Applying Hypnosis in Dermatology

Applying Hypnosis in Dermatology
by Philip D. Shenefelt, Dermatology Nursing (January 6, 2004)

Abstract
Introduction
Methods of Medical Hypnotherapy
Hypnotic Relaxation During Dermatologic Surgery
Hypnotherapy for Specific Dermatologic Conditions
Randomized Control Trials
Nonrandomized Control Trials
Case Series
Single or Few Case Reports
Advantages and Disadvantages of Medical Hypnotherapy
Training in Medical Hypnotherapy
Legal Requirements for Practicing Medical Hypnotherapy
Patient Selection

Abstract:
Hypnosis is a tool with many useful dermatologic applications. It involves guiding the patient into a trance state for a specific purpose such as relaxation, pain or pruritus reduction, or habit modification. Return to the top of the page.

Introduction:
Hypnosis is the intentional induction, deepening, maintenance, and termination of the natural trance state for a specific purpose. The hypnotic phenomenon has been used since antiquity to assist healing. For medical hypnotherapy, the intent is to reduce suffering, to promote healing, or to help the person alter a destructive behavior pattern. We all experience spontaneous mild trances daily while absorbed in watching television or a movie, reading a book or magazine, or other focused activity. After appropriate training, we may intensify this trance state and use this heightened focus to induce mind-body interactions that help alleviate suffering or promote healing. The trance state may be induced by using guided imagery, relaxation, deep breathing, meditation techniques, self-hypnosis, or hypnosis-induction techniques. Individuals vary in their ability to enter the trance state, but most can obtain some benefit from hypnosis. In dermatology, suggestions given during trance may help decrease skin pain and pruritus, intervene in psychosomatic aspects of skin diseases, and lead to the resolution of some skin diseases, including verruca vulgaris. Even without formal trance induction, suggestion alone may be effective in some cases. Sulzberger and Wolf (1934) reported on the use of suggestion to treat verrucae.

A precise definition of hypnosis is challenging. Marmer (1959) described hypnosis as a psychophysiologic tetrad of altered consciousness consisting of narrowed awareness, restricted and focused attentiveness, selective wakefulness, and heightened suggestibility. For a more detailed discussion of the definitions of hypnosis, see Crasilneck and Hall (1985) or Watkins (1987). Many myths exist about hypnosis that overrate, underrate, or distort the true capabilities of hypnosis.

Hypnosis can 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. An amazing report by Braun (1983) on different allergic responses, dermatologic reactions, and effects on seizure disorders, pain control, and healing in the same individual person with multiple personality disorder (now called dissociative identity disorder) depending on the personality present showed how much influence the mind can have on physiological reactions and disease processes.

Hypnosis may be used to increase healthful behaviors, decrease situational stress, reduce needle phobias, control harmful habits such as scratching, provide immediate and long-term analgesia, ameliorate symptoms related to disease such as pruritus, accelerate recovery from surgery, and enhance the mind-body connection to promote healing. Hypnosis can be especially helpful when dealing with skin diseases that have a psychosomatic aspect. Griesemer (1978), who was trained both in dermatology and psychiatry, recorded the incidence of emotional triggering of dermatoses in his patients during 1 year. He developed an index for various skin diseases, with 100 indicating an absolute psychosomatic component and zero indicating no psychosomatic component for the skin disease.

Good reference sources on the responsiveness of skin diseases to hypnosis are found in the somewhat outdated book by Scott (1960) and in the chapter on the use of hypnosis in dermatologic problems in Crasilneck and Hall (1985). Koblenzer (1987) also mentions some of the uses of hypnosis in common dermatologic problems. A review of hypnosis in skin diseases is provided by Shenefelt (2000). Grossbart and Sherman (1992) discuss mind-body interactions in skin diseases and include hypnosis as recommended therapy for a number of skin conditions in an excellent resource book for patients. Some of the common skin conditions that have responded to hypnotherapy are discussed below. Return to the top of the page.

Methods of Medical Hypnotherapy:
Hypnosis is not a therapy in and of itself. Instead it is a tool that can be used to cut through psychological/ behavioral roadblocks to healing. In adults, induction of the hypnotic state is achieved by any of a number of methods that focus attention, soothe, and/or produce monotony or confusion. In children, the hypnotic state can be induced by having the child play make-believe that he or she is watching television, a movie, a play, or by using some other distractive process that employs the imagination. Therapies that can be enhanced by hypnosis include supportive (ego-strengthening), direct suggestion, symptom substitution, and hypnoanalysis (Scott, 1960). See Table 1 for an outline of the sequence of a hypnotic trance during medical hypnotherapy. Return to the top of the page.

Hypnotic Relaxation During Dermatologic Surgery:
A variety of dermatologic procedures can produce pain or anxiety in patients. Skin procedures that are somewhat painful but usually do not require local anesthetic include moderate-depth chemical peels, cryodestruction of skin lesions, curettage of molluscum, excision of skin tags, extrusion of comedones, incision and expression of milia, laser treatment of vascular lesions, strong microdermabrasion, and sclerotherapy. Dermatologic procedures that require local anesthetic include electrodesiccation and curettage, incision and drainage of abscesses, laser ablation of skin lesions, liposuction, punch biopsy, shave biopsy, surgical excision, and surgical repair. Cutaneous procedures that may require conscious sedation include deep chemical peel, dermabrasion, laser resurfacing, and extensive liposuction. All of these procedures may be augmented by hypnotic relaxation and/or hypnotic analgesia.

For the majority of people, hypnotic suggestion relieves pain regardless of the type of pain they are experiencing. Light and medium trance is sufficient for most purposes, but deep trance is required for hypnotic anesthesia for surgery. Montgomery, Weltz, Seltz, and Bovbjerg (2002) studied 20 women randomized to standard care versus preoperative hypnosis for excisional breast biopsy. They found brief (10 minute) hypnosis to be effective in reducing postsurgery pain and distress both before and after surgery. Lang et al. (2000) conducted a prospective randomized trial of adjunctive nonpharmacologic analgesia for invasive radiologic procedures with three groups: percutaneous vascular radiologic intraoperative standard intravenous (IV) conscious sedation care, structured attention, and IV conscious sedation that included self-hypnotic relaxation. Pain increased linearly with time in the standard and the attention group, but remained flat in the hypnosis group. Anxiety decreased over time in all three groups, but more so with hypnosis. Drug use was significantly higher in the standard group, intermediate in the structured attention group, and lowest in the self-hypnosis group. Hemodynamic stability was significantly higher in the hypnosis group than in the other two groups. Procedure times were significantly shorter in the hypnosis group than in the standard group. Their conclusions were that hypnosis was better in reducing pain and anxiety, in maintaining hemodynamic stability, and in shortening procedure time than standard intraprocedural care; structured attention was in between hypnosis and standard care.

Letting the patient choose his or her own self-guided imagery seems to allow most individuals to reach a state of relaxation during procedures. Shenefelt (2003) has used this technique modified from the invasive radiologic studies for dermatology with good success in dermatologic surgery. Shenefelt (2003) developed a script for trance induction, maintenance, and termination. It consists of a rapid eyeroll induction just before the surgical procedure, deepening through floating, self-guided imagery trancework during the surgical procedure, and trance termination after the procedure. Return to the top of the page.

Hypnotherapy for Specific Dermatologic Conditions:
Many older reports of the effectiveness of hypnosis on specific dermatologic conditions are based on one or a few uncontrolled cases. They are included below, although the validity of those findings await further confirmation. The word “may” is used to note recommendations that are based on skimpy evidence. This should be kept in mind when evaluating the information and recommendations presented below. Recently, the trend toward controlled trials has produced more reliable information. Unfortunately, randomized controlled trial results are still not available for most of the disease categories (see Table 2). The list of dermatologic conditions below is not all inclusive, but it does include common dermatologic conditions for which hypnosis is reasonably helpful in reducing symptoms or improving aspects of the condition. Return to the top of the page.

Randomized Control Trials:
Verucca Vulgaris
The early report by Sulzberger and Wolf (1934) on the efficacy of suggestion in treating warts has been confirmed numerous times (Sheehan, 1978) to a greater or lesser degree. Numerous reports attest to the efficacy of hypnosis in treating warts. In a well-conducted controlled study that serves as a typical example (Surman, Gottlieb, Hackett, &  Silverberg 1973), 53% of the experimental group had improvement of their warts 3 months after the first of five hypnotherapy sessions, while none of the control group had improvement. Another randomized controlled study with similar findings was that of Spanos, Williams, and Gwynn (1990). Hypnosis can definitely be helpful as complementary or alternative therapy for warts.
Psoriasis
Stress plays an important role in the onset, exacerbation, and prolongation of psoriasis. Hypnosis and suggestion have positive effects on psoriasis. Tausk and Whitmore (1999) performed a small randomized double-blind controlled trial using hypnosis as adjunctive therapy in psoriasis with significant improvement of highly hypnotizable subjects. Hypnosis can be quite useful as a complementary therapy for resistant psoriasis, especially if there is a significant emotional factor in the triggering of the psoriasis. Return to the top of the page.

Nonrandomized Control Trials:
Atopic Dermatitis
In a nonrandomized controlled clinical trial, Stewart and Thomas (1995) 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. The results were statistically significant (p<0.01) for reduction in itch, scratching, sleep disturbance, and tension. Reported topical corticosteroid use decreased from the original amount by 40% at 4 weeks, 50% at 8 weeks, and 60% at 16 weeks. For milder cases of atopic dermatitis, hypnosis can be sufficient along with moisturization as a primary alternative treatment. For more extensive or resistant atopic dermatitis, hypnosis can be a very useful complementary therapy that reduces the amounts required of other conventional treatments. Return to the top of the page.

Case Series:
Urticaria
Inhibition of immediate-type hypersensitivity response by direct suggestion under hypnosis was reported for 8 of 12 subjects by Black (1963). In a study of hypnosis with relaxation therapy on 15 patients with chronic urticaria of 7.8 years average duration, Shertzer and Lookingbill (1987) found that within 14 months, six patients were cleared and another eight patients improved, with decreased medication requirements reported by 80% of the subjects. In selected individuals, it appears that hypnosis may be useful as complementary or even alternative therapy for chronic urticaria. Return to the top of the page.

Single or Few Case Reports:
Acne Excoriee
Hollander (1959) reported success in two cases in controlling acne excoriee 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. It was the excoriations that resolved, not the underlying acne. Shenefelt had similar success in one case. Hypnosis may be an appropriate primary alternative treatment for the excoriation aspect of acne excoriee, with standard acne treatments for the acneiform aspects.
Alopecia Areata
Gupta, Gupta, and Watteel (1997) found a very strong correlation between high-stress reactivity and depression (p<0.001) in patients with alopecia areata. Hypnosis can be used to teach patients how to control high-stress reactivity. Although there are anecdotal reports of hypnotherapy improving alopecia areata, a small clinical trial by Harrison and Stepanek (1991) of medical hypnotherapy in five patients having extensive alopecia areata showed significant increase in hair growth in only one patient. Three patients had slight increase in hair growth and one had no change. The hypnosis did improve psychological parameters in these five patients. It appears that hypnosis may be more appropriate as a complementary therapy rather than as a primary alternative treatment method for alopecia areata.
Dyshidrotic Dermatitis
Reduction in severity of dyshidrotic dermatitis has been reported with the use of hypnosis by Tobia (1982) as a complementary treatment. Greisemer’s data (1978) indicate a significant psychosomatic component for dyshidrosis, so hypnosis may be useful as a complementary therapy.
Herpes Simplex
Ameliorization of discomfort from herpes simplex eruptions is similar to that for postherpetic neuralgia (see below). Reduction in the frequency of recurrences of herpes simplex following hypnosis has also been reported by Bertolino (1983). In cases with an apparent emotional trigger factor, hypnotic suggestion may be useful as a complementary therapy for reducing the frequency of recurrence.
Hyperhidrosis
Hypnosis or autogenic training may be useful as adjunctive therapies for hyperhidrosis, as noted by Hoelzle (1994).
Lichen Planus
Both the pruritus and the lesions may be reduced in selected cases using hypnosis as a complementary therapy for lichen planus, according to Scott (1960).
Neurodermatitis
Several cases of neurodermatitis have resolved using hypnosis as an alternative therapy, for example as reported by Lehman (1978). The neurodermatitis stayed resolved with up to 4 years of followup. Hypnosis may be useful as a complementary or even alternative therapy for neurodermatitis.
Nummular Dermatitis
Reduction of pruritus and resolution of lesions has been reported by Scott (1960) with use of hypnotic suggestion as complementary therapy for nummular dermatitis.
Postherpetic Neuralgia
The pain of acute herpes zoster and of postherpetic neuralgia can be reduced by hypnosis, according to Scott (1960). Hypnosis may have a place as a complementary therapy for postherpetic neuralgia.
Pruritus
The intensity of pruritus may be modified and improved by hypnosis, according to Scott (1960). Hypnosis may be used as a complementary therapy for intractable pruritus.
Rosacea
Improvement of rosacea, especially the vascular blush component, has been reported by Scott (1960) in selected cases of resistant rosacea where hypnosis was added as a complementary therapy. Return to the top of the page.

Advantages and Disadvantages of Medical Hypnotherapy:
Hypnosis is underused as an alternative or complementary therapy in dermatology. 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 dermatology nurse 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 those for screening, preparing, and educating patients about cutaneous surgery and then actually having the dermatologist perform the surgery. Just as many dermatologists choose to refer patients with complex cutaneous surgical problems to competent specialists in dermatologic surgery, many dermatologists may choose to refer patients with complex psychosomatic dermatologic problems to competent specialists in hypnosis-assisted therapy. Those dermatology nurses who prefer to refer patients to hypnotherapists or who desire further information about training in hypnotherapy may 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 where other treatment modalities have failed, ability to reduce relapses, and ability of patients to self-treat and gain a sense of control when taught self-hypnosis reinforced by using audiotapes. Adding this treatment capability can result in very pleased and grateful patients.

Disadvantages of medical hypnotherapy in dermatology 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 when compared with procedural therapies such as cutaneous surgery. 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 (Spiegel & Spiegel, 1978; Spiegel, Greenleaf, & Spiegel, 2000). Return to the top of the page.

Training in Medical Hynotherapy:
Various organizations offer training in hypnosis. The American Society of Clinical Hypnosis offers regional weekend 20-hour courses in beginning, intermediate, and advanced hypnosis. Information may be obtained from its Web site. Mentors are available once the practitioner has obtained the necessary basic training. Most practitioners find that learning to use hypnosis is not difficult and is enjoyable. Return to the top of the page.

Legal Requirements for Practicing Medical Hypnotherapy:
In the United States, practicing nursing requires a state license. Medical assistant rules vary from state to state. The exact details in terms of legal limitations on the use of hypnotherapy also vary from state to state, so checking state statutes is recommended. In some states, for example Florida, the practice of hypnotherapy is limited to licensed practitioners (McBride, 1985). The training requirements depend upon the type of license. Again, checking state statutes is imperative. Outside of the United States, most jurisdictions have their own laws or statutes that dictate who may legally practice hypnosis. Check for details in your local area.

As is the case with all medical procedures, informed consent is crucial before proceeding with medical hypnotherapy. This need not be a written consent, but it should be well documented in the nursing notes that informed consent was obtained if no written form is signed by the patient.

In many states, prior hypnosis may be considered to taint legal testimony given by patients, so if the area to be addressed by medical hypnotherapy is something that might be open to future litigation, the credibility of the patient’s testimony may suffer. This potential legal issue should be included in the informed consent discussion.

Delving into repressed memories is a legally risky issue because of legal claims by patients that therapists have created false memories. It is recommended that only adequately trained psychiatrists and psychologists venture into this area.

The above information is not warranted to be legally correct. If indicated by your situation, it is recommended that you confer with a qualified attorney to obtain legal advice. Return to the top of the page.

Patient Selection:
Suitable patients for medical hypnotherapy are patients who are mentally intact, not psychotic nor intoxicated; motivated, not resistant, and preferably medium or high hypnotizable as rated by the Hypnotic Induction Profile (Spiegel & Spiegel, 1978) modified to a 16-point scale (Spiegel et al., 2000) or Stanford Hypnotic Susceptibility Scale and its variants. However, a moderate or high-degree of hypnotizability is not critical to the success of self-guided imagery for relaxation and discomfort reduction. Patient selection is an important aspect of successful medical hypnotherapy in dermatology. Part of the art of being a dermatology nurse is the ability to select 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 which are otherwise known to be responsive to intervention with hypnosis. As with any therapy, it is best to start with simple, easy 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 very effective and gratifying in many cases when applied appropriately. Like any other tool, it is not a panacea. It appears to work miracles for some and 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 side effects.
CE Information
The print version of this article was originally certified for CME credit. For accreditation details, contact the publisher. Jannetti Publications Inc, Dermatology Nursing, East Holly Avenue, Box 56, Pitman, NJ 08071-0056, phone (856) 256-2300. Return to the top of the page.

Table 1: Sequence of Hypnotic Trance During Hypnotherapy
Trance Introduction
Rapid (1 to 3 minutes): Eyeroll (Shenefelt, 2003, p. 232)
Slow (10 to 30 minutes): Progressive relaxation

Trance Deepening
Trancework:
– Direct Suggestion
– Indirect Suggestion
– Relaxation for Procedures

Trance Termination

Table 2: Dermatologic Conditions Reported Responsive to Hypnosis
Randomized Control Trials
Hypnotic relaxation during procedures
Verruca vulgaris
Psoriasis

Nonrandomized Control Trials
Atopic dermatitis

Case Series
Uritcaria

Single or Few Case Reports
Acne excoriee
Alopecia areata
Congenital ichthyosiform erythroderma
Dyschidrotic dermatitis
Erythromelalgia
Furuncles
Glossodynia
Herpes simplex
Hyperhidrosis
Ichthyosis vulgaris
Lichen planus
Neurodermatitis
Nummular dermatitis
Postherapic neuralgia
Pruritus
Rosacea
Trichotillomania
Vitiligo