Episode 7 - Psychodermatology

In this episode, we speak to Prof Anthony Bewley and Prof Andrew Thompson about psychodermatology, a growing and exciting subspecialty within dermatology. We discuss multidisciplinary teams, methodological approaches to psychodermatology research and opportunities to get involved in the subspecialty.

Transcript

SPEAKER_00 0:18

Hello everyone and welcome to BJD Talks, the official podcast of the British Journal of Dermatology. In this podcast, we look well beyond published studies and explore the real-world implications of dermatology research in a relaxed and accessible way. The podcast is for anyone out there with an interest in skin health research. Whether you're a dermatology professor, researcher, registrar, patient, or just simply a skin enthusiast. We hope you'll join us as we build on our world-leading research and friendly discussion. My name is Dr. Johnny Gockian, and I am a dermatology registrar here in Leeds in the United Kingdom. As well as the BJDs, a podcast associate editor. Together, we'll dive into a huge, wide range of issues that's important to dermatology, including patient and public involvement in research, social media and dermatology scholarship, qualitative research, and artificial intelligence. Well, after a short break, we are back with a subject quite close to my heart. It's not just a subject, it's an entire sub-specialty. Psychodermatology. Psychodermatology is going from strength to strength in terms of recognition within the dermatology world. And this is no different in dermatology scholarship. From the findings of the mental health and skin disease report from the all-party parliamentary group on skin to the implications of new biologic therapeutics on mental health. This is an exciting time for psychodermatology. Fittingly, I have some exciting guests from the land of psychoderm. Uh firstly, I have Professor Andrew Thompson, consultant clinical psychologist at Cardiff University and Associate Editor here to BJD. Hi, Andrew. Hi, Johnny. Thanks for the invitation. Brilliant. Also, I'm delighted to welcome Professor Tony Beauleigh, Consultant Dermatologist at Burps and honorary professor of dermatology at Queen Mary University London. Thanks for joining, Tony. Hi Johnny. Hi, everyone. Brilliant. So let's let's trip this back to the very basics. As some of our more junior listeners, or perhaps some patients or non-dermatologists, might not have actually heard very much about psychodermatology. Perhaps if I start with you, Tony, what is psychodermatology and why does it matter so much?

SPEAKER_01 2:26

Well, psychodermatology is a newer and emerging subspecialty of dermatology. And it's really two sides of the same coin. It is either primary psychiatric disease, which presents to dermatology healthcare professionals. So that's things like delusional infestation, body dysmorphic disorder, dermatitis artifacta, the people who pull their hair out or pick holes in their skin or scratch their skin, all of that. Or it is primary dermatological disease in which there is large psychosocial comorbidity. So that's things like eczema, psoriasis, fitiligo, acne, where patients have disorders of affect, in other words, anxiety andor depression, or have self-esteem issues, or even feel so awful that they would consider not living rather than living with their skin disease. In other words, they would consider suicide rather than continuing to live with the skin condition that they have.

SPEAKER_00 3:31

So there's a lot of quite emotive but of absolutely fascinating possibilities there. Why do you think that psychodermatology has become more of interest and more commonly known about recently?

SPEAKER_01 3:46

Well, there are several things that we need to remember about psychodermatology. First of all, it's very much a multidisciplinary team. So it involves very much the interactions of dermatologists, psychiatrists, psychologists, GPs, so primary care colleagues, and dermatology nurses. And all of these individuals are really crucial in managing the well-being of our patients with psychodermatological disease. So we know from the all-parts of parliamentary group on skin reports that 98% of patients with skin disease have disorders of affect or anxiety and/or depression. So pretty much all patients have some degree of psychosocial comorbidities. So it's quite clear that it's a really major thing for our patients. So it's not just about the skin disease, it's not just about psoriasis or vitiligo or eczema, it's about the patient and it's about managing the patient holistically. And what we know is that for decades, people with psychosocial comorbidities or with primary psychiatric disease have not been managed well for quite a long time by either dermatologists or by GPs. So that when you set up a psychodermatology clinic, you find that there are loads of patients who are desperately in need of the expertise that you can offer. For me, it's a bit like um probably before you were born, Johnny, actually, but in the years gone by in the 1980s, people set up vulva clinics. And patients with vulnerable disease were managed moderately by gynecologists or other people. And then when people set up vulva clinics, all of a sudden the expertise and the management of patients with vulnerable disease became a multidisciplinary process. And these women were managed effectively and comprehensively. And so it is with psychodermatology, the emerging specialty or subspecialty of psychodermatology. It's now being realized that patients with psychodermatological disease need a multidisciplinary team approach. And then they will get better, and they'll get better more comprehensively, and there'll be less recurrence of their problems, and also they'll get better much more quickly. Am I going to really depress you if I tell you I'm a 90s kid? Not at all. You don't even look that old, Johnny. I would have thought that you were the generation Z or whatever it is these days.

SPEAKER_00 6:19

Just talking about teams and mentioning psychology. So Andrew, would you be able to tell us a bit about the psychologist's um perspective within this subspecialty of psychodermatology?

SPEAKER_02 6:30

Yeah, I mean the clinical psychologist's role is really to assess in detail the nature of the psychological presenting issues and then to offer appropriate intervention. And that could involve individual therapy, and we can draw on sort of tried and tested mental health therapies such as cognitive behavioural therapy or compassion-focused therapy or acceptance and commitment-based therapy, those sorts of approaches. Or it might involve providing group intervention to people, or it might actually involve co-working alongside dermatologists and dermatology nurses to design a plan to say support someone in uh reducing their scratching behaviour using relatively simple techniques like habit reversal. On some occasions, it might just be spending a short amount of time with the patient assessing them and then providing them with some guidance towards self-help. But often, uh, you know, given what Tony was just saying there about a level of distress, we are um offering people uh an in-depth uh psychological therapy.

SPEAKER_01 7:33

And what is interesting, you know, Andrew, is that we as dermatologists on the whole don't really haven't really got our head around talk therapies. We understand a bit of mindfulness and relaxation techniques, and we know about CBT, but really our that's where our knowledge usually ends, which is why it's really important to have dedicated psychologists attached to at least regional psychodermatology clinics. I don't know if he wants to talk a little bit about that because for us it can be so confusing about the different talk therapies.

SPEAKER_02 8:08

I think the thing about psychological therapies is they are a time-consuming intervention. So you typically see in someone for a sort of a 50-minute period, the evidence base for sort of common mental health disorders looks at around about sort of 12 sessions or so. So it's not something that you can build in alongside your regular consultation. I mean, it's really important to say that it is absolutely everyone's responsibility working in dermatology to be assessed for psychological distress. And if you don't ask, you won't get, you know, people will often be very used to presenting themselves in the busy clinic, you know, presenting their skin. Often if you don't ask them, how are you doing today? How is this affecting you? You know, just simple questions like that. They often won't tell you how they're feeling. Sometimes you can see it, sometimes you can really see the distress, but other times people are masking it or hiding it. So, you know, I think it's everyone's responsibility to assess. There are some interventions, psychological interventions, that obviously dermatologists and dermatology healthcare professionals can offer and build into their practice. But the therapy itself involves specific training and tried and tested interventions, as well as giving people the opportunity to go into some detail about the nature of things that are distressing them.

SPEAKER_01 9:30

But what we do have as well, don't we, Andrew, is we can signpost patients to things like IAPT improving our access to psychological therapies. And, you know, all of our patients can be signposted via online Google searches looking for IAPT, IAPT services. Most of our patients can actually self-refer to that. But also it is really important to remember that we are a multidisciplinary team service and that psychological interventions are available for our patients.

SPEAKER_02 10:04

Yeah, and I think another thing that we've not mentioned as well is the wider impact on the family. So, you know, we've been doing some work recently to support parents in relation to the stress that can be attached. I mean, parenting can be stressful anyway for all of us that are parents. But if you have a child with a long-term skin condition, that can present uh and cause some distress in the wider family. So I I think psychological interventions are available there as well to help parents manage that impact.

SPEAKER_01 10:36

I did just want to say as well, if I could, that you and I are both working with the BAD, the British Association of Dermatologists, to develop an online service for dermatology patients so that they can have some kind of access to material via the skinhealthinfo.org.uk, which is the BAD patient hub, so they can access some kind of guidance around psychological therapies and also some kind of basic assessment. And I know that you did some of this work up in Sheffield, didn't you, Andrew? Yeah, thanks, Tony.

SPEAKER_02 11:12

Yeah, I think we in mainstream mental health now uh we offer sort of stepped care model. And as I'm sure people the listeners are aware that a lot of primary care mental health uh interventions, people have a choice so that they can access self-help materials, they can attend groups, and as Tony's mentioned there, they can get that through our IAP services. We have spent some time developing specific resources for IAP services to use for uh relation to skin-related distress, and we are tweaking those to make them more accessible to the wider public. I think they do have the potential to reduce mild distress, and they also have the potential to destigmatise the fact that people are experiencing distress and give people a nudge to seek the further support that they may need and deserve to get help with, either via their GP or via obviously talking to uh the dermatology healthcare professional. Um, one of the things that I think is really important, and we've alluded to this uh a few times in terms of the multidisciplinary nature, but also in terms of the assessment, I can't stress strongly enough how much I think patients, if we had a patient on here now, I'm sure who's received good holistic care, people do really value being asked about how there's psoriasis or eczema or whatever the primary disease is, how that's impacting upon them. And then obviously, when you're getting into the more tricky situations where you've got, as Tony was talking about, sort of primary psychiatric conditions, then obviously the dermatologist, it's really the gatekeeper because these people are really, really focused on their skin. And if you try and nudge them and push them towards going and seeing their GP to see another healthcare professional, someone like me, a psychologist or a psychiatrist, they're often just gonna tell you where to go and walk off in a more distressed place. And dermatologists have a really key role in really opening up the door to them receiving the psychological and psychiatric support that they need. But you won't get there without the dermatologist.

SPEAKER_00 13:25

Well, exactly. And I think our listeners will now appreciate just how exciting and interesting the world of psychoderm is, given that even with just one question, we are now almost 15 minutes into this podcast. Just from asking what is psychodermatology, so we can see how passionate obviously you both are, but also how so much is going on um uh at the moment and the kind of complex um interplay between the teams and between dermatologists and patients. Kind of moving gently away from practice. Obviously, we will come back to that throughout, but I want to talk about um research, considering this is a research-based podcast. What are the current like academic issues, updates, or debates going on in psychodermatology at the moment? What's trendy?

SPEAKER_01 14:05

Well, there are loads of things which are really worth highlighting. The first thing to say is that psychodermatology.co.uk have an annual meeting. Well, actually, it's it's twice a year. There's one at the BAD and there's one that's separate over at St. John's on the fourth Thursday in January. So have a look at psychodermatology.co.uk and you'll see the program there. It looks really good. Second thing is that ESDAP, the European Society for Dermatology and Psychiatry, which is psychodermatology.net, also has a biennial, in other words, every other year conference. And that conference is going to happen next June in Rotterdam in the Netherlands. And that also two or three-day conference, really good, really great research. What's happening in the world of research and psychodermatology? Well, from a primary psychiatric disorder perspective, then there has been the recent guidance, and this is a global first about the management of patients with delusional infestation, and that was published earlier this year in the British Journal of Dermatology with Alia Ahmed as the lead author, but it was very much a multidisciplinary team authorship, and that's a global first trying to give us guidance about the management of patients with delusional infestation. SDAP have produced some studies recently which are very interesting. There was the first study back in 2015 and the JID from Florence Dalgard looking at the different spectrum of psychological disorders associated with skin disease. So if you look up Dalgard F on JID from about July 2015, you can find that paper, and it really tells us very clearly about the psychosocial comorbidities of just about every skin disease. SDAP have actually moved further from that and are now studying across the whole of Europe and actually North America, looking at stigmatization in dermatology. And that's really important because lots of patients who have dermatological disease do have psychosocial comorbidities, but they won't own those psychosocial comorbidities. So if you say to a patient, well, this is clearly really upsetting you, you know, and I'm wondering if you might be a bit depressed, and I'm wondering about thinking of starting an antidepressant or even some torque therapies. And there were some patients just will not own that they might be feeling that way because there are stigmas associated with having psychological disease, which people don't have with physical disease. So that stigmatization is important, and those mindsets are important. So they might be cultural, they might be social, and there might be a whole range of different reasons why they're there. But the point is that they are there. So SDAP have identified that too. And then the third thing of research, which I already want to highlight, is the whole idea of neuroinflammation. And this is really important and really growing. The basic premise is that long-standing chronic inflammatory skin disease has its own individual chronic inflammatory signature within the brain. In other words, the anxiety andor depression associated with living with long-standing severe or not so severe psoriasis or eczema can lead to its own cytokine changes within the brain, neuroinflammation. And if we can get that cytokine signature altered quickly and comprehensively, then you can deconstruct that neuroinflammation and resolve the anxiety andor depression with anti-inflammatories, which is a really fascinating concept. And that's growing at the moment. And I know that some of the colleagues from Manchester are being quite preeminent in that. So that's people like Elise Klein and Chris Griffiths from up in Manchester.

SPEAKER_00 17:43

I would say in that, I mean, have having done a bit of a deep dive in reading about the neuroinflammatory side of things, it's absolutely fascinating. So I really would recommend that for our listeners. And you've both also touched on stigma as well, which I'm going to come back and talk about um shortly because it's a fascinating and quite moving area to talk about too. But before I do, um, Andrew, in terms of your perspective, if you had to recommend one paper, one study, or even just one area within psychodermatology research, what do you think you would highlight?

SPEAKER_02 18:12

Oh wow, that's a big question. You should know the answer to that. We'd never recommend read just one thing. You know we're on a lifelong CPD journey here, aren't we? And with the BJD, we'd say, you know, read the whole thing, you know, but make sure you're up to date. There's some great books that have come out recently on psychodermatology, and there's some good chapters as well. They're good starting places. I've just had a study published on mindful parenting as an intervention to reduce parenting stress associated with parenting the child with expert. Um, you know, there's a collaborating with a group of researchers um in Southampton at the moment, developing an acne uh facing resource, and we've been circulating that on uh social media. We've actively recruited for that study. So it'd be great if uh people can be signposted to that. And another little plug is I'm uh co-editing a special issue in Frontiers in Medicine in the dermatology section, and we've got a call out for the moment for any research that's focused on psychosocial issues, including things that cover some sort of nuanced issues that patients commonly complain of, such as itch, where psychological uh interventions and mechanisms are often implicated. And that's probably enough for me on research.

SPEAKER_00 19:34

That's great. So regular listeners to this podcast, I know I like to ask kind of just really quite big, sometimes leading questions. As with all my guests, I'm always very happy to have people plugging things. So I'm very happy that you're both doing that. So in uh I just wanted to touch on um kind of in line with the stigma side of things, but uh, we're seeing more and more research looking at the psychosocial needs of patients in major dermatology journals, and including, I should say, with a plug on my own, um, um, four from the BJD in the last month alone. And these are particularly often using uh qualitative methodological research uh approaches. Has this always been the case in the past? I mean that is a very leading question because I don't think it has, but and if that's changed, why do you think that's changed?

SPEAKER_01 20:17

Well, you know, the quality of the psychodermatology research is going up and up and up. So when I first entered into psychodermatology, some of the papers which were published were all right, but now there is much greater rigor around the quality of psychodermatology research. So, for example, delusional infestation is very difficult to research in terms of randomized controlled clinical trials because there is inherently a conflict of interest as soon as you set up some kind of ethics committee, and we know this because we tried to get a randomized controlled clinical trial in delusional infestation agreed by an ethics committee back in 2004, and they forced us to generate a patient information leaflet saying you have delusional infestation, and we're going to randomize you to either have a medication which is an antipsychotic or a placebo. And of course, whenever we processed that with our patients, we just got zero uptake. And psychiatrists tell me that organizing randomized controlled clinical trials in patients who have persistent delusional disorder is more difficult. It's not quite so difficult in schizophrenia, but it is more difficult in persistent delusional disorders. So that we are inevitably looking much more at observational and qualitative research. And we must not dismiss real-world evidence and qualitative research because it really does add to the holistic picture of research. So, as I say, the research which is being published and presented at meetings like the ESDAP meeting next year in Rotterdam in June, www.psychodermatology.net, or SDAP 2023 is really good, as is the research that's presented at the Psychodermatology UK meetings, which is psychodermatology.co.uk. I would say as well that there is going to be a special issue of skin health and disease journal, the online journal, which is edited by George Millington. There is going to be a dedicated psychodermatology journal. So that particular issue is going to be specifically geared towards psychodermatology. And I think that more and more people are recognizing that psychodermatology is the quality of the work is actually getting better and better. I mean, which begs the question of should we have our own psychodermatology journal? And I think at the moment, probably the answer is no. At the moment, for example, SDAP puts its papers through ECTA. We did have a psychodermatology journal about 10, 15 years ago with uh Carger as the publisher, but it just didn't have the readership at that time to survive. In time, maybe it will do, but I certainly would promote the idea. BJD has got better and better and better as time goes on. And I would definitely promote the idea of having a section of the BJD, as we now have various sections in the BJD, a section dedicated to psychodermatology. So, John Ingram, if you're listening, perhaps a section on psychodermatology in the BJD would be where we should go to next.

SPEAKER_02 23:25

I mean, for me, I think it's important to flag up that we use the methods to answer the question. And qualitative research is really important in relation to development of interventions, for example. So you do the work to underpin the intervention using qualitative methods to make sure that it's accessible, understandable, fit for purpose. And also qualitative methods can also really help us to understand what's going on for a patient in terms of their lived experience having a particular condition. But it is important to recognise that psychological research into skin conditions requires use of all scientific methods from experimental methods and surveys right through to biological research as well, to understand some of the uh relationships and these inflammatory pathways that we mentioned earlier. I actually think BJD's really led on bringing psychodermatology to the fore. Uh, it actually has had some special issues previously uh on some aspects of psychological research. It has people like myself and previously people like Pauline Nelson as associate editor. So I think it's been very, very forward thinking, and other journals have really followed.

SPEAKER_00 24:44

Thanks, Andrea. And I definitely didn't tell them to say that. So that's that it's definitely it's it's true. Um the point I'm just going to make as well is that that the research follows your question, and so many of the questions that we ask in psychodermatology are, I think, are quite fitting to those cost of methods in the lived experience. Um you you can't answer some of the questions about lib experience with the RCT, you have to look at some sort of like interpretive phenomenological analysis, for example. So it suits a uh qualibod like me. I wanted to talk about the future. What do you guys think the next big research question should be centering on within psychoderm?

SPEAKER_02 25:20

For me, we still need to develop and of course test psychological interventions. So there's still a massive gap there in the evidence based. We know a lot about the level of distress. What we don't know is which interventions work. And I think that's across the board. I think that's talking about medications as well as psychological therapies and low-intensity interventions, by which I mean self-help and digital interventions. I also think we're moving in a direction where we need to answer some questions about the mechanisms that are underpinning some of this psychological distress. And I'm really keen that we don't lose sight of some of the social mechanisms that maintain the distress related to stigma, but also actually, it's really exciting to look at some of the pathways that are connecting the brain, the gut, the skin, and that we know are implicated in maintaining people's distress and vulnerability with a number of skin conditions.

SPEAKER_01 26:22

Yeah, I agree. I think there is such a lot of work that needs yet to be done. And the future is looking very open in psychodermatology research. So I'm forever being asked by medical students, junior doctors, have you got any projects for me, you know, so that it can progress their career? Which is absolutely brilliant and fine. And we always do, there is loads of stuff that we can do in research. So, I mean, for example, there is the whole idea of neuroinflammation, which is really important, and that's a growing area of research. The whole research around the basic psychiatric or the primary psychiatric diseases presenting to dermatologists, really understudied, particularly things like personality disorders in dermatology patients, all of that stuff really needs to be looked at. Also, the interventions. We have got various interventions, but we don't know which is the best. For example, we don't know which is the best antipsychotic in delusional infestation. We don't fully understand how best to manage things like body dysmorphic disorder and dermatitis artifacta. And then in other areas of psychodermatology, for example, quality of life, there is a growing understanding that standardizing and making sure that quality of life measures are consistent and reproducible. In other words, papers that look at quality of life use the same quality of life measures is really important. Remembering that quality of life measures can be non-dermatology specific, can be dermatology specific, or can be disease-specific, such as rosaqualf or rosacea. But standardizing these and making sure that papers that are measuring quality of life in the various dermatological conditions are consistent is really crucial. And then also managing patients with long-standing skin disease in our psychodermatology clinics. At the moment, we, you know, they're not managed particularly well. So we recognize the burden of disease, and there's still lots of work to be done about the burden of disease, but there's even more work to be done about the interventions that are available. Finally, research about making sure that we as healthcare professionals are kept in our own areas of safety and are encouraged and allowed to thrive. So I'm very, very keen about looking after us as dermatology healthcare professionals as well as our patients and making sure that our boundaries and our well-being is well maintained, not least in terms of complaints or in terms of the burdens or the volume of patients that we have to see, but also in terms of pacing ourselves. And there is a growing interest in mentoring and in training and in making sure that we as dermatology healthcare professionals are facilitated in being able to produce the excellent quality of work that we are very used to providing.

SPEAKER_00 29:26

That's a really interesting point, um, actually. And I want to just touch on that a little bit more because when I talk about psychoderm to some of my colleagues, just trainees across the UK, some of the points that are made of that is that it must be a very emotive and draining experience and that that issue of training transference from patients to doctor and the really kind of difficult challenges that people experience, including concerns about complaints. I imagine there are some myths there, but there are potentially some difficult experiences that psychoderm clinicians must deal with. Can you tell me a bit more about how we look after clinicians?

SPEAKER_01 30:01

And that's why it's so important that training is available. So there is training available via the annual dermatology training weekend. And again, you can find that either by emailing me, anthony.bewelly at nhs.net, or my colleague aliaar, dr dr. aliaal.armed, a h-m-ed-d at nhs.net. Now, uh, so we have uh and the the booking for the training weekend is well booked up for several years in advance. Myself and Alia are beginning to uh explore developing a diploma in psychodermatology. There is a diploma in psychodermatology available via ESDAP, the European Society of Dermatology and Psychiatry, but that is also very oversubscribed. So training is very important. That's the first thing to say. And then networking. So we have set up a national MDT, a national multidisciplinary team meeting to which you can come. It's once a month. Again, it's alia Ahmed. So dr. aliaalia.armed a h-m-ed at nhs.net. And we have a monthly meeting where we all get together, that's ourselves as dermatologists, psychologists such as Andrew Thompson, uh, psychiatrists such as Ruth Taylor, and we all get together and we talk and we share best practice, but also people will talk about the cases that they're finding really challenging at this time. And you get national leaders from across the UK and the Republic of Ireland who will be able to say, okay, well, I think in this case this is a difficult case, but this is how I would manage it. And you get a written sheet sent to you, which then if the patient complains, you can say to managers or colleagues, Well, I took this case to the national MDT and this was the advice I got. So it's really a port that we support each other in the management of some of these patients because something can be very challenging.

SPEAKER_02 32:04

I just flag up as well that there are some training resources available on Health Education England's uh website on the digital website. If you log in there and go to the dermatology section, there's a few slide sets there on psychodermatology. And uh it does for me start with assessment and just trusting your core skills and making sure that you're prepared to manage risk if it uh arises. And it's not a difficult thing to do. It's just being uh prepared and knowing where to signpost people to. And I I think people find this really rewarding as well. It completes the circle of the elastic care, and you know, what you'll get back from your patients by and large is a huge amount of gratitude that you're taking that additional interest in their well-being.

SPEAKER_01 32:53

Yeah, I think that's right, Andrew. I think I did want to just really emphasize that point that actually working in psychodermatology is hugely rewarding. And it's like any other area of dermatology, if you have the right training and the right support, for example, like medical dermatology or dermatological surgery, it's hugely rewarding and it's a really developing, growing area. So if you wanted to be at the cutting edge of dermatological research, then come into psychodermatology. There really is a lot of very interesting things which are happening right now.

SPEAKER_00 33:26

Fantastic. Well, I think you you both actually anticipated and mostly answered my final question, which is really if if you had one piece of advice or recommendations for an early career academic or clinician interested in getting stuck into psychodermatology for the first time, what tip would you give them?

SPEAKER_02 33:44

I think from the academic perspective, getting involved in multidisciplinary research would be the first tip always, because research is a team sport to learn about some of the psychological approaches and models and theories that maybe underpin the sort of biopsychosocial model. So that'd be one thing. And also that some relatively straightforward involvement in qualitative research can be really helpful as well because it gives you that opportunity to hear some nuanced stories from your patients, which we may not get the opportunity to hear in a busy clinic. And then I'd just say um read, read some of these recent textbooks that have come out on psychodermatology, which can really open your eyes to the breadth of the subdiscipline.

SPEAKER_01 34:26

Yeah, I think that's right. And also just by all means get in touch with one of the people who are who are running psychodermatology services across the UK, um, because most of us are really open to having colleagues come and join us, fit in, uh, you know, take part in the clinics, take part in research that's happening. We're all very, very keen on that. And we're all very enthusiastic. And I think that's what matters because it is actually quite good fun. I mean, patients are challenging, but they're also very interesting. And it is such a new, uh exciting area of dermatology. Yep. So come and talk to one of us. We would be only too happy to hear what's going on.

SPEAKER_00 35:02

Well, you've heard it here first, folks, for those medical students and early career educators who who all want a project. Um, you know I all have Tony's email address. Um, so I'll expect your inbox to be absolutely full of can you give me a project? But no, honestly, it's it's I'm really, really welcome to hear how encouraging um you both are for the the next generation of dermatologists and psychodermatologists, hopefully, because there is, as you say, loads of exciting things uh happening right now. And I'm sure after listening to this, we'll have converted a few more to the cause. Okay, uh, so that brings us to the end of today's uh special episode of BJD Talks. Uh, we've covered the hottest research topics uh within psychodermatology, discussing the key themes of uh multidisciplinary teamwork and uh issues uh such as stigma and different uh research methods that can be used within the subspecialty. We look forward to sharing the next episodes of BJD Talks. And in the meantime, please do let us know if there's any interesting issues within dermatology that you think we should discuss. Uh, we're always very busy and active in social media, so you can reach us via brjdermatol on Twitter and BRJ Dermatology on Instagram, or by using the hashtag hashtag bjd talks. Bye for now, you can see that you're gonna be a bit of a lot of people.