Counseling in Pemphigus.

Pemphigus is a chronic, potentially life threatening, autoimmune intraepidermal blistering disease affecting the skin and the mucous membrane. Pemphigus may have profound impact on the quality of life in the affected patients. Counselling and adjuvant psychotherapy may be beneficial at least in few patients and should be considered as a part of multidisciplinary approach.

What was known?

Pemphigus is a chronic disease thereby necessitating the need for prolonged therapy with steroids and/or immunosuppressive medications Affected patient may suffer from profound psychological trauma.

Introduction

There is a strong interrelationship between mind and skin. Comorbidity of psychiatric problems is common in dermatologic disorders. Approximately 30% of all dermatologic patients show psychiatric disturbances.[1]

Pemphigus is a chronic, potentially life-threatening, autoimmune blistering disease affecting the skin and the mucosae. The disease is known to have a protracted course with periods of remission and relapses. Affected patients may therefore at risk of undergoing a lot of psychological trauma.

Quality of Life in Pemphigus

Quality of life (QoL) is increasingly recognized as an important subjective tool for evaluating effectiveness of patient care. A study using generic health-related QoL instrument (the SF-36) has shown that pemphigus patients have dramatically reduced QoL when compared to the general population.[2] According to the authors, physical and emotional status of pemphigus patients was comparable to patients with psoriasis. Depression was present in over 50% of the study population, and patients with depressive traits had worse health status.[2] In another study, 70% of the patients expressed enormous shame about their appearance.[3] Corticosteroids which are often used in high doses in these patients may precipitate psychiatric symptoms.

Impact of Psychological Distress on Pemphigus

The interaction between immune system and nervous system (neuroimmunology) is very well established. Experiences from several other autoimmune diseases indicate that psychological distress and personality disorders play an important role in the disease initiation, maintenance, and progression. Psychological impairment may play a similar role in triggering pemphigus as well.[4]

Noncompliance and Counseling

Numerous factors may adversely affect treatment compliance in patients with chronic disease like pemphigus. Long duration of treatment and the relapses that occur regularly in pemphigus may have negative impact on the motivation for compliance with therapy.[5] Other factors that contribute to treatment compliance include patient–physician relationship, satisfaction with various aspects of care, cost of medications, taste of medication, multiple drug therapy, frequency of drug administration, duration of drug therapy, and adverse drug reactions. Counseling by a trained pharmacist in centers where facilities exist not only enhances compliance but also reduces complications, resulting from nonadherence to treatment.[6]

Pregnancy and Counseling

Female patients in the childbearing age should be reassured that active diseases need not affect the fertility; on the flip side, they should be told that there is a theoretical risk of disease aggravation, especially in the first trimester. Pemphigus may also affect the pregnancy outcome adversely, albeit in minority of patients. Another important issue that might crop up is the affection of newborn; they should be counseled regarding the neonatal pemphigus which might affect about 50% of the newborn. When it happens, they should be reassured about the transient nature of the disease. During antenatal visit, they should be encouraged to go for vaginal delivery instead of cesarean section.[7]

Psychotherapy and Counseling

Counseling or brief psychotherapy, as well as judicious use of psychotropic drugs, might be valuable for those dermatological patients who have clinically relevant symptoms of depression or anxiety, even if these symptoms are of a reactive nature.[8] Various forms of psychological therapies such as relaxation techniques, meditation, hypnosis, habit reversal training, cognitive behavioral therapy, and stress management training have been found to be beneficial in patients with skin complaints.[9] Establishing a strong doctor–patient bond may encourage patients to be more treatment complaint and will potentially improve outcome.[10] The physician may find many opportunities during the patient interview to establish this bond. To start, the physician should sit within touching distance of the patient and palpate the lesions (blisters) as a part of physical examination. This act helps the patient overcome social inhibitions and sends a strong message to the family and the society regarding the noncontagious nature of the illness. Patients and relatives often ask cause of the disease and the role of food. The concept of autoimmune disorder must be explained. For example, they can be told that the immunity of our body which is meant to protect acts against us in pemphigus. Patients and their relatives should be educated about the chronic nature of the disease, available treatment options which will effectively control the disease. Adverse drug reactions related to pemphigus treatment should be emphasized, and importance of regular follow-up and monitoring should be stressed. They should be warned against abrupt stoppage of medications once the remission is induced. At the same time, they should be encouraged not to lose heart when there are occasional blisters during the period of maintenance treatment.[11]

Patients with educational background and who have access to the internet should be encouraged to join online support communities for patients (www.pemphigus.org). These virtual communities may be a valuable educational resource and a source of psychological and social support to patients.[12]

Conclusion

Pemphigus, a potentially a life-threatening, autoimmune blistering disease, can cause serious impact on the psyche of the affected patients. The presence of psychiatric comorbidities not only affects the QoL adversely but also may lead to poor treatment compliance. Coexistent psychological problems need to be identified and addressed accordingly in patients with pemphigus

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

What is new?

Counselling and psychotherapy may help the patient to overcome the stressful period and may improve the overall morbidity due to the disease. It should be considered as a part of standard care in all affected patients.