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Dr Jane Hutton is a Consultant Clinical Psychologist at King’s College Hospital and South London and Maudsley NHS Trusts

How can mindfulness help patients with skin conditions?

Jane Hutton

In recent years the evidence for the benefits of practicing mindfulness regularly, and of mindfulness-based interventions, has grown hugely. This has brought much coverage in the mainstream media, which has been helpful in raising awareness but, at times, has been oversimplified or misleading. This article begins by defining mindfulness and goes on to summarise the evidence for its benefits, and the mechanisms by which they occur, with particular reference to dermatology. Courses and other ways of cultivating mindfulness are described. A list of useful resources is included.

Citation: Hutton J. How can mindfulness help patients with skin conditions? Dermatological Nursing 2016, 15(3): 32-35

Dermatological Nursing, 2016, Vol 15, No 3 www.bdng.org.uk

What is mindfulness?Mindfulness can be defi ned as ‘paying attention to what’s happening in the present moment in the mind, body and external environment, with an attitude of curiosity and kindness’1. It can be cultivated through a range of structured practices and in everyday life, through observing our experience, acknowledging that this is how it is at this moment, and allowing it to come and go, without becoming caught up in judging it as right or wrong, or in struggling against it.

Becoming more mindful helps us to be more clearly aware of our own bodily sensations, the thoughts that go through our minds, the ways we respond emotionally to events, and how all of these things affect one another and change from moment to moment. This gives us greater fl exibility to choose wisely and fl exibly how to respond to all of these experiences. In

of 20 or 30 people and consists of eight weekly two-hour sessions and one full day spent together. Daily practice at home, with guidance via audio recordings from a teacher, is just as important as the group sessions. Participants are introduced to sitting and walking practices, the body scan (in which attention is slowly guided from the feet to the head), gentle yoga and mindfulness of everyday activities.

Mindfulness-Based Cognitive Therapy (MBCT) was adapted from MBSR by the psychologists Mark Williams, John Teasdale and Zindel Segal in the early 21st century. The format is similar, but groups are generally somewhat smaller and some components of cognitive behavioural therapy (CBT) are woven into the sessions and home practices. CBT is a widely-used psychological therapy with a very strong evidence base, and is centred on the principle that how we think affects how we feel and what we do, and vice versa. More recently, carefully tailored mindfulness-based programmes have been developed for specifi c populations, including Mindfulness-based Relapse Prevention for people with substance misuse problems, and the .b (stop and breathe) programme for mindfulness in schools.

Much of the evidence is based on these programmes. Learning mindfulness can sometimes be challenging, and support and guidance from a teacher is valuable.

particular, it can help us decide how best to address the issues we can do something about, and to develop greater acceptance of those things we cannot change.

The All-Party Parliamentary Group for mindfulness produced its fi nal report, Mindful Nation UK1 in autumn 2015, which provides a more detailed introduction to mindfulness. The report made clear recommendations for the implementation of mindfulness-based working in physical and mental healthcare, the criminal justice and education systems, and the workplace, with a particular emphasis on NHS employees.

The growth of mindfulness-based interventionsThe roots of mindfulness can be traced back to ancient spiritual traditions, particularly — but not exclusively — those of Buddhism. It draws on the tradition of insight meditation, which is based on open, rather than concentrated, attention. Mindfulness can be practiced through meditation and also in everyday life.

Jon Kabat Zinn, a molecular biologist by background, working at the University of Massachusetts from the 1970s onwards, has been the central fi gure in translating these traditions into secular, structured programmes, which are accessible to those of any religious faith or none. Kabat Zinn’s Mindfulness-Based Stress Reduction (MBSR) programme is delivered to groups

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There is qualitative evidence for the benefi ts of learning mindfulness alongside peers. Less intensive distance-learning programmes are also available for those who are not able to access a face-to-face course or are not ready to do so. ‘Headspace’2 is a well-structured online programme, which is easy and appealing to use. ‘Mindfulness: A practical guide to fi nding peace in a frantic world’3, is a self-guided programme for improving stress management and general wellbeing, consisting of a book and audio-recorded guided mindfulness practices. It is based on an abbreviated version of MBCT. A similar programme, ‘Mindfulness for Health: A practical guide to relieving pain, reducing stress and restoring wellbeing’4, is designed for people living with pain and other medical problems, and is based on the Breathworks programme for pain, stress and illness. The evidence for these programmes is more limited, although there is a lack of direct comparisons with face-to-face studies.

Some concerns about adverse effects of mindfulness have been reported in the mainstream media, although there is no evidence for harm caused by any of the programmes described above. Nevertheless, it is important that mindfulness teachers working with people who are vulnerable are skilled and qualifi ed to do so. Good practice guidelines for mindfulness teachers, and a register of teachers5 who have been verifi ed as meeting these guidelines6, are available online and it is wise for anyone considering a mindfulness course to consult the register and, if a teacher is not listed, to check if they meet the guidelines. Teacher training consists of a rigorous pathway, followed over the course of at least a year, and teachers are also required to have their own personal mindfulness practice.

How does mindfulness work? (Figure 1)Much has been written on the mechanisms by which mindfulness might be helpful, and the evidence that these mechanisms are operating7,8. This section will summarise some key fi ndings from the literature.

It has been demonstrated that mindfulness practice improves our capacity

to orient our attention, and to sustain its focus. The relevance of this is apparent for dermatology patients, whose distress may be exacerbated by their attention being constantly drawn to the sensation of itch. The intention in practicing mindfulness is not to try to avoid this sensation, but to give it no more attention than other aspects of experience, thus reducing the tendency to become caught up in distressing and unhelpful vicious cycles of itch and scratching.

Mindful awareness can help us to see our own thought processes more clearly and to recognise our thoughts as thoughts. This can help us to react less automatically to them and, instead, to choose how to respond. It can also enable us to be less caught up in distressing, unproductive, circular, ruminative thinking. For example, a person with a dermatological condition might become more aware of their tendency to worry that everyone is looking at their skin and more able to notice whether or not this is actually

happening in any given situation. They might also be able to choose more consciously whether to avoid a situation where this might happen, or go into it anyway, in the interests of doing what is most important to them in life.

Mindfulness has also been shown to improve our ability to hold information in mind while we are under stress and to remember more specifi cally what has been helpful in previous diffi cult situations. It also reduces our tendency to try to avoid distressing emotions, and helps us to regulate these emotions more skilfully. It can therefore help us to take care of ourselves in more fl exible and helpful ways, rather than trying to avoid thinking about our problems. This can support better concordance with treatments and healthier ways of living.

There is good evidence that increased kindness to ourselves, cultivated through practicing mindfulness, is an important mediator for the benefi ts of mindfulness.

Practicing mindfulness can, for example, help dermatology patients avoid getting caught up in the itch-scratch cycle.

Figure 1

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What is the evidence that mindfulness can be helpful?Two important reviews were published in 2015. The fi rst9 considers the evidence for the benefi ts of Mindfulness-Based Stress Reduction and Cognitive Therapy for people with health problems. The authors conducted a systematic review and meta-analysis of systematic reviews of randomised controlled trials using MBSR or MBCT. They included 23 reviews, covering 115 unique RCTs and 8,683 unique individuals living with various conditions. Compared to control treatments of waiting list or treatment as usual, the mindfulness-based interventions signifi cantly improved depressive symptoms, anxiety, stress, quality of life and physical functioning. The limitations of the evidence were the lack of long-term follow-up and of studies using active control conditions. The authors concluded that the available evidence supports the use

The benefi ts of mindfulness have been demonstrated across a range of conditions, with benefi ts including reduced fatigue and improved quality of life, sleep, and sense of control over one’s health. These gains are often greatest for those participants who were most distressed before the intervention.

There is good evidence that mindfulness can attenuate pain through enhanced cognitive and emotional regulation, stability and fl exibility of attention and acceptance; reappraisal of pain and related thoughts and feelings as fl eeting, reduced anticipation and altered neurological processing16.

Mindfulness and dermatologyThere have been a few studies in which the benefi ts of mindfulness for dermatology patients, specifi cally those with psoriasis, have been directly evaluated. The fi rst of these was conducted by Jon Kabat Zinn and colleagues in 199817. In a randomised, controlled trial, participants received UV treatment with or without mindfulness practice guidance delivered by audio recording while the patient was in the light booth. These instructions specifi cally referred to awareness of the skin. Resolution of psoriatic lesions was signifi cantly more rapid for the patients who received this guidance.

A more recent study in 201418 showed that, prior to mindfulness training, people who have psoriasis tend to show lower levels of mindful awareness, and a great tendency to judge themselves harshly for having particular thoughts and feelings, than people without psoriasis. This may be related to trying to avoid distressing experiences, thoughts and feelings related to psoriasis, an understandable but counterproductive response, and might suggest they have more to gain from training in mindfulness.

D’Alton and colleagues19 conducted a controlled trial of MBCT adapted for the needs of people with moderate-severe psoriasis. They found signifi cantly reduced depression, and increased kindness towards the self, following this intervention.

Fordham and colleagues20 explored the benefi ts of mindfulness-based cognitive

of MBSR and MBCT as adjunctive treatments to alleviate psychological and physical symptoms for people with cancer, cardiovascular disease, chronic pain, depression and anxiety, and as preventative interventions.

The second review10 considers the evidence for the benefi ts of MBSR for healthy adults. It includes 29 studies and 2668 unique individuals. The review showed large effect sizes for anxiety, depression, stress and distress, and quality of life (Hedges’ g values of .55, .68, .83 and .57 respectively for within- and between-group comparisons). Changes in these variables were correlated with changes in mindfulness and compassion, and there was good maintenance of gains at follow-up (to an average of 19 weeks).

Physiological benefi ts of mindfulnessPhysiological benefi ts of MBSR have been shown in healthy populations, including better immune function11, reduced blood pressure and reduced reactivity of BP to stress12 and, with particular relevance to dermatology, weaker infl ammatory skin response to a stress test using topical capsaicin cream13.

Evidence from the brainThere is striking evidence that regular mindfulness practice can not only change brain activity, but also increase functional connectivity and grey matter concentration in certain regions of the brain, including those involved in emotion regulation14. The writing of Rick Hanson15, who is a clinical psychologist with many years of experience as a mindfulness practitioner and teacher, is an excellent resource for those interested in the neuroscience of mindfulness.

Mindfulness and medical problemsMBSR was developed primarily for people with chronic medical problems. It offers a way of changing our relationship to physical symptoms, with an emphasis on integrated awareness of body and mind, and of responses which may have previously followed automatically from the symptoms, and on cultivating balance between acceptance of the current situation and mindful action towards change, and towards more skilful and fl exible coping.

Further information on mindfulness is available at:The Centre for Mindfulness Research and Practice, Bangor: www.bangor.ac.uk/mindfulnessOxford Mindfulness Centre: www.oxfordmindfulness.org

For a list of registered mindfulness teachers, and information about teacher training, see:http://mindfulnessteachersuk.org.uk

Self-help programmes for patients, including guided mindfulness practices:Williams M, Penman D. Mindfulness: A practical guide to fi nding peace in a frantic world. Piatkus, London. 2011.Burch V, Penman D. Mindfulness for Health: A practical guide to relieving pain, reducing stress and restoring wellbeing. Piatkus, London. 2011.

Guided meditationsMP3s can be downloaded free of charge from the following sites:www.bangor.ac.uk/mindfulness/audio/index.php.enwww.kcl.ac.uk/ioppn/depts/pm/research/imparts/Self-help-materials.aspx [this includes some dermatology-specifi c guidance]

Psoriasis-specifi c meditations can be downloaded at a cost of $10 from:www.mindfulnesscds.com/collections/mp3s

BOX 1

Resources.

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therapy for people with psoriasis. Some participants noticed an improvement in the appearance of their psoriasis while others reported no visible change but did notice a change in their reactions towards their condition. Increased control over their thoughts and actions in response to their psoriasis symptoms might have contributed to the improved sleep and greater energy that some participants reported. Participants reported feeling calmer, more confi dent and sociable, suggesting improved self-effi cacy in dealing with social interactions.

Conclusion In summary, the evidence continues to grow that mindfulness can be helpful for our patients. This comes from specifi c evaluation of mindfulness-based interventions for people with psoriasis, and the wider literature. More research is needed on the role of mindfulness for other dermatological conditions.

These benefi ts will be maximised by ensuring the use of specifi c evidence-based mindfulness interventions, delivered by appropriately qualifi ed and skilled teachers.

References1. Mindfulness All-Party Parliamentary Group. Mindful Nation UK, 2015. Available at: http://

themindfulnessinitiative.org.uk/images/reports/Mindfulness-APPG-Report_Mindful-Nation-UK_Oct2015.pdf [accessed 7.5.16]

2. Headspace Inc (2016). Headspace [online]. Available at www.headspace.com [accessed 8.5.16]

3. Williams M, Penman D. Mindfulness: A practical guide to fi nding peace in a frantic world. Piatkus, London. 2011

4. Burch V, Penman D. Mindfulness for Health: A practical guide to relieving pain, reducing stress and restoring wellbeing. Piatkus, London. 2011

5. UK Network for Mindfulness-Based Teacher Training Organisations. Good practice guidelines for teaching mindfulness-based courses [online]. 2015. Available at http://mindfulnessteachersuk.org.uk/ [accessed 7.5.16]

6. UK Network for Mindfulness-Based Teacher Training Organisations Listing, 2016. Available at http://mindfulnessteachersuk.org.uk/ [accessed 7.5.16]

7. Lykins ELB, Baer RA. Psychological functioning in a sample of long-term practitioners of mindfulness meditation. J Cogn Psychother 2009, 23(3): 226-41

8. Kuyken W, Watkins E, Holden E, et al. How does mindfulness-based cognitive therapy work? Behav Res Ther 2010, 48(8): 1105-12

9. Gotink RA, Chu P, Busschbach JJ, Benson H, Fricchione GL, Hunink MG. Standardised mindfulness-based interventions in healthcare: an overview of systematic reviews and meta-analyses of RCTs. PLoS One 2015, 10(4): e0124344

10. Khoury B, Sharma M, Rush SE, Fournier C. Mindfulness-based stress reduction for healthy individuals: a meta-analysis. J Psychosom Res 2015, 78(6): 519-28

11. Davidson RJ, Kabat-Zinn J, Schumacher J, et al. Alterations in Brain and Immune Function Produced by Mindfulness Meditation. Psychosom Med 2003,

There is good evidence that mindfulness can be helpful for people with long-term medical conditions in general, and some evidence that it can have specifi c benefi ts in psoriasis. There are sound theoretical reasons why mindfulness is likely to be helpful for people with skin problems that are uncomfortable, visible or both. It is therefore important that clinicians working in dermatology have a working knowledge of what it is, and how to direct patients to appropriate resources. Busy clinicians may also fi nd mindfulness very helpful for their own wellbeing.

Who is it for? How can I fi nd a course?

Mindfulness-based stress reduction (MBSR)

Anyone living with physical illness or stress

Some local Improving Access to Psychological Therapy and clinical health psychology services and in the private sector

Breathworks As above www.breathworks-mindfulness.org.uk

Mindfulness-based cognitive therapy (MBCT)

As above, but with more emphasis on patterns of thinking

Some local Improving Access to Psychological Therapy and clinical health psychology services and in the private sector

Mindfulness-based relapse prevention (MBRP)

People in recovery from addictive behaviours

Some substance misuse services

Mindfulness in schools (.b) Children and adolescents, with a view to teaching mindfulness as a life skill and improving wellbeing, self-awareness and concentration

https://mindfulnessinschools.org/

All of the above courses consist of eight weekly classes, often supplemented by a full day of practice, with the exception of .b, which consists of 10 lessons, integrated with the school timetable.

BOX 2

Mindfulness courses.

BOX 3

Implications for dermatological practice.

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12. Nyklícek I, Mommersteeg PM, Van Beugen S, Ramakers C, Van Boxtel GJ. Mindfulness-based stress reduction and physiological activity during acute stress: A randomized controlled trial. Health Psychol 2013, 32(10): 1110-3

13. Rosenkranz MA, Davidson RJ, Maccoon DG, Sheridan JF, Kalin NH, Lutz A. A comparison of mindfulness-based stress reduction and an active control in modulation of neurogenic infl ammation. Brain Behav Immun 2013, 27(1): 174-84

14. Hölzel BK, Carmody J, Vangel M, et al. Mindfulness practice leads to increases in regional brain gray matter density. Psychiatry Res: Neuroim 2011, 191(1): 36-42

15. Hanson R. Hardwiring Happiness: How to reshape your brain and your life. 2014. Rider, London

16. Zeidan F, Grant JA, Brown CA, McHaffi e JG, Coghill RC. Mindfulness meditation-related pain relief: evidence for unique brain mechanisms in the regulation of pain. Neurosci Lett 2012, 520(2): 165-73

17. Kabat-Zinn J, Wheeler E, Light T, et al. Infl uence of a mindfulness meditation-based stress reduction intervention on rates of skin clearing in patients with moderate to severe psoriasis undergoing phototherapy (UVB) and photochemotherapy (PUVA). Psychosom Med 1998, 60(5): 625-32

18. Vari C, Velotti P, De Campora G, Giromini L, Garofalo C, Zavattini GC. EPA-0629 — Investigating mindfulness facets in dermatology patients: a crosssectional study. European Psychiatry 2014, 29(supp1)

19. D’Alton P, O’Malley G, Adamzik K, et al. The link between mindfulness, self-compassion, and telomerase activity in psoriasis: Results from a controlled MBCT trial [online presentation for Centre for Mindfulness Research and Practice conference 2013]. Available at:http://www.cmrpconference.com/ mindfulnessselfcompassionandttelomeraseinpsoriasis_daltonetal2013.pdf [accessed 7.5.16]

20. Fordham BA, Nelson P, Griffi ths CEM, Bundy C. The acceptability and usefulness of mindfulness-based cognitive therapy for people living with psoriasis: a qualitative study. Br J Dermatol 2015, 172(3): 823-5

DN

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