Stress reduction with individual brief dynamic psychotherapy in children as young as 5 years old was found to significantly benefit children with atopic dermatitis in a randomized control trial [19]. A total of 11–18 sessions were required over a 6 month period. This can also help stressed adults with skin disorders, especially those with a psychosomatic overlay on their skin disorder.

Stress reduction can also occur through cognitive-behavioral therapy (CBT) methods that help to alter dysfunctional thought patterns (cognitive) or actions (behavioral) [20]. These methods include habit reversal therapy. Adding hypnosis to cognitive-behavioral therapy can facilitate virtual aversive therapy and enhance desensitization and other cognitive-behavioral methods [16]. A randomized controlled trial using CBT for atopic dermatitis aimed to reduce scratching frequency and stress [11]. The subjects maintained scratching diaries and were instructed in habit reversal techniques, relaxation techniques, distraction techniques, positive self talk, and applying ice to itchy skin. Assessments at 1 year for CBT showed significantly improved atopic skin conditions with significantly decreased topical corticosteroid use compared with standard dermatological treatment or education groups [11].

Emotional freedom techniques (EFT) [21] are related to acupressure. EFT starts with selecting a negatively emotionally charged memory or problem area, focusing intently on that thought or memory or condition, pressing on the subclavicular “sore spot”, and repeating an affirmation such as “Even though I have this problem with _______, I deeply and completely accept myself” while progressively tapping with the combined index and middle fingers on a series of up to 14 specific acupuncture sites on the head, chest, and hand. For infants, toddlers, and preschoolers, this tapping process can be done for them, either directly on them or on a surrogate. Older children, adolescents and adults can be taught to use the technique themselves. EFT can neutralize negative emotional charged memories or problem areas, reducing anxiety and stress and enhancing performance [21]. Anecdotally reported improvements or resolution of skin conditions on www.​EFTuniverse.​com include acne, allergic contact dermatitis, atopic dermatitis, lupus erythematosis, needle phobia, procedure anxiety, psoriasis, and warts. A controlled comparison of EFT with EMDR (see below) in a study that included older adolescents and adults showed that for post traumatic stress disorder (PTSD) both produced significant therapeutic gains [22]. Some patients do develop PTSD as a result of life events that were overwhelmingly traumatic to them, including hospitalizations and medical procedures. Reducing emotional distress often results in improvement of inflammatory skin conditions such as acne, atopic dermatitis, and psoriasis.

Eye movement desensitizing and reprocessing (EMDR) also involves selecting a negatively emotionally charged memory or problem area, focusing on that thought, and doing an alternating bilateral activity such as following a finger from side to side with the eyes [23], hearing alternating left and right tones through headphones, feeling alternating left and right vibrations in handheld paddles, or alternately tapping left and right distal thighs or upper arms. It is slightly more effective than EFT in producing positive benefits in PTSD [22]. The efficacy of EMDR has been evaluated in a meta-analysis. The post treatment effect size was medium and significant [24]. When combined with the EFT affirmations it becomes a hybrid known as Wholistic Hybrid derived from EMDR and EFT (WHEE), reducing anxiety and stress and enhancing performance [25]. EMDR has been reported effective for improving atopic dermatitis and psoriasis [26].

Guided imagery involves trance induction often through progressive relaxation followed by deepening, guided imagery of a scenario, and re-alerting. It is a form of hypnosis. The scenario often vividly describes suggested sensory experiences during the deepening phase followed by a journey, story, or other relaxing or therapeutic script. While guided imagery is commonly used to help induce relaxation and stress reduction and there are many available scripts and recordings, there has not yet been appreciable scientific study of its effectiveness related to patients with skin disorders.

Hypnosis consists of guiding the patient into a trance state of narrowed awareness, focused attention, selective wakefulness, and heightened suggestibility for a specific purpose such as relaxation, pain or pruritus reduction, or habit modification. Autogenic training and guided imagery are considered to be forms of hypnosis. Autogenic training is discussed above. Guided imagery intentionally involves trance induction, while story-telling often induces spontaneous trance. Meditation is a close cousin to hypnosis. Both hypnosis and meditation involve the use of trance phenomena. Hypnosis is a western concept and focuses more on fixing something, while meditation is more of an eastern concept and focuses more on centering and balance. Both can reduce psychological roadblocks to healing. The hypnotic trance has objectively documented differences in regional cerebral blood flow [27] and EEG [28] patterns compared with the usual waking state. The use of hypnosis may improve or clear numerous skin disorders. Examples include acne excoriée, alopecia areata, atopic dermatitis, congenital ichthyosiform erythroderma, dyshidrotic dermatitis, erythromelalgia, furuncles, glossodynia, herpes simplex, hyperhidrosis, ichthyosis vulgaris, lichen planus, neurodermatitis, nummular dermatitis, post-herpetic neuralgia, pruritus, psoriasis, rosacea, trichotillomania, urticaria, verruca vulgaris, and vitiligo [29, 30]. Most children ages 4 and above are good hypnotic subjects, with hypnotic ability reaching a peak at around age 8–12 years [31]. Thereafter there is some mild decline in hypnotizablity into adulthood. A randomized controlled trial showed hypnosis to result in significantly greater resolution of verrucae than controls [32]. A small pilot study randomized controlled trial with psoriasis demonstrated significant improvement in high hypnotizables [33]. Similarly a non-randomized controlled trial utilizing hypnotic suggestions showed that atopic patients had significant improvement and significantly less use of topical corticosteroids by 6 weeks and maintained up to 2 years compared with controls [34]. Hypnosis is most useful in high and medium hypnotizables, and should generally not be used with schizophrenics or others who are not mentally intact. Relaxation with hypnosis can reduce anxiety and pain associated with dermatologic procedures. Hypnosis has been shown in a randomized control trial to significantly reduce anxiety during dermatological procedures [35]. Psychosomatic hypnoanalysis has been successful in reducing erythema nodosum, herpes simplex reactivation, neurodermatitis, neurotic excoriations, rosacea, urticaria, and verrucae [36, 37]. Hypnoanalysis of 41 consecutive cases of verrucae resistant to prior hypnotic suggestion, including 11 prepubertal children and 5 adolescents, resulted in the warts resolving in 31 cases [38]. The psychosomatic hypnoanalysis appears to remove psychological obstacles to healing.

Various forms of meditation have been used since antiquity. They are an efficient and effective means of reducing stress. The various types of meditation may broadly be divided into concentrative meditation where the focus is on one object such as a candle flame or mandala, image, sound, word, or mantra and mindfulness meditation where the focus is on emotional nonattachment but broad awareness of many objects, sounds, other sensations, or thoughts. For concentrative meditation, the focus is on a single item, while for mindfulness meditation the focus is open to the flow of all stimuli. Both may involve entering a trance. The concentrative trance reduces external awareness, while the mindfulness trance maintains external awareness while remaining calmly centered. There are parallels of concentrative meditation to internally focused hypnotic trance and of mindfulness meditation to alert awake hypnotic trance.

Mindfulness meditation has also been used extensively for stress reduction. Originally associated with Buddhism and in particular Zen, it has been adapted for medical use. Jon Kabat-Zinn [39, 40] has been a major proponent of this methodology, employing mindfulness meditation and hatha yoga stretching. He developed the Mindfulness-Based Stress Reduction program. The 8 week course had weekly 2 h classes where techniques of breath, awareness of body sensations, and stretching yoga combined with at half day of meditation and daily homework of 45 min taped guided meditation or 30 min of meditation on their own helped them to develop nonjudgmental, moment to moment awareness, attention monitoring, and acceptance. He also performed a study [41] with randomization of psoriasis patients undergoing ultraviolet B (UVB) or psoralen plus ultraviolet A (PUVA) light treatments into two groups, those listening to mindfulness meditation tapes and those who were controls. Patients in the mindfulness meditation tape group reached the halfway point in clearing and the clearing point significantly more rapidly than the controls for both UVB and PUVA treatments.

Slow calming music such as classical music with a tempo of 60–70 beats per minute has been demonstrated to reduce anxiety in children in a waiting room in an emergency department setting [42]. This technique can also be used for relaxation of children and adults prior to and during skin procedures. The slower tempo helps to shift the patient out of sympathetic into parasympathetic dominance with its ensuing relaxation. Another approach has been to loan an MP-3 player (iPod Nano) to individual children while in the pediatric emergency department. The MP-3 players were color coded with different kinds of music for infants/toddlers, preschoolers, school-aged children, and adolescents [43]. This method is more expensive but allows provision of age-appropriate music. A systemic review of randomized control trials using music therapy for children listed and assessed the various studies and their generally favorable results [44]. In a randomized control trial, music was shown to reduce adult patient anxiety significantly during Mohs micrographic surgery [45].

Positive expectations and a positive doctor-patient relationship can affect the child’s experience of treatment, can reduce pain, and may influence outcome. Negative expectations can produce negative nocebo results [46]. Care must be taken in selecting language that will have a positive rather than negative effect on the patient. Research on the placebo effect illustrates that the natural healing capacities of individuals can be enhanced and nurtured [47]. The placebo effect for some common dermatologic conditions such as acne and urticaria is about 30 % [48]. The Griesemer index [49] rates dermatologic disorders on a percentage scale from 100 % to zero percent based on emotional triggering of the condition. Those disorders higher on the Griesemer scale are more likely to have a significant placebo effect. Younger children are often easily influenced, while adolescents may resist influence by physicians and parents. Adults vary in their responsiveness. Ethical considerations often limit the application of the placebo in clinical practice.