British Journal of Dermatology 1995; 132: 778-783.

Hypnotherapy as a treatment for atopic dermatitis in adults

and children
A.C.STEWART AND S.E.THOMAS
Department of Dermatology, Barnsley District General Hospital, Gawber Road, Barnsley S75 2EP, U.K.
Accepted for publication 4 August 1994

Summary Eighteen adults with extensive atopic dermatitis, resistant to conventional treatment, were treated
by hypnotherapy, with statistically significant benefit (P < 0-01) measured both subjectively and
objectively, which was maintained at up to 2 years where results were available. Twenty children
with severe, resistant atopic dermatitis were treated by hypnosis. All but one showed immediate
improvement, which was maintained at the following two clinic appointments. In 12 children,
replies to a questionnaire at up to 18 months after treatment, showed that 10 had maintained
improvement in itching and scratching, nine in sleep disturbance, and seven maintained improve-
ment in mood.

Claims have been made for the therapeutic efficacy of
treatment under hypnosis since the time of Mesmer, but
it is only relatively recently that there has been any
attempt at its scientific evaluation. The reasons for this
are complex. The activities of stage hypnotists have led
to hypnosis being discredited in the public eye as a valid
medical treatment. People tend to be apprehensive of
hypnotherapy, believing that they will lose control of
their behaviour, and viewing it as a sfightly sinister
procedure.
However, lay practitioners have continued to use
hypnosis in the treatment of behaviour disorders—
phobias, anxiety states, smoking and obesity—and
such treatment has become famifiar and acceptable.
Medical interest has increased over the last 30 years,
and practitioners are using hypnosis in a variety of
disorders, including asthma,^ irritable bowel syn-
drome,^ migraine,^ and have reported on its efficacy.
However, there is Uttle literature on its use in the
treatment of dermatitis. There are isolated case
studies*"'^ which report its beneficial effect, but there
are no clinical trials.
Patients suffering from atopic dermatitis have been
shown to have significantly higher anxiety ratings
as measured on the Spielburg State Trait Anxiety
Inventory.* This confirms clinical expectancies as: (i)
they are suffering from a chronic distressing and
disfiguring disease; (ii) exacerbations of dermatitis are
noted to follow stressful events in the patient's fife. It has
been documented that 70% of adults with atopic
dermatitis have had a stressful event precipitating
their dermatitis.^ In a series of 72 patients with atopic
dermatitis, treatment of stress, where identified, was
shown to benefit the skin condition. ^"^ Not only have
such patients been shown to be more anxious, but also
more insecure, dependent, and with more inhibited
aggression than controls. ^^
Stresses in children with atopic dermatitis have not
been closely studied. However, atopic dermatitis often
presents as a family disease in the true sense of the
word—a disease of sleepless nights, fretful tired chil-
dren, and overwrought parents who are irritable and
distressed. One study^'^ reported a statistically signifi-
cant number of parental separations. In the present
study, nine of the children had parents who were
divorced or separated, and precipitating stress could
be clearly identified in 11.
Various psychological treatments have been used to
treat atopic dermatitis successfully;
1 behavioural techniques aimed at eliminating
scratching by positive reinforcement^^ or aversion;^*
2 biofeedback by EMG of frontalis muscle linked to
3 cognitive behavioural methods;^'^
4 stress management.^"
Such methods were all considered to be useful adjuncts
to medical treatment.^* Hypnosis is known to be a
valuable therapeutic tool in treating anxiety quickly
and effectively.
Hypnosis is difficult to define. It is akin to a state we
have all experienced when absorbed in music or a book,
or in 'highway trance' (when one has no full recollection

778 1995 British Association of Dermatologists

 HYPNOTHERAPY IN ATOPIC DERMATITIS
of a journey driven when absorbed in thought). A major
controversy is whether it exists as a separate state, or is
merely an extension of everyday experience brought
about by imaginative involvement with a hypnotist's
suggestions. Such arguments are largely academic in
the clinical context. When one sees a patient in a
hypnotic 'trance' it is difficult to believe that this is
not a unique 'state'. Using the 'state' theory of hypnosis
one can define it as an altered state of consciousness in
which the subjects will accept suggestions put to them,
and which allows greater access to the unconscious
processes. A suggestion is defined as a proposition or
idea offered to a subject for uncritical acceptance, often
leading to autonomic or involuntary activity. During
hypnosis the critical faculty is bypassed. The guardian
at the gate of the 'unconscious' is lulled into inactivity,
and suggestions can slip in and be accepted, or sup-
pressed memories and feelings accessed; both these
effects can be used therapeutically. Suggestions made
and accepted can result in altered behaviour or, in some
way not yet understood, in alteration of autonomic
function. Past events and memories, when pleasant,
can be used in relaxation and ego strengthening
(treatment aimed at increasing self-confidence). Trau-
matic events and memories can be ventilated, and
associated negative reactions resolved.
There are two principal approaches for the treatment
of anxiety by hypnosis;
1 neutral hypnosis;
2 hypnosis aimed at treating more specific problems.
Neutral hypnosis is used in non-specific relaxation and
ego strengthening, and has been shown to reduce auto-
nomic arousal and benefit patients with psychosomatic
disorders.^^ Psychosomatic illness has been defined as a
symptom or complaint due to a path of physiological
somatic response to emotional stress.'^^ Both approaches
to treatment of anxiety were used in our programme.
A further line of treatment was direct suggestion of
improvement of the eczema and cessation of scratching
and itching. To those unfamiliar with hypnosis, to
suggest that the skin will become 'smooth and soft,
cool and comfortable' may seem futile, but hypnotic
suggestion has been shown to affect the function of the
autonomic and immune systems by; an increase and
decrease of skin temperature,"^^ an increase and
decrease of heart rate,"^"^ a decrease in gastric secre-
tion,^^ an increase in peak fiow rate,^* a resolution of
warts."^^ It seems reasonable to postulate a similar efi'ect
on the skin in eczema sufi'erers.
Decrease in scratching may be suggested and
achieved as in any other habit disorder, e.g. nail biting.
© 1995 British Association of Dennatologists, British Journal of Dermatology, 132, 778-783
779
Scratching behaviour may be independent of itching,
and purely a habit. To discontinue or break the habit
will result in a reverse spiral in the itch/scratch cycle.
The suggestion of cessation or reduction of itching
may be effective in the same way as pain control is
achieved under hypnosis by suggesting decrease or
alteration of its perception. Although independent of
pain, itch is closely related to it, and shares the same
pathways to the higher centres.
It is possible to induce hypnosis in most people,
although the depth of hypnosis or the intensity of the
experience is variable. However, even the least suscept-
ible or responsive can obtain therapeutic benefit from
the procedure.
For many years children were thought to be unhyp-
notizable, and this is still true if techniques for adults are
used. Using techniques appropriate to their age and
interests, children are responsive subjects. Their imagi-
nation is easily engaged in visualization of a favourite
occupation, television programme or computer game,
and this can be used to induce the relaxation necessary
for acceptance of suggestion. With younger children the
suggestion can be given in an extended metaphor or
story, and benefit extended after consultation by a tape-
recording used at home, perhaps at bedtime. This is
particularly valuable for atopic children, who infiict
much of the damage to their skin by nocturnal scratch-
ing. Suggesting comfort and sound sleep can produce a
break in the itch/scratch cycle and a dramatic improve-
ment in the dermatitis. A particularly valuable techni-
que for children of any age is 'magic music'.^^ With this
technique a tape is promised for use at bedtime, and
expectancy is built up by this promise. Introduced by
what amounts to hypnotic induction, a story is tailor-
made for each child, and the central character is one
with whom the child can identify, and work through a
similar problem to its successful resolution, the thera-
peutic element being a piece of music—the 'magic
music'. The suggestion in the story may be for the
skin, or for other problems, such as fear of the dark,
sibling rivalry, or unhappiness at parental separation.
The unspoken suggestion is that the magic in the music
will also be effective for the child.
A study was undertaken to evaluate the effect of
hypnotherapy in severe, refractory atopic dermatitis of
adults and children.
Methods
Five male and 13 female patients were treated by
hypnotherapy. The mean age was 33 years (range
780 A.C.STEWART AND S.E.THOMAS
18-51). The criterion for offering therapy was the
failure of dermatological treatment, e.g. topical ster-
oids, emollients, oil of evening primrose, and antihista-
mines. Eight of the patients had a history of at least one
hospital admission, and five at least one course of
systemic steroids. Initially introduced as an end-of-the-
line therapy, it was continued and formalized as a study
because of its apparent efficacy.
The programme offered to the adult patients involved
the following treatment.
1 Relaxation. The hypnotic induction involved pro-
gressive relaxation, and it was suggested that the
patient repeat the relaxation procedure daily under
self-hypnosis. The feeling of relaxation and calmness
was cued to a word (e.g. calm) or a gesture (e.g.
clenched fist).
2 Stress management. The patient was given the oppor-
tunity to face or to find any problem initiating or
maintaining the activity of his/her dermatitis. Problem-
solving techniques were used to achieve their resolu-
tion.
3 Direct suggestion of non-scratching behaviour.
4 Direct suggestion of skin comfort and coolness. This was
linked to imagery of coolness—often cold water or a
cool breeze (often cued to a word or gesture for use in
the everyday situation when itching).
5 Ego strengthening. This was aimed at relieving the
patient's anxiety, tension, lack of confidence and depen-
dence—whether arising firom his/her personality or
skin condition.
6 Post-hypnotic suggestion. This is a suggestion made
under hypnosis to be acted upon after hypnosis. Sugges-
tions were made of ease of relaxation, ease of access to
the feeling of calmness and skin comfort, and ease of
self-hypnosis,
7 Instruction in self-hypnosis. The patient was instructed
in the technique of self-hypnosis, with the intention that
this be practised daily to maintain the improvement
achieved during the therapeutic sessions. A tape-
recording of one of the sessions was often made to
supplement the self-hypnosis.
Twenty children with severe refractory atopic der-
matitis were given a tape of 'magic music', which
incorporated the elements of relaxation, stress manage-
ment, ego strengthening, skin comfort, and post-
hypnotic suggestion. The age range was 2-15 years
(one adult, aged 24 years, requested such a tape, and
was included in the series). The intention was for them
to use the tape nightly until they were next seen in the
clinic. A retrospective assessment of the severity of
their dermatitis was made from the records of three
1995 British Association of Dermatologists, British Journal of Dermatology, 132, 778-783
consecutive cUnic appointments preceding receipt of the
tape, and they were subsequently assessed, using the
same scale of severity, on three visits thereafter. The
scale employed was the extent of improvement or
deterioration—mild, moderate or considerable. A ques-
tionnaire was sent out to the patients at up to 18
months after receipt of the tape. The children, or their
parents, were asked to indicate any change in itching,
scratching, sleep disturbance, and mood—whether
unaltered, improved or worsened (a little or a lot)
since receiving the tape.
The adults' response to treatment was measured in
the following way.
1 The patients' estimation of the severity of their
conditions on an analogue scale (0-10), of four para-
meters—itch, scratch, sleep disturbance and 'tension'
(this last being a non-specific estimation of how stressed
they considered themselves to be), where 0 = complete
absence, and 10 = the most extreme episode remem-
bered. The patients' assessment of the treatment was
considered to be the important measure of its efficacy.
2 A general objective measure of improvement of the
eczema was the reported amount of topical steroid used.
Assessments were performed at 4, 8, 16 and 26
weeks, and compared with the pretreatment assessment.
The duration of the treatment was determined by the
patients' response and ability in self-hypnosis. An
average of 5-3 sessions (range 3-12) were given over
2-7 months (range 1-5-7). Initially, sessions were
weekly, then fortnightly or monthly until completion;
thereafter, patients were followed-up 6-monthly. The
patients were considered to be their own controls, as
treatment was started when their eczema had become
severe and failed to respond to conventional out-patient
treatment. The alternative to hypnotherapy was hos-
pitalization and/or systemic steroids. Hospitalization
was avoided in all, and only one patient had a further
short course of systemic steroids.
Results
The initial measurement on the analogue scale was
compared with that recorded at each visit—a shift to
improvement being recorded as positive. The number of
positives in each set were subjected to a non-parametric
sign test to assess their statistical significance.
Four weeks after starting treatment, 16 of the 18
adult patients reported considerable improvement in
itching. It was unchanged in one and increased in
another. This statistically significant improvement
was maintained at 8 weeks and at up to 2 years, the
 HYPNOTHERAPY IN ATOPIC DERMATITIS 781

Table 1. Assessment of improvement after up to 2 years of follow-up. The first figure is the numher of patients, and the figure in parentheses is
the numher improved

Week

1-4 1-8 1-16 1-26 1-25 1-104

Itch 18(16) 18(16) 17(16) 16(15) 9(8) 6(5)
P<001 P < 0 01 P < 0 01 P < 0 01 P < 0 01 P < 0 05
Scratch 18(17) 18(16) 17(15) 17(16) 8(7) 6(5)
P < 001 P < 0 01 P<001 P < 0 01 P < 0 01 P < 0 05
Sleep 16(13) 16(14) 15(14) 15(13) 8(8) 5(5)
disturhance P < 00023 P < 0 01 P<001 P < 0 01 P < 0 01 P < 0 01
Tension 17(12) 17(12) 16(14) 14(13) 9(6) 5(5)
P < 00245 P < 00245 P < 0 01 P < 0 01 P < 00898 P < 0 01

Other patients having used these techniques for a lesser
time. The same pattern was observed in scratching
behaviour, sleep disturbance and tension (Table 1),
Table 2 shows the mean and range of improvements
in the patients' scores. Using the non-parametric sign
test, this improvement is shown to be statistically
signiflcant for each of the four parameters, as shown
in Table 1, comparing the initial values on the analogue
scale with those at 4, 8, 16, 26, 52 and 104 weeks.
Reported topical steroid use had decreased to 40% of the
original amount at 4 weeks, 50% at 8 weeks, and 60%
at 16 weeks. The amount recorded after a longer time
interval was unreliable.
Figure 1 shows the short-term effect of the tape on the
children's eczema. The symbols to the left of the vertical
line record the activity of the eczema at clinic atten-
dances before use of the tape, and those to the right
indicate activity after using the tape.
Figure 2 illustrates the longer-term effect the tape
had on the activity of the children's eczema, and

3rd visit 2nd visit 1st visit Tape 1st visit 2nd visit 3rd visit
before tape before tape before tape after tape after tape after tape

Clear

Very much
improved

Very good

Improved

Chronic
eczema

Worse

Exacert)ation

Severe ,. fl g g
exacerbation a 8 8

Figure 1. Activity of eczema on three consecutive cUnic appointments before and after receipt of the tape. The assessments hefore receipt of the tape
were based on retrospective referral to the cUnicians' records, and those after using the tapes were performed at the time of clinic attendance.

© 1995 British Association of Dermatologists. British Journal of Dermatology, 132, 778-783

782 A.C,STEW ART AND S.E.THOMAS

Table 2. Average, and range of improvement in score on analogue scale of the four parameters, compared with the baseline assessment

Week

1-4 1-8 1-16 1-26 1-52 1-104

Itch Mean +2 +33 +3-0 +4-4 +4-5 +40

Range (+5 5 to - 4 ) (+9 to -0-8) (+9 to -2) (+9 to -1) (+8 to -1) (+8 to -1)
Scratch Mean +1-75 +3-1 +30 +3-5 +325 +2-7
Range (+5 to - 3 ) (+5 to -1) (+7 to -1) (+8 to-1) (+7 to -3) (+7 to -3)
Sleep Mean +2-4 +3-4 +34 +3-2 +4 +4-4
Range (+8 to - 2 ) (+9 to -2) (+7to-l) (+7 to -2) (+7 to +1) (+10 to +2)
Tension Mean +2-0 +2-7 +31 +26 +36 +40
Range (+6 to -3) (+7 to -3) (+6 to -1) (+6 to -1) (+6 to -7) (+8 to +1)

demonstrates a marked improvement. There were 12 Discussion

respondants to the questionnaire. Of these, 10 remained
These preliminary results indicate that a larger study,
much improved with regard to itching and scratching,
with a series of controls and more detailed pretreatment
and seven with regard to sleep pattern and mood.
assessment of the activity of the children's eczema,
would be useful in evaluating the benefit of hypnother-
10
apy in atopic eczema. Although the pre-tape assessments
8
were the clinicians' retrospective evaluation of the
6 O severity of the children's eczema, it was felt justifiable
o
4 o o to include these in the study because of the apparent
o o
2 o o significant benefit that the children obtained. It would be
o o of interest to separate the elements of the programme, for
0
different groups of patients, in an attempt to identify the
10 effective element. Many of our patients reported signifi-
8 cant improvement in other aspects of their lives following
6 o hypnotherapy. This may indicate that the improvement
o was achieved more by anxiety reduction and stress
4 o o
o o management than by direct suggestion. We believe
2 o o that our programme of hypnotherapy is effective in the
o o
0 short and long term, and is economical in both money
10 and time, as three or four 20-30-min sessions produce
8 long-term benefit. It is unique in that it is free from any
harmful side-effects, unlike other treatments for severe,
6
o refractory atopic eczema, such as systemic steroids,
4 o o
o o PUVA or cyclosporin. It is particularly valuable for
2 o o o children who, by learning these techniques early in
o o o
0 the course of a chronic relapsing condition, may avoid
the long-term physical and psychological effects of a
iOr
distressing, disfiguring disease and its treatment.
8
6
o Acknowledgments
4 o
o o
2 o o o o We thank Professor R.M.Loynes and Andrea Chambers
o o o o
0 from the Statistical Services Unit, University of Sheffield,
Lot more Little more Same Little less Lot less for help with the statistical data, the Department of
Figure 2. Reported efifect of 'magic music' tape, in response to a
Medical Illustration, Northern General Hospital NHS
questionnaire sent 1-2 months after receipt of the tape, recording
the effect the tape had on itching, scratching, sleep disturbance and
Trust for graphics, and Mrs M.Howarth and Mrs
tension. J.Hawksby for secretarial assistance.

1995 British Association of Dermatologists. British Journal of Dermatology, 132, 778-783

 HYPNOTHERAPY IN ATOPIC DERMATITIS
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