Postdoctoral fellow Karen Mallin, PsyD, sees herself blazing a trail to a new area of psychology with great opportunities for research and practice: psychodermatology. She is the only psychologist in the country in a postdoctoral program focused on children and adults with skin diseases that cause them and their families mental distress.

Based in the pediatric dermatology clinic at the University of Miami/Jackson Memorial Hospital, Mallin's postdoc sprung from her predoctoral internship there. The postdoc, which began last October and runs for one year, is funded by pharmaceutical companies Novartis, Fujisawa Healthcare Inc., Medicis Pharmaceutical Corp. and Proctor & Gamble.

In it, Mallin provides counseling for children whose physical appearance poses challenges to their self-esteem, helps children comply with their skin treatments and supports parents dealing with the stress of caring for a child with a severe dermatological condition. She also fields referrals and treats individuals with conditions primarily psychiatric in nature, such as trichotillomania, dermatitis artefacta, psychosis of parasitosis, and those that include psychophysiologic factors such as alopecia areata, urticaria, eczema, atopic dermatitis and acne.

In the past, says Mallin's adviser, psychologist Barry Nierenberg, PhD, director of behavioral medicine in the hospital's department of family medicine and community health, physicians often weren't sure where to turn to meet patients' psychological needs. Now, he says, Mallin's work has convinced many of them that psychotherapy and cognitive-behavioral methods--including positive reinforcement, self-monitoring and behavioral homework, habit reversal training, relaxation training, and cognitive restructuring--can improve the social, emotional and health functioning of youngsters with potentially disfiguring skin conditions.

"Especially at first, I spent a lot of time educating the doctors about what kind of important services could be provided right there in the clinic," Mallin says. "Then I demonstrated that often my involvement helped to facilitate a smoother, briefer and less traumatic experience for the child and parent, especially if an invasive medical procedure was warranted."

Mallin meets with patients to determine if there are psychological factors impeding either their treatment or cognitive development. Much of her interaction with them is just checking to make sure they are comfortable with treatments and don't have any psychological barriers to complying with those treatments. But she also screens for depression and anxiety disorders and identifies patients who need additional or routine counseling. Then she either begins routine therapy sessions to work on issues of psychosocial dysfunction, depression, self-esteem and social interaction, or she refers them to a psychologist in their outlying community.

Making a difference

The children Mallin sees in the clinic face a variety of dermatological problems, from port wine stains to alopecia areata--a disease that causes hair loss--to more common complaints like acne and atopic dermatitis, an inflammatory disease that causes intense itching and redness. Patients with atopic dermatitis often have trouble controlling the urge to itch and will wake in the night bloody from scratching in their sleep.

There are many psychosocial repercussions from a disease like atopic dermatitis, Mallin says: Patients' sleep can be affected, and they can be more prone to allergies and attention problems. They can also experience anxiety about their appearance, ridicule from peers and social limitations that often exclude them from normal school activities like physical education and group projects. The stress often spreads to the rest of the family. Parents lose sleep, siblings face embarrassment and family tensions result from trying to stop a child from scratching.

"There's an itch/scratch cycle with these kids that's just vicious," Mallin says. "Parents will say 'don't scratch' and it just makes the child more itchy--it's a true physiological reaction."

Parents can end up feeling helpless about their child's condition, but there are ways to help, Mallin says. "I try to help parents know that they'll never get a 100 percent reduction in scratching behavior, but if they give positive reinforcement for appropriate behavior--like a child asking for skin treatments when they are itchy--you will often see a reduction in itching," she says.

Improving compliance rates in patients with complicated or unpleasant treatment regimens is another primary area where psychology can aid dermatological care, Mallin says. Dermatological treatments can include oral antibiotics, systemic medications and a series of topical medicines applied multiple times per day. These regimens can be too complicated and precise for a child to understand and carry out, she says.

"If the child isn't going to comply because of the treatments themselves, doctors need to anticipate it and know how to counter the problem," Mallin says. Psychological research exploring the perceptions of patients with dermatological disease could have a significant influence on understanding factors that affect a child's quality of life. This knowledge can help create better approaches for administering treatments and identifying which patients are likely to need a little extra guidance--possibly increasing treatment success rates.

In fact, that's a large part of why pharmaceutical companies have provided most of the funding for Mallin's postdoc: They recognized the value of having a psychology fellow specializing in psychodermatology support research on the effectiveness of their products.

"In today's extremely competitive market, having research to back a claim that your product can improve quality of life over a brief period of time is extremely valuable," Mallin says.

Encouraged by the interest from pharmaceutical companies and the positive response of patients in the clinic, Mallin has been granted a full-time faculty position at the Miami clinic. In that position, she says she will work toward creating a center for the study of psychodermatology.

"It's been known for well over a century that there's a link between psychology and dermatology, just the fact that we blush proves it," Mallin says. "But the real study of the mind-body connection is only now being taken seriously."