8 Review Article DOI: 10.1111/j.1610-0387.2007.06406.x

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Keywords• Psychosomatics• Stress• Skin• Psyche• Psychodermatosis

IntroductionWhat do the skin and the psyche have incommon? The skin appears to be only asuperficial covering, a mere sheath sepa-rating the Self from the environmentwhile the psyche, the seat of the person-ality, encompasses far more. We are whatwe think (and, unfortunately, increasing-ly what we own). Yet, the skin and thepsyche do indeed share a few things incommon: the skin and the brain bothdevelop from the embryonic ectoderm;both are organs of communication,manifesting our emotions, and both aresensory organs. The skin and the psycheeach contribute to making humanbeings individuals - the skin by virtue ofits unique appearance, e.g., fingerprints,and the soul by virtue of individualthoughts, perceptions, memories, andcharacter. The skin is a mirror for thesoul and the soul a mirror for the skin.Healthy skin, like a healthy soul, isessential for individual physical and psy-

chological well-being and self-confi-dence. Anzieu takes this idea even further in hisconcept of the “skin ego” [1] whichdescribes, on the one hand, the skin as aboundary between the Self and the envi-ronment, and on other, the barely tangi-ble boundary (a fictitious skin) in thepsyche that separates an individual’sinner life from the outside world. Most physicians are aware of just howquickly one can enter the deepest, dark-est reaches of the psyche - the patient’sunconscious mind – during any (morethan merely superficial) examination ofthe skin. As numerous studies haveshown, about 30 % of dermatologypatients have symptoms of at least onepsychological comorbidity [2].The treatment of psychosomatic disor-ders is often a challenging and complexprocess. Yet, it can also be a rewardingexperience insofar as patients with psy-chosomatic disorders can enable the der-

matologist a closer look at the mystery oflife, providing a valuable experience iffor this reason alone.

Age, society, and languageWhen one thinks of the role of the skinas an organ of communication, one ofthe first things that comes to mind aretattoos. Tattooing has been practiced invarious cultures throughout history,often as a means of showing that an indi-vidual belongs to a certain group (partic-ularly as a form of stigmatization).Tattooing is currently “in”, especiallyamong younger people; ten percent ofGermans have at least one tattoo and thetrend is growing in terms of numbersand variety [3].Various other techniques also exist bywhich the skin is used to communicateindividual characteristics such sex, age,success, religion, social status, health and(often unintentionally) disease. Cosmetics,jewelry, and piercings are a means of

SummaryAbout 30 % of dermatology patients have signs or symptoms of psychologicalproblems. Dermatologists should be familiar with the basics needed to identi-fy, advise and treat these patients. Because of the complex interaction betweenskin and psyche, it is difficult to distinguish whether the primary problem is theskin or the psyche. Sometimes the clinical picture is a consequence of interac-tions between them and other factors. The interactions between skin and psy-che are well known in history, art and literature – perhaps better known todaybecause the marked emphasis on such images in our modern multimedia soci-ety. Aging is increasingly perceived as an illness and not as a physiologicalprocess. Through globalization, many different cultural approaches to the skinhave entered in our daily life and influence our communication. This articleconsiders the most important dermatoses which often show primary or sec-ondary interaction with the psyche.

Skin and psyche – From the surface to the depth of

the inner world

Helmut Beltraminelli, Peter ItinDepartment of Dermatology, University Hospital, of Basel Switzerland

JDDG; 2008 • 6:8–14 Submitted: 11. 2. 2007 | Accepted: 27. 3. 2007

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continual nonverbal communication,capable of even transforming the wearerinto a living sculpture, artwork, or can-vas. (In Berlin a girl recently offered herbreasts on the Internet as advertisingspace [Berlin, 19 January, 2007].)The word “skin” also appears in differentlanguages in various figures of speech,often metaphors describing emotions.(The reader is directed to a book by C.Benthien [4] for more detail on inter-pretation and etymology). Examples ofsuch expressions include : “show meyour skin, show me your face, and I’lltell you who you are”, “save your skin”,“red with anger”, “green with envy”,“save one’s hide”, “have a thick/thinskin”, “feel comfortable/uncomfortablein your own skin”. First impressions are primarily based onsubjective assessment of external fea-tures. In addition to clothing, the condi-tion of a person’s skin, hair and nailscommunicate essential aspects of his orher personality (along with physique,figure, facial expression, voice, speech,odor, jewelry). A maximum of (tempo-rary) conclusions are derived from aminimum of actual information, withnoticeable, distinctive features dominat-ing over all other “sources of informa-tion.” These features (excluding speechand voice) are key stimuli in nonverbalcommunication.Appearance has always been extremelyimportant to human beings and “cosme-tologists” have been around for as long ashumanity itself. The art of decoratingthe body or hiding defects, for instanceas a means of enhancing one’s sexualattractiveness, has been practiced inevery culture throughout the ages.Not only the skin, but also the hair func-tions as a cultural symbol, serving as asign of social status and conveying animage of masculinity or femininity;changes in hairstyle are subject to pre-vailing fashion. The appearance of theskin and hair are related to the perceivedhealth or illness of an individual. Skinchanges are frequently viewed by othersas contagious and also may be associatedwith sexually transmitted disease, inade-quate hygiene, or uncleanliness. Peoplewith skin disease are often consideredsexually unattractive [5].A healthy sex life is important for emo-tional health. Lewis-Jones has shownthat normal-appearing skin is a prerequi-site for physical and psychological well-

being and is an important factor in sex-ual attractiveness [6]. Pasini has similar-ly shown evidence of the occurrence ofmodifications in emotional and affectivedistance in intimate relationships due tolonger use of topical dermatologicalagents (some with an unpleasant odor)in various inflammatory skin diseases[7].Given that the skin is an organ of com-munication, as well as the heightenedimportance in the modern era of “seem-ing and appearing”, many patients alsoview age-related skin changes as restrict-ing (nonverbal) communication. Thenormal process of aging is often treatedas a disease and a social problem result-ing in a global run on products thatpromise rejuvenation. People increasing-ly believe that the skin should appearyoung and firm, and that outwardappearance is very important. Accordingto the American Society of PlasticSurgeons (www.plasticsurgery.org), inthe last 15 years there has been a markedincrease in plastic surgery (+775 % in2005, compared to 1992), the mostcommon interventions being breastenhancement, liposuction, rhinoplasty,eyelid procedures, and abdominoplasty.Modern media and advertising, whichpropagate an unrealistic ideal bodyimage, along with various healthcareprofessionals, bear a certain responsibili-ty. The faces of the elderly, lined withwrinkles, were previously viewed withrespect, having borne witness to a life-time of experience and evidencing thewisdom that comes with it, presentingopen book on an individual’s life history.In an era in which people have noqualms about publicly revealing themost intimate aspects of their lives, thereis an attempt at masking certain othersigns of the life a person has lived, basedon the underlying assumption that look-ing younger boosts self-confidence andimproves social connections. It is as ifthe desire to be healthy has been con-fused with the illusion of looking per-fect. The psychological effects of age-related skin changes clearly outweighany physical effects since from a biologi-cal standpoint aging is not a disease.

Psychosomatic dermatology – generalinformationPsychoneuroimmunology is concernedwith investigating the connectionsbetween the mind, body, and immune

system. During the past 30 years, a num-ber of studies have shown how moodand stress can alter the immune system[8–10]. The term “stress” (derived fromthe Latin “stringere”, meaning to drawtight) can be used to refer to externalstimuli (stressors) which elicit psycho-logical or physiological reactions inhumans or animals which enhance func-tion, or it can refer to the resulting phys-ical and mental stress. Epidermal perme-ability [11] and wound healing alsoappear to be influenced by stress. Thehuman body contains a multidirectionalpsychoneuroimmunologic network con-sisting of various polypeptides and theirreceptors which are found in the nervousand immune systems [12]. (Langerhanscells, for example, contain neuropeptidesas well as neuropeptide-receptors thatallow bi-directional communicationbetween the immune and nervous sys-tems [13].)Individual health depends on a widearray of variables. Lutgendorf andCostanzo [14] have proposed a biopsy-chosocial model for interpreting theirinteractions that contains several levels:psychosocial processes (individual differ-ences, mood, resources), biological fac-tors (genetics, exposures), healthy behav-ior (lifestyle), stress factors (illness, acci-dents, socio-economic status), psycho-logical interventions, and neuroen-docrine processes of adaptation which,depending on emphasis, lead to a certainvulnerability or resistance. Symptomsappear later, eventually leading to clini-cal exacerbation of the disorder and ulti-mately playing a critical role in the sur-vival and quality of life of the patient.In psychosomatic disorders, stress, aswell as inner psychological conflicts andearly-childhood trauma play an impor-tant role in the development of disease;psychosomatic disorders are reactive skindiseases.Various classifications exist for differentforms of psychodermatosis [15, 16].Their main value is didactic. In terms ofpathophysiology and biopsychosocialfactors, they are not always useful giventhat in many instances multiple factorscontribute to “psychodermatosis” andalso interact with each other. Table 1provides a classification system based oncurrent knowledge which divides skindiseases of primary psychological originfrom secondary psychological disordersand multifactorial etiologies. Dermatology

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occupies a special position within psy-chosomatic medicine in that it dealswith an organ that is readily accessible tosight and touch. Such a level of exposurehas clear psychological implications.

Examples of comorbiditiesDepressionDepression is a psychiatric disorder com-monly encountered in dermatologicpractice. Gupta et al. have observed adirect and statistically significant correla-tion between the severity of pruritus andthe severity of symptoms of depressionin patients with psoriasis, atopic der-matitis, and chronic urticaria [18].Chronic dermatoses alter the appearanceof the patient, potentially contributingto significant psychological distress.Severe pruritus and skin diseases causingsevere cosmetic problems have beenassociated with an increased frequency ofsuicidal thoughts [19]. Dehen and col-leagues reported that 23.6 % of derma-

tology outpatients had symptoms ofdepression [20]. There was a statisticallysignificant difference between patientswith and without appointments, where-by symptoms were more marked in thelatter group (especially in men). Thosereceiving inpatient care for psoriasis andthose being treated on an outpatientbasis for acne were most frequentlydepressed; in another study, patientswith atopic dermatitis were also among those with depression [21].Dermatologists should not hesitate toaddress such issues, including suicide, inpatient consultations. If, as a practicingdermatologist, one feels uncertain orunqualified to accurately assess such asituation, psychiatric evaluation shouldbe obtained.

Anxiety disordersAnxiety is the fear of potential suffering.It describes a situation of perception andbehavior consisting of uncertainty and

tension triggered by an actual or antici-pated event (e.g., pain). It is importantto distinguish between acute panic disor-der, chronic anxiety, and specific phobia.In dermatology, cortisone phobia hasbeen repeatedly reported [22]; patientswith social phobia, which may manifestas flushing or palmar hyperhidrosis, areless often encountered.

Obsessive-compulsive disordersObsessive-compulsive disorders encom-pass obsessive thoughts and compulsiveactions (e.g., hand-washing or disinfect-ing, and rubbing the skin or hair).Dermatologic sequelae include eczemaand lichenifictaion, as well as infections.

Dissociative disordersSomatoform dissociation, formerlyknown as conversion, is another comor-bid condition. In somatoform dissocia-tion, psychological conflicts manifest assomatic symptoms. Classic examples

Table 1: Classification of psychodermatoses after Harth and Gieler, 2006 [17].

Skin disorders of primary psychological origin

Artefacts

True artefacts, para-artefacts (neurotic excoriation, acne excoriée, morsicatiobuccarum, cheilitis factitia, pseudo-knuckle-pads,onychophagia, trichotillomania), simulations

Skin diseases resulting from delusion orhallucination

Parasitosis, obsession with own body odor,hypochondria, body dysmorphic disorder, folie à deux

Somatoform disordersSomatization disorder, hypochondria, somatoform autonomic function disorder,dysesthesias

Skin disorders resulting from obsessive-compulsive behavior

Compulsive washing, lichen vidal

Multifactorial skindisorders

Atopic dermatitis, acne vulgaris, psoriasis vulgaris, alopecia areata, anal eczema,dyshidrosiform hand eczema, herpes labialis,hyperhidrosis, hypertrichosis, lichen ruber, lupus erythematosus, perioral dermatitis, sclero-dermia, prurigo, rosacea, seborrheic eczema, legulcers, urticaria, verrucae vulgaris, vitiligo

Secondary psychological disorders and comorbidities

Congenital disfiguring skin disorders and sequelae (genodermatoses)

Ichthyoses, epidermolyses, lipomatoses, phakomatoses

Congenital disfiguring skin diseases and sequelae

Infections, autoimmune skin diseases, trauma,keloid, neoplasias

Comorbidities

Depressive disorders, anxiety disorders, obsessive-compulsive disorders, adaptive disorders, dissociative disorders, personality disorders

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include pseudoneurologic symptoms inhysterical paralysis or – in the realm ofdermatology – vague skin sensations suchas a feeling of “something crawling orrunning on my skin.” Patients frequentlyexhibit artefacts, pruritus, numbness, andpseudoallergic reactions. As Saxe and col-leagues have shown, skin disease is foundmore often in patients with dissociationcompared with a control group [23]. Themain characteristic of a dissociative disor-der is partial or complete loss of normalintegrative functions such as memory,consciousness, perception, and controlover bodily functions. Dissociative disor-ders involve repression (as a defensemechanism) of stressful emotions andexperiences such as trauma.

Personality disorders The skin plays a symbolic role in border-line syndrome, a previously unsatisfacto-rily defined disorder that involves psy-chosis, neurosis, and personality disor-der; today, standardized diagnostic crite-ria by Kernberg are used [24]. Patientsmay exhibit signs of autoaggression and4-9 % of patients with borderline syn-drome commit suicide [25]. Patientswith borderline syndrome who consult adermatologist usually have artefacts andpara-artefacts (worsening of pre-existingskin disorders). Autoaggression takesvarious forms: patients may cut, scratch,stab, pinch, burn, cauterize, slash, carve,inject, bite, or hit themselves; woundhealing is also often prevented. Variouslevels of autoaggression are defined inthe literature. These generally rangefrom mild (superficial) to moderate(resulting in scarring) or severe (resultingin mutilation) bodily injury.

Examples of skin diseases of primarypsychological originSomatizationSomatization is the process of bodilysymptoms (somatoform symptoms) aris-ing as a sign of underlying psychologicaldistress, for example, anxiety disorder orpsychosis. Table 1 lists several somato-form disorders. Dermatologic disorders such as dyses-thesias, pruritus sine materia, belief thatone’s body odor is offensive, facial orbodily ticks, localized cutaneous pain,artefacts, vulvodynia, glossodynia, andhypochondria are examples of a certaintype of “body language” and may maskpsychiatric disease.

Body dysmorphic disorder is anotherexample of somatic disease (somatoformdisorder, classified under hypochondria).Affected patients are excessively preoccu-pied with their (basically normal)appearance and view even the mostminor skin irregularity as disfigurement.That the incidence of disease is on therise reflects the age in which we are liv-ing. Patients also have a high comorbid-ity for depression and social phobia. The consequences of body dysmorphicdisorder include social isolation, job-related problems, psychiatric hospitaliza-tion, suicidal thoughts, and suicide.Patients frequently attempt to hide per-ceived deficits with their hair, make-up,or clothing. Unfortunately, correct andearly diagnosis is rare [26]. Why does somatization occur? It is diffi-cult to provide a scientifically soundanswer. The skin is so accessible, it oftenbecomes the target of various tension-reducing bodily ticks. Also, from thetime of childhood, the skin serves as theprimary organ of communication andprobably stores “body memories” [27].Patients who are not sufficiently able toverbalize personal problems in particularcome to rely on the skin as the most vis-ible organ of communication. Castillo and colleagues have publishedan analysis based on a review of the liter-ature on somatization among immi-grants and refugees (asylum-seekers)[28]. Immigrants, especially refugees,have often had traumatic experiences(war, fleeing their home country, fear ofdeath); they are living far from homeand often feel lonely and “isolated” intheir new country. All of these factorscan lead to psychosocial stress, and it istherefore not entirely surprising whensymptoms of somatization develop.Clearly, immigrants and refugees are notalone in developing somatization; identi-cal symptoms are observed in non-immi-grant patients.

Dermatitis artefacta (factitial dermatitis)The skin changes that occur in dermati-tis artefacta have a characteristic mor-phology with typical locations, sharply-defined geometric shapes, and often alinear pattern; women are affected moreoften than men. Various lesions havebeen reported, including vesicles, blis-ters, erosions, ulcerations, purpura, ery-thema, edema, granulomas, and scar-ring. The disease involves abnormal per-

ception of the self, in particular withregard to body image [29]. Dermatitisartefacta may be associated with variouspsychiatric disorders (comorbidities),among these are often borderline syn-drome or depression. In some patients,the disorder may be considered a “cry forhelp.” Around 20 % of patients withdermatitis artefacta have lost either aparent or sibling during the first decadeof life as a result of death or divorce [30].Other social problems and conflicts suchas unemployment are also frequentlyreported [31], and there is an increasedincidence of reported sexual abuse, gen-erally occurring during childhood oradolescence [32]. One example of der-matitis artefacta is acne excoriée inyoung women. Some authors (Harthand Gieler, 2006) consider acne excoriéeto be a para-artefact, an impulse controldisorder that leads to manipulation.Early stages are characterized by exces-sive manipulation of a minimal primarylesion.Most patients with artefacts reject thediagnosis. It is thus preferable not toconfront the patient during an initialconsultation, but rather to provideempathy and support. The decision todiscuss with the patient the diagnosismay be weighed at a later stage after thepatient’s trust has been gained. Referralfor psychological or psychiatric supportis usually resisted initially. Therapeuticmeasures that involve a high level of“nursing” are strongly recommended,e.g., applying occlusive bandages to the“ulcerations” to protect against furthermanipulation.

Neurotic excoriations (skin-picking syndrome)Dermatitis artefacta should be distin-guished from neurotic excoriations. Thelatter are also a sign of dissociation andare occasionally seen in obsessive-com-pulsive disease (belonging to anxiety dis-orders) or depressive syndromes; addi-tional social problems are often discov-ered. Clinically, the disease presents asrather small, clustered erosions in a lin-ear arrangement as well as scarring andpigmentary changes on easily-accessibleareas of the skin (e.g., hands, shoulders,or neck), often in combination with pru-ritus. Patients tend to acknowledge theself-inflicted nature of the skin lesionsand psychiatric or psychological treat-ment is generally more successful than inpatients with dermatitis artefacta.

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TrichotillomaniaTrichotillomania is the compulsivepulling out of hair. Patients usually pullout the hair on their heads, but may alsopull out eyebrow hair, eyelashes, or otherbody hair; less often, they pull out thehair of a partner or pet. The hair is thenoften ingested (trichophagia), with theassociated risk of formation of a hair ball(trichobezoar) in the gastrointestinaltract, potentially interfering with peri-stalsis and causing related complications.A special variant is trichokryptomania, asimilar disorder in which the hair is notpulled out, but instead the scalp is rubbedso vigorously that alopecia develops.Patients initially exhibit single or multi-ple areas of alopecia, initially withoutscarring (though scarring can develop inchronic disease) and usually on the head,less often involving the eyebrows or eye-lids. The disorder mainly affects women.Trichotillomania is interpreted as a signof psychological distress, usually associ-ated with depression, frustration, or anx-iety disorder. In terms of pathophysiolo-gy, obsessive-compulsive behavior withpartial loss of impulse control and/ordissociative symptoms has been suggested.A similar pathophysiological basis is pre-sumed in habitual nail-biting (and inges-tion). Both disorders share increased ten-sion immediately before the pathologicbehavior followed by relief [33]. Thebehavior tends to occur in calm situa-tions in which the patient is alone or“lost in thought.” As elsewhere in medi-cine, the boundary between a “badhabit” and a true pathology is blurredand the determination of whether abehavior is one or the other depends onseverity, frequency, and site of injury.Patients typically reject the diagnosis;they are often ashamed of their behaviorand hide its visible results from others,including their doctors.

Multifactorial skin diseasesThe major multifactorial skin diseasesare atopic dermatitis, psoriasis, chronicurticaria, alopecia areata, lichen planus,warts, vitiligo, and acne. This group alsoincludes less commonly occurring diag-noses such as severe burn injuries, neu-rofibromatosis, extensive angiomas andnevi, ichthyoses, as well as other congen-ital disorders. In the first group of dis-eases, the cause is presumed to be animmunological disorder, which, depend-ing on up-regulation or down-regulation

of cytokines, exacerbates the skin disor-der. In the second group, the psycholog-ical stress of living with a long-standingskin disorder plays a key role. It is worth noting that patients withepithelial skin tumors, i.e., with diseasethat from a medical and biologicalstandpoint is considered more “severe”,report a much lower [34] decrease inquality of life compared to patients withchronic inflammatory skin disorders.Wessely and Lewis found that there wasno correlation between psychiatric mor-bidity and the site or severity of skin dis-ease [35] although their findings haveyet to be corroborated by other studies. Hospitalization can improve the statusof even chronic and recalcitrant skin dis-orders and in certain situations may evenbring about healing, although precise,systematic analyses are needed. Thus it isnot certain which of the following fac-tors plays the most important role:intensive treatment carried out byhealthcare professionals, eliminatingeveryday stress, or daily touch (possiblyreminiscent of a mother’s care and atten-tiveness [36]).

PruritusSchneider and colleagues have examinedpsychiatric comorbidity in patients withpruritus who were hospitalized for skindisease, finding 1–6 psychiatric diag-noses in more than 70 % [37].Psychosomatic factors and psychiatriccomorbidity can influence pruritus onseveral levels, e.g., perception, handling,and coping. Pruritus has many causesincluding internal disease (lymphoma,neoplasias, metabolic disorders), neuro-logic (neuropathies), infectious (para-sitosis) and allergies involving the skin.Several triggers are known to be involvedin the pathophysiology of pruritus: pHchanges, opiates, proteases, cytokines,acetylcholine, neurotropins, and hista-mine. Given that histamine alone is notresponsible for pruritus, H1-antihista-mines have a limited antipruritic effect.Pruritus is also seen in various psychi-atric disorders. The hypothesis that pru-ritus is all “in the head” and that“scratching the brain” is the actualresponse, has been described by Paus andcolleagues [38] who attribute it to neu-ronal projections, from centrallyprocessed stimuli, that are felt on theskin. Pruritus is presented as an illusionproduced by the brain that something is

happening on or within the skin. Thishypothesis of psychoneuroimmunologicnetworks could prove useful for treat-ment, for example in the use of sugges-tion, hypnosis, and conditioning.

Other disordersCertain psychiatric disorders, such asanorexia nervosa, are associated withnon-psychogenic skin changes [39].Some patients with bulimia also havexerodermia (71 %), cheilitis (76 %), nail dystrophy (29 %), dry or damaged hair (48 %), alopecia (24 %), lanugohairs (62 %), cold acral skin (38 %),acrocyanosis (33 %), livedo reticularis(48 %), periungual erythema (48 %),gingival changes (37 %), pruritus, orcarotenodermia. Anorexia nervosa is atypical disease of the times, and is in partencouraged by a society obsessed withunrealistic fashion ideals. (Many modelsand beauty pageant contestants have abody mass index [BMI] between 16 and20 [normal: 20–25 kg/m2].) Fortunately,the tide appears to be turning (at leastpartly) and in several European coun-tries, minimum weight standards havebeen introduced for models.

Practical tipsIn dermatologic practice, it is difficultduring a brief patient consultation toevaluate the entire skin as well as variouspsychological factors, and have a discus-sion about these with the patient. Guptaand colleagues [40] wrote a didacticpaper on psychological evaluation of thedermatologic patient, using examples toillustrate the questions and statementsthat are best used during such a discus-sion. Important questions include howthe skin disorder and/or psychologicalstress influences the patient’s quality oflife as well as questions that help assessthe patient’s own view of disease (how heor she interprets and experiences havingthe disease). Patients with significant psychologicaldistress tend to be less compliant andhave difficulty coping, which adds to thechallenge of treatment. Poor complianceand skepticism are often the result oflacking or “inaccurate” communicationduring consultation. With sound knowledge of psychologicalprofiles of diseases, a motivated derma-tologist can turn the treatment of eventhe most difficult patient into an inter-esting and stimulating challenge. One

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should keep in mind, however, that forsome patients being ill is a way of life;not every patient wishes to be cured [41].A number of possibilities exist for treat-ing patients with dermatologic and psy-chological problems [42] (e.g., psycho-analysis, biofeedback, behavioral thera-py, relaxation therapy, and counselling).The appropriate approach should bedetermined individually. Dermatologists should also have basicknowledge of psychotherapeutics sincemany patients refuse referral to a psychi-atrist. Important precautions concerningthe use of psychotherapeutics are outlinedin a recent review by Navi and Koo [43].Patients with “psychodermatosis” needour help and it is important that we arein a position to offer it as often as possible.

ConclusionThe abundance of information pub-lished on this topic evidenced itself onmy desk, which came to be coveredwith a hundred articles and numerousbooks. At times I was so absorbed inwhat I was reading that I lost control ofmy hand and it wandered to easilyreachable parts of my shoulder or to myhead, searching for places to scratch.Fortunately for me, I was reading abouttension and unconscious touching ofthe skin and was thus aware of my ownpsychosomatic reactions. Without adoubt, not everyone shares the goodfortune of finding the solution to his“problems” right in front of him, e.g.,in his work.It would be a welcome development tosee an increased awareness among physi-cians that the way in which a person livesand experiences life is a crucial factor inhealing. As doctors, we should continu-ally strive to inform patients of the rela-tionship between such factors. <<<

Conflict of interestNone.

Correspondence toDr. H. BeltraminelliDermatologie, Universitätsspital BaselPetersgraben 4 CH-4031 BaselTel.: +41-61-26 54 08 4Fax: +41-61-26 54 88 5E-mail: hbeltraminelli@uhbs.ch

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