit.
(13:22):
Europe has quite a way to go.
Dr George Moncrieff (13:23):
I think a lot of that achievement in the UK is down
to you, we've got a lot to thank youfor Tony, you've been an ambassador
for this, championing this for years.
I've known you talk aboutthis for a long, long time.
It's lovely to feel that maybe theprofession is coming up behind you
now, and supporting this, and we mightsee some improvement in our approach,
(13:45):
holistically, to our patients with thisparticular, very common and very important
area of their skin care management.
Thank you very much indeed.
I just wonder whether, have you gotany quick tips, for patients, to
help break the itch-scratch cycle?
Professor Anthony Bewley (14:01):
Yeah, so the itch-scratch cycle is, as
we know, a self-driving cycle.
If you have itchy skin, you scratch it.
If you scratch it, itleads to more itching.
So there are various thingsthat are really quite important
in trying to break that cycle.
The first one is physically.
So, to try and improve the skin barrierfunction with plenty of emollients.
(14:23):
And then if you have got itchy skin,that implies there is inflammation of the
skin, so using something that is goingto be anti-inflammatory is quite helpful.
That can be topical steroids,topical calcineurin inhibitors, so...
ointments.
Dr George Moncrieff (14:36):
You mean things like the, things like Protopic®?
Professor Anthony Bewley (14:39):
Yeah, ointments which work as an anti-inflammatory.
That can be steroids or othernon-steroid, anti-inflammatory ointments.
And it can, these days, be sunlighttreatment or tablets or even injections.
There are physical treatmentsthat work for the...
Dr George Moncrieff (14:55):
...Control the disease and the inflammation
as best you can, yes.
Professor Anthony Bewley (14:59):
And then there is the whole process of the
habit of itch, and we know that atleast part of the itch is habit.
Now, if you say to somebody who'sitchy, who has eczema, "For goodness
sake, will you stop scratching?"
So when I was a young person, I hadeczema and my parents would say to
me, "For goodness sake, Anthony,will you stop scratching?", and
(15:19):
it just made no difference at all,because I'd just carry on scratching.
I'd probably scratch even moreactually, because it added to the
whole stress of the situation.
Because the itch is so awful and sorecalcitrant, it is very difficult to
resist, and that's one of the thingsthat patients with itchy skin, like
atopic eczema, feel most keenly.
(15:40):
They feel the out of controlness.
For example, I'd go to bed atnight, when I was a young person
with eczema, and think, I hope Idon't scratch tonight, I've put the
ointments on, I've done all I can.
I hope I don't scratch tonight.
The following day I'd wakeup with scratched skin and
blood on the sheets and so on.
And that out of control, and that um,shame and disappointment that, despite all
(16:03):
my best efforts and doing all that I cando, I still managed to scratch my skin,
which of course led to more inflammation,which led to more itching and so on.
So physical treatment's really important.
And then there are treatments forthe, for the itch itself, which can
be antihistamines, though they may notwork particularly well in the long-term.
(16:25):
But there are growing, there is agrowing interest in other treatments,
other tablets or injection typetreatments, that can work for itch.
And then, as I say, there isthe habit component of itch.
Now, what do I mean by thehabit component of itch?
What I mean by that is that thereare certain times of the day when
it becomes much more likely thatyou will scratch at your skin.
(16:47):
And that's usually first thingin the morning or last thing at
night before you go to bed orat various times during the day.
So for example, when I had eczemaas a child, I would quite like to
come home from school and have alittle scratch or have a little pick
because it works as a stress buster.
So, if you scratched at your skin, weknow that releases kind of stress busting
(17:08):
chemicals in the brain, which can give youa temporary kind of stress relief process.
You can identify those times during theday when you're more likely to adopt
the habit of scratching at your skin.
, and you can replace the habitof scratching or rubbing at your
skin with a different habit.
That can be grasping alapel or pinching the skin.
(17:32):
There are various other habits thatyou can do, that we know that that
leads, in the long term, to betteritch control and actually reduction
in the inflammatory skin disease.
And that technique iscalled, habit reversal.
. You can look at a module on habitreversal on www.atopicskindisease.com.
(17:54):
Or some units have trained habitreversal programmes, which are four
appointments, usually run by a nurse.
And over those four appointments,you will recognise how often that you
habitually scratch at your skin, clickon a clicker counter every time that
you habitually scratch at your skin.
(18:16):
And then over the four weeks, by replacingthe habit of scratching at your skin
with a different habit of, as I say, likegrasping your lapel or pinching the skin,
then you'll watch the clicker counter comedown and you will also watch as your skin
improves, the inflammatory skin improves.
(18:36):
However, we also know that othertechniques really help with itch,
and that can be really quitestraightforward techniques like
mindfulness or relaxation techniques.
Any of these techniques can reallyhelp suppress the whole itch.
What I find is that patients say tome, "I'm okay during the day because
I'm at work or at school", or whateverit is, "I come home and I sit down
(18:58):
and watch...", whatever it is on thetelevision, "and that's when I think,
oh, my God, I'm so [itchy]...", andthey, you know, they can sit watching
the television, scratching at their skin.
And what we know about that is thatwhilst we're busy, active during the day,
the brain is active in other processesso that the focus of the brain during
the day is simply not on the itch, andthen in the evening, when we're sat in
(19:21):
front of the television or just relaxing,and the brain doesn't have so many
competing stimuli, so many competingthings to do, that the brain expands
the whole thing of, okay, actually now'san opportunity to really feel itchy.
So it's really common forpatients to say it's in the
evening when I feel most itchy.
So again, relaxation techniques,mindfulness, meditation, really
(19:47):
can make a big difference, togetherwith habit reversal, together
with the appropriate use of, ofphysical treatment for the skin.
Dr George Moncrieff (19:55):
Yes, brilliant, thank you so much.
What I'm taking from that, is thatit isn't that easy to help, but,
really important to manage theinflammatory element of the disease
and control the skin disease asbest you can, because it is very
definitely a vicious cycle, isn't it?
You scratch the skin, scratched skinis damaged, damaged skin is itchy, and
(20:15):
therefore you have to scratch it again.
So if you can somehow break that cycle,whether it's with relaxation techniques,
mindfulness or these click counters andthings, supported by a specialist nurse,
once you break the cycle, you can getout of that vicious cycle, hopefully,
but it also does demand good controlof the disease, whatever that takes.
Professor Anthony Bewley (20:37):
And I think you alluded to a good point there,
if I can just say, George, whichis that it's not just the patient
that suffers with all of this...,
Dr George Moncrieff (20:44):
It is indeed the family.
Professor Anthony Bewley (20:45):
...it is actually the family as well.
I think you alluded to that, thefrustration, because it's such an
easy trap to fall into, you know, "Forgoodness sake, will you stop scratching?"
And, you know, "What am I doingwrong as a parent, that I can't
get my child to stop scratching?"
So it can carry quite a burden for thefamily and for the loved ones as
well, and they can get frustrated andagain, first thing is, you know, try
(21:10):
not to beat yourself up about this.
Try and be understanding that actually,it is a really recalcitrant itch.
It is an inflammatory skin disease. Itis, it is something that we can, we
can control and improve and get better.
And for the parents and for the carersand for the loved ones, again, trying
to take a deep breath in and relax.
(21:33):
And, again, think about mindfulness, thinkabout relaxation techniques, think about
trying to support whoever has the eczema,and saying, okay, well, you know, "How
can I help you put the ointments on?"
People talk these days, don't they,about motivational interviewing.
With motivational interviewing, you set,you get the patient to set the goal.
Okay.
"What is it that is stopping youfrom applying your ointments?
(21:58):
What is it that is stopping you fromdoing the stuff that you want to do,
to be able to get control of your skin?
Is it time or is it that you're abit bored of using the ointments or
is it that you're a bit fed up andhow can you deconstruct the hurdles?
How can you stop yourself fromfalling into a trap where you're
(22:22):
stopping yourself from progressing?"
Dr George Moncrieff (22:23):
Yeah.
Professor Anthony Bewley (22:24):
And then "How can you achieve the sort of
aims that you want to achieve, interms of getting good skin control?"
Dr George Moncrieff (22:30):
Tony, that was absolute gold dust, fantastic advice and so helpful.
It's interesting, isn't it,that itch is such an unpleasant
sensation that sometimes patientswould prefer to be in pain.
They will tear their skin till it'sactually painful because, severe pain
in the skin from a severe scratch andpicking it, is preferable to the itch.
(22:51):
But wow!
I think you are really bringing toour attention how important this is to
manage, and thank you very much indeedfor that wonderful summary of advice.
We could be talking here all morning,I know, but thank you very much indeed.
Dr Roger Henderson (23:06):
Well, I think that's a good point to end this
particular podcast, and George andI do hope you found this chat about
skin and mental health interesting.
And our thanks do go to ourwonderful guest, Professor Anthony
Bewley, for all his help with it.
I do hope you have found him asinteresting as George and I did.
Now, in addition, in the upcoming podcast,we'll be looking at the scale of the
(23:29):
problem, looking at some conditionswhere the skin can be the presentation
of a mental health condition, and we'llalso look at how your doctors should
be responding to some of the shockingfacts and figures linked to mental health
issues in people with skin disease.
Dr George Moncrieff (23:47):
We have been honoured to be joined by
Professor Bewley for this episode.
Thank you so much for your expertise,wisdom and your contribution.
Tony will be joining us for ournext podcast and look forward
to that very much indeed.
Roger and I do hope you'll join us then.
We'd also like to thank our sponsor,AproDerm®, for all their help in putting
(24:10):
these Skin Deep podcasts together.
We couldn't have done it without them.
Dr Roger Henderson (24:16):
If you do like our podcast, and George and I really hope you
do, then leave us a review, or rate us, orsend us some feedback, so do get in touch.
We really do love to hear from you.
But until the next time,it's goodbye from George.
Dr George Moncrieff (24:31):
Goodbye.
Dr Roger Henderson (24:32):
And as always, it's goodbye from me.
Goodbye.
Hello and welcome to this Skin Deep podcast
where we look at skin relatedissues, conditions, and treatments
in an interesting and informed way.
I'm Dr Roger Henderson, I'm a GPwith a long-standing interest in
this particular area of health.
Dr George Moncrieff (00:20):
And I'm Dr George Moncrieff.
I was also a GP, although I've now retiredfrom my practice, and I'm a former Chair
of the Dermatology Council for England.
Dr Roger Henderson (00:32):
And in this podcast, George and I will be looking
at the impact that skin diseases canhave on someone's mental wellbeing.
And this is the first of twopodcasts on this topic, and we're
delighted to be joined by ourvery special guest and expert in
this area, Professor Tony Bewley.
Now George, we both know just how muchsomeone's mental and physical health
(00:55):
is intrinsically linked, and being bothvisible and a very large organ, skin
diseases can have a massive impact onsomeone's quality of life, especially when
areas such as the face, the hair, or eventhe genitals can be involved, can't they?
(01:20):
So I suppose if someone is listening,with a skin condition that they feel
is impacting on their mental health,and one of the things that George and I
really hope you're going to get out ofthis podcast is a sense of empowerment.
We want you to feel that you can approachyour healthcare professional and explain
just how your skin condition is impactingon you, and not be afraid to do so.
(01:46):
And we hope that what we can tellyou in this podcast will give you
the confidence to go and do that, andmove your care forwards, rather than
being stuck in a rut, if you feelthat's where you are at the moment.
Dr George Moncrieff (02:01):
Yeah, because what we have come to realise,
very clearly, is that healthcareprofessionals often underestimate
and underappreciate, and don't evenrecognise, that there's a problem here.
So unless you tell them, unlessyou make that the purpose of going
to see your doctor, they won'tknow and they can help a lot.
(02:23):
They can help to signpostand they need to be involved.
So don't be backward aboutcoming forward with these issues.
Tony, one of the things we've beendiscussing is that the medical
profession is not always alert to theseconcerns and can easily miss things,
especially during a busy consultation.
And so, one of the messages I'd liketo get out there, is to encourage
(02:46):
our patients to actually make thisthe purpose of coming to see us.
Have you got any particularthoughts on that idea?
Professor Anthony Bewley (02:55):
Well, I think that's right George, I mean, I always
say, when I'm talking to patients or tohealthcare professionals, "Don't suffer in
silence, there is always help out there."
There are treatments availableand there are treatments which are
being developed day in, day out.
So what was a possible set of treatmentsa year ago will have changed by now.
(03:20):
And also healthcare professionals arebecoming increasingly aware of what
it is to live with a skin condition.
So we know from research from theAll-Party Parliamentary Group on
Skin report, which was in 2020,which showed that a massive 98%
of patients who live with a skincondition have psychological distress
(03:44):
from living with that skin condition.
And sadly, 82% of patients arenot signposted via healthcare
professionals to psychological support,or they just simply didn't ask.
Over half of patients simplydidn't ask about, "well, I
feel a bit dreadful right now.
(04:05):
What, what's available totry and help support me?"
So we as healthcare professionals needto get a little bit better about that.
And there are reasons why healthcareprofessionals tend to be a bit
more reticent about embracing thataspect of patient's wellbeing.
(04:25):
Things like time and fear about what canof worms they might think they're opening
up, and that's why really we love it whenpatients come to us and say, "Look, you
know, I'm really struggling with this.
Please can you help?"
You know, "What can I do?"
So, well prepared patients who comealong with an idea of what they want
(04:49):
from the consultation really helpsthem, but certainly it really helps
us as healthcare professionals.
Dr George Moncrieff (04:55):
Yes, and what I say is actually, look, make that the
reason for coming to see your doctor.
Not just to discuss what we're going todo for your skin, but make the reason
for coming to see us that you want us tobe aware of how this is affecting you.
And for the doctor, you haven'tgot to sort it out in that
consultation, just acknowledgingit and maybe signposting them.
Professor Anthony Bewley: Yeah, I think that's right. (05:17):
undefined
I think just, from what I hearfrom patients, providing a patient
feels heard and listened to,that for them is half the battle.
What they don't want is to have somekind of resistance from healthcare
professionals, or even worse, dismissalfrom healthcare professionals where it's
not weighted or taken seriously enough.
(05:41):
That can feel incredibly disempowering.
Dr George Moncrieff (05:45):
Having said all that, the report, which actually you
chaired, highlighted that there arequite limited mental health resources.
Professor Anthony Bewley (05:53):
Yeah sadly, there are few dedicated psychodermatology
healthcare units around the UK,and mental health services are
stretched, especially post COVID.
But there are services around, andas I say, if a patient feels heard,
(06:14):
that really is half the battle, andI think that healthcare professionals
are getting better and better at this.
We still have an awfully long way togo, but I think we are getting better.
I think the message is, in medicalschool and in postgraduate training
for younger doctors, making surethat the patient is at the centre
(06:34):
of a decision and that the patientgets heard, is really very important.
And I do think the UK, becauseof the NHS and socialised
medicine, is not so bad at this.
When I do training schools abroad,in Europe or outside of Europe,
there are other factors whichmean that healthcare professionals
(06:56):
do not embrace the whole patientcentricity, quite as eagerly as we do.
So we have got some reasonsto, to champion what has been
good advances in the UK, butwe still have a long way to go.
Dr George Moncrieff (07:11):
`Yeah, absolutely.
That's nice to hear.
Another thing that you highlighted inthis report was that children need special
attention and we really do need dedicatedpaediatric psychodermatology resources.
Because children have the wholeof their life ahead of them.
Any particular thoughts there?
Professor Anthony Bewley: Yeah, I think that's right. (07:29):
undefined
And, and paediatric mental healthis so crucial, and a lot of, in
psychodermatology units, a lot of thepsychosocial support that we have,
professionally, is from adult trainedpsychiatrists and psychologists.
So, accessing CAMHS, or Child andAdolescent Mental Health Services, can
(07:51):
be quite a challenge because they're evenmore stretched than the adult services.
However, as I say, dermatologistsare, all dermatologists are
paediatric dermatologists.
We are all trained to be able to managepatients from the age of zero to whenever,
and that's the same in general practicetoo, so, so we do have some training.
(08:14):
It might not be as specific as welike, but we can listen, and we can
hear and we can signpost, and thereare places to which we can signpost.
I did want to mention as well,the concept of the cumulative life
course impairment, CLCI, which isabout disease modification really.
So we're increasingly aware indermatology, that if you live with
(08:38):
a skin condition, that carriesits own psychological burden.
And if you start living with thatskin condition aged ten, then you
have many decades in which you'recarrying the psychological burden.
And that becomes the cumulative, in otherwords, the year by year addition, of the
(08:59):
psychological burden throughout that life.
And so these days, dermatologists anddermatology healthcare professionals,
are talking about disease modification.
In other words, reducing thatcumulative life course impairment.
In other words, treating the skin andthe psychological problems as early and
(09:23):
as comprehensively as you can, so thatwe try not to build up that burden that
the patient may carry throughout life.
Dr George Moncrieff (09:32):
Indeed.
For example, a disturbance of someone'sself-esteem, self-confidence, can
affect relationships, it can affectwhether you join a team, it can affect
your sporting activities therefore.
It can affect your choice of subjects youdo, it may affect important relationships
and intimate relationships, that canaffect your future partner, your career.
(09:53):
So something quite minor, relativelyminor, to us perhaps, not necessarily
to the patient, early in life can goon to have really pretty devastating
longer term consequences, on whatyour achievements are in life.
Whether you're going to become thePrime Minister, simply because you had
skin disease when you were a teenager,that affected your self-confidence.
(10:15):
So, this concept of the cumulativelife course impairment, which
is so much more devastatingfor a younger person, isn't it?
Professor Anthony Bewley (10:24):
Yeah, and I think that, I think you alluded to a
point there, which is quite important aswell George, and that is that it doesn't
really matter the extent of the disease.
We know from research that patients withminor disease can have quite significant
psychological burdens associatedwith that limited skin condition.
(10:45):
And some patients who have quiteextensive disease cope quite well.
So, I think that patients need toknow that we will take seriously
any skin condition, and we won'tdismiss it as being, well, it's
only affecting X part of your body.
We will, and we should, take anydisease burden, however insignificant
(11:09):
it might seem compared to lotsof patients, we need to take that
seriously, and the patient needs toknow that we will take that seriously.
Dr George Moncrieff (11:16):
These are all such critically important issues, aren't they?
But I'm just aware that there weretwo previous All-Party Parliamentary
reports for this, in this field, oneI think, was in 2003 and one in 2013.
And I feel that the recommendationsfrom those two reports haven't really
been implemented by policymakersor service commissioners.
(11:40):
Have you got any confidence that thisreport, is going to make a difference?
Professor Anthony Bewley (11:45):
I think it's slow, steady progress, so you're
absolutely right, the progress from adecade or so ago has not been as explosive
or as comprehensive as I would have liked.
And there are some parts of the UK,especially in the devolved nations
of the UK, where psychodermatologyprovision is really not very good at all.
(12:11):
But, the message of making surethat we have, at least regional
psychodermatology units across theUK, is steadily improving in momentum.
And as I said before, Ithink, but we do okay.
We don't do brilliantly by anymeans, in the UK, but we do okay.
And we're probably doing better than alot of Europe or the rest of the globe.
(12:36):
That's not a good reason to be complacent,and that's the reason why we published
the All-Party Parliamentary Group on Skin.
We do need to make sure thatwe do have, at least, regional
psychodermatology units across the UK.
Interestingly as well, in Europe, there'san organisation called ESDaP, European
Society for Dermatology and Psychiatry,and we are a member of ESDaP, and we
(13:00):
have mirrored the UK message acrossEurope, with a white paper published
in 2023, to say that we are, in Europe,we also agree that there should be,
at least, regional psychodermatologyunits across the whole of Europe.
And there are plenty of statesin Europe where there is no
dedicated psychodermatology unit.
(13:22):
Europe has quite a way to go.
Dr George Moncrieff (13:23):
I think a lot of that achievement in the UK is down
to you, we've got a lot to thank youfor Tony, you've been an ambassador
for this, championing this for years.
I've known you talk aboutthis for a long, long time.
It's lovely to feel that maybe theprofession is coming up behind you
now, and supporting this, and we mightsee some improvement in our approach,
(13:45):
holistically, to our patients with thisparticular, very common and very important
area of their skin care management.
Thank you very much indeed.
I just wonder whether, have you gotany quick tips, for patients, to
help break the itch-scratch cycle?
Professor Anthony Bewley (14:01):
Yeah, so the itch-scratch cycle is, as
we know, a self-driving cycle.
If you have itchy skin, you scratch it.
If you scratch it, itleads to more itching.
So there are various thingsthat are really quite important
in trying to break that cycle.
The first one is physically.
So, to try and improve the skin barrierfunction with plenty of emollients.
(14:23):
And then if you have got itchy skin,that implies there is inflammation of the
skin, so using something that is goingto be anti-inflammatory is quite helpful.
That can be topical steroids,topical calcineurin inhibitors, so...
ointments.
Dr George Moncrieff (14:36):
You mean things like the, things like Protopic®?
Professor Anthony Bewley (14:39):
Yeah, ointments which work as an anti-inflammatory.
That can be steroids or othernon-steroid, anti-inflammatory ointments.
And it can, these days, be sunlighttreatment or tablets or even injections.
There are physical treatmentsthat work for the...
Dr George Moncrieff (14:55):
...Control the disease and the inflammation
as best you can, yes.
Professor Anthony Bewley (14:59):
And then there is the whole process of the
habit of itch, and we know that atleast part of the itch is habit.
Now, if you say to somebody who'sitchy, who has eczema, "For goodness
sake, will you stop scratching?"
So when I was a young person, I hadeczema and my parents would say to
me, "For goodness sake, Anthony,will you stop scratching?", and
(15:19):
it just made no difference at all,because I'd just carry on scratching.
I'd probably scratch even moreactually, because it added to the
whole stress of the situation.
Because the itch is so awful and sorecalcitrant, it is very difficult to
resist, and that's one of the thingsthat patients with itchy skin, like
atopic eczema, feel most keenly.
(15:40):
They feel the out of controlness.
For example, I'd go to bed atnight, when I was a young person
with eczema, and think, I hope Idon't scratch tonight, I've put the
ointments on, I've done all I can.
I hope I don't scratch tonight.
The following day I'd wakeup with scratched skin and
blood on the sheets and so on.
And that out of control, and that um,shame and disappointment that, despite all
(16:03):
my best efforts and doing all that I cando, I still managed to scratch my skin,
which of course led to more inflammation,which led to more itching and so on.
So physical treatment's really important.
And then there are treatments forthe, for the itch itself, which can
be antihistamines, though they may notwork particularly well in the long-term.
(16:25):
But there are growing, there is agrowing interest in other treatments,
other tablets or injection typetreatments, that can work for itch.
And then, as I say, there isthe habit component of itch.
Now, what do I mean by thehabit component of itch?
What I mean by that is that thereare certain times of the day when
it becomes much more likely thatyou will scratch at your skin.
(16:47):
And that's usually first thingin the morning or last thing at
night before you go to bed orat various times during the day.
So for example, when I had eczemaas a child, I would quite like to
come home from school and have alittle scratch or have a little pick
because it works as a stress buster.
So, if you scratched at your skin, weknow that releases kind of stress busting
(17:08):
chemicals in the brain, which can give youa temporary kind of stress relief process.
You can identify those times during theday when you're more likely to adopt
the habit of scratching at your skin.
, and you can replace the habitof scratching or rubbing at your
skin with a different habit.
That can be grasping alapel or pinching the skin.
(17:32):
There are various other habits thatyou can do, that we know that that
leads, in the long term, to betteritch control and actually reduction
in the inflammatory skin disease.
And that technique iscalled, habit reversal.
. You can look at a module on habitreversal on www.atopicskindisease.com.
(17:54):
Or some units have trained habitreversal programmes, which are four
appointments, usually run by a nurse.
And over those four appointments,you will recognise how often that you
habitually scratch at your skin, clickon a clicker counter every time that
you habitually scratch at your skin.
(18:16):
And then over the four weeks, by replacingthe habit of scratching at your skin
with a different habit of, as I say, likegrasping your lapel or pinching the skin,
then you'll watch the clicker counter comedown and you will also watch as your skin
improves, the inflammatory skin improves.
(18:36):
However, we also know that othertechniques really help with itch,
and that can be really quitestraightforward techniques like
mindfulness or relaxation techniques.
Any of these techniques can reallyhelp suppress the whole itch.
What I find is that patients say tome, "I'm okay during the day because
I'm at work or at school", or whateverit is, "I come home and I sit down
(18:58):
and watch...", whatever it is on thetelevision, "and that's when I think,
oh, my God, I'm so [itchy]...", andthey, you know, they can sit watching
the television, scratching at their skin.
And what we know about that is thatwhilst we're busy, active during the day,
the brain is active in other processesso that the focus of the brain during
the day is simply not on the itch, andthen in the evening, when we're sat in
(19:21):
front of the television or just relaxing,and the brain doesn't have so many
competing stimuli, so many competingthings to do, that the brain expands
the whole thing of, okay, actually now'san opportunity to really feel itchy.
So it's really common forpatients to say it's in the
evening when I feel most itchy.
So again, relaxation techniques,mindfulness, meditation, really
(19:47):
can make a big difference, togetherwith habit reversal, together
with the appropriate use of, ofphysical treatment for the skin.
Dr George Moncrieff (19:55):
Yes, brilliant, thank you so much.
What I'm taking from that, is thatit isn't that easy to help, but,
really important to manage theinflammatory element of the disease
and control the skin disease asbest you can, because it is very
definitely a vicious cycle, isn't it?
You scratch the skin, scratched skinis damaged, damaged skin is itchy, and
(20:15):
therefore you have to scratch it again.
So if you can somehow break that cycle,whether it's with relaxation techniques,
mindfulness or these click counters andthings, supported by a specialist nurse,
once you break the cycle, you can getout of that vicious cycle, hopefully,
but it also does demand good controlof the disease, whatever that takes.
Professor Anthony Bewley (20:37):
And I think you alluded to a good point there,
if I can just say, George, whichis that it's not just the patient
that suffers with all of this...,
Dr George Moncrieff (20:44):
It is indeed the family.
Professor Anthony Bewley (20:45):
...it is actually the family as well.
I think you alluded to that, thefrustration, because it's such an
easy trap to fall into, you know, "Forgoodness sake, will you stop scratching?"
And, you know, "What am I doingwrong as a parent, that I can't
get my child to stop scratching?"
So it can carry quite a burden for thefamily and for the loved ones as
well, and they can get frustrated andagain, first thing is, you know, try
(21:10):
not to beat yourself up about this.
Try and be understanding that actually,it is a really recalcitrant itch.
It is an inflammatory skin disease. Itis, it is something that we can, we
can control and improve and get better.
And for the parents and for the carersand for the loved ones, again, trying
to take a deep breath in and relax.
(21:33):
And, again, think about mindfulness, thinkabout relaxation techniques, think about
trying to support whoever has the eczema,and saying, okay, well, you know, "How
can I help you put the ointments on?"
People talk these days, don't they,about motivational interviewing.
With motivational interviewing, you set,you get the patient to set the goal.
Okay.
"What is it that is stopping youfrom applying your ointments?
(21:58):
What is it that is stopping you fromdoing the stuff that you want to do,
to be able to get control of your skin?
Is it time or is it that you're abit bored of using the ointments or
is it that you're a bit fed up andhow can you deconstruct the hurdles?
How can you stop yourself fromfalling into a trap where you're
(22:22):
stopping yourself from progressing?"
Dr George Moncrieff (22:23):
Yeah.
Professor Anthony Bewley (22:24):
And then "How can you achieve the sort of
aims that you want to achieve, interms of getting good skin control?"
Dr George Moncrieff (22:30):
Tony, that was absolute gold dust, fantastic advice and so helpful.
It's interesting, isn't it,that itch is such an unpleasant
sensation that sometimes patientswould prefer to be in pain.
They will tear their skin till it'sactually painful because, severe pain
in the skin from a severe scratch andpicking it, is preferable to the itch.
(22:51):
But wow!
I think you are really bringing toour attention how important this is to
manage, and thank you very much indeedfor that wonderful summary of advice.
We could be talking here all morning,I know, but thank you very much indeed.
Dr Roger Henderson (23:06):
Well, I think that's a good point to end this
particular podcast, and George andI do hope you found this chat about
skin and mental health interesting.
And our thanks do go to ourwonderful guest, Professor Anthony
Bewley, for all his help with it.
I do hope you have found him asinteresting as George and I did.
Now, in addition, in the upcoming podcast,we'll be looking at the scale of the
(23:29):
problem, looking at some conditionswhere the skin can be the presentation
of a mental health condition, and we'llalso look at how your doctors should
be responding to some of the shockingfacts and figures linked to mental health
issues in people with skin disease.
Dr George Moncrieff (23:47):
We have been honoured to be joined by
Professor Bewley for this episode.
Thank you so much for your expertise,wisdom and your contribution.
Tony will be joining us for ournext podcast and look forward
to that very much indeed.
Roger and I do hope you'll join us then.
We'd also like to thank our sponsor,AproDerm®, for all their help in putting
(24:10):
these Skin Deep podcasts together.
We couldn't have done it without them.
Dr Roger Henderson (24:16):
If you do like our podcast, and George and I really hope you
do, then leave us a review, or rate us, orsend us some feedback, so do get in touch.
We really do love to hear from you.
But until the next time,it's goodbye from George.
Dr George Moncrieff (24:31):
Goodbye.
Dr Roger Henderson (24:32):
And as always, it's goodbye from me.
Goodbye.
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