ROME – A pediatric atopic dermatitis treatment plan is not complete without a psychological element, Dr. Caroline Koblenzer said at the 10th World Congress of Pediatric Dermatology.
“Without adding a psychological component to treatment, patients with atopic dermatitis can stay in a chronic course of remission and exacerbation,” said Dr. Koblenzer of the University of Pennsylvania, Philadelphia.
“Most patients do respond well to treatment, but in recalcitrant patients, you need to explore the experience of early infancy.”
Studies have shown that up to 60% of dermatology patients have at least one coexisting psychiatric condition, she said.
Atopic children tend to be more emotionally and behaviorally immature than do controls.
Often, these children use their scratching behavior as a tool to manipulate their parents, define weak boundaries, or express anger and aggression.
The foundation for these behaviors is laid in infancy, when the atopic infant, itchy and restless, fails to perceive empathic touch while absorbing negative psychic energy from an anxious, guilt-ridden mother.
This initiates a self-renewing cycle of emotionally and physically related events that trigger more atopic flares for the infant.
In infancy, Dr. Koblenzer said, empathic touch, usually from the mother, helps develop the infant's capacity to release and regulate tension.
This release is modulated by nonverbal two-way communication with the mother: The infant uses the mother as a mirror of his/her feelings until he/she develops emotional self-regulation.
“The relaxed mother will have a soothing effect, while the anxious, unhappy mother will increase the infant's distress,” Dr. Koblenzer said.
“Failure to internalize this emotional control can lead to continued tension discharge through physical pathways.
“This stress may cause physical symptoms.”
In addition to promoting the atopic cycle, this dance between the mother and infant has the ability to blunt the child's behavioral and emotional growth. “The itchy, restless infant whose anxiety continues to rise and who is difficult to soothe results in a mother who feels anxious and frustrated,” Dr. Koblenzer said.
These feelings of anxiety and frustration can raise the mother's anxiety even more, leading to a corresponding increase in the infant's anxiety, she said.
The mother may feel inadequate and then guilty about her perceived inadequacy. As a result, the mother may fail to set boundaries, thereby retarding the child's emotional development and perpetuating the negative emotional cycle.
Other family members also feel the impact of this problematic relationship, she said.
“The emotional and financial costs of atopic dermatitis are actually greater for the family than if the child has insulin-dependent diabetes,” Dr. Koblenzer said. “And because the mother's time is monopolized, siblings may act out with attention-seeking behavior.”
Additionally, she said, atopic children, whose sense of body integrity is poorly developed, may interpret treatments as assaults. That is particularly the case when treatments, involve the face, neck, and genital areas.
It is crucial that physicians recognize and bring to the surface the emotional aspects that influence atopic dermatitis, particularly with patients who don't readily respond to conventional therapy, Dr. Koblenzer said.
The value of the doctor-patient relationship with these families can't be understated, she stressed.
“It's really important for us to empathize and understand the burdens on the parents, the patient, and the family.”