Vol.1, No.4, 290-293 (2009)
doi:10.4236/health.2009.14047
SciRes Copyright © 2009 Openly accessible at http://www.scirp.org/journal/HEALTH/
Health
Body balance reduces eczema in stress-related atopic
dermatitis
Anna Utterström, Solbritt Lonne-Rahm
Department of Medicine, Karolinska University Hospital, Solna, Stockholm, Sweden;
Received 20 September 2009; revised 13 October 2009; accepted 14 October 2009.
ABSTRACT
Atopic dermatitis (AD) is a common chronic,
pruritic, relapsing inflammatory skin disease
that affects about two to three percent of the
adult population in Sweden. It is characterized
by dry, itchy skin and is aggravated by stress.
This study examined if relaxation through
movement and body awareness can reduce
stress and eczema in patients with AD. Nine pa-
tients with atopic dermatitis whose condition
worsened due to stress were treated with a
body balance relaxation method. Estimation of
extent of skin lesions, pruritus, salivary cortisol,
as an objective marker for chronic stress, and
subjective stress, and DLQI, were performed. Of
these parameters, the extent of skin lesions,
pruritus, and the subjective stress were de-
creased as well as chronic stress. This study
indicated that relaxation using body balance
reduced stress and eczema in patients with
stress-related atopic dermatitis.
Keywords: Atopic Dermatitis; Body Balance;
Eczema; Relaxation; Stress.
1. INTRODUCTION
Atopic dermatitis (AD) is a common, pruritic, chroni-
cally relapsing inflammatory skin disease that is often
associated with other atopic manifestations such as
bronchial asthma, allergic rhino-conjunctivitis and food
allergies. The etiology of AD is unknown, but it is pre-
sumed to be multifactorial with interaction between ge-
netic and environmental factors [1]. The skin disease is
typically present in early childhood and may continue or
recur later. It affects about two to three percent of the
adult population [2]. There is geographical variation in
the prevalence of eczema in adults both within and be-
tween countries and it has become more prevalent in
recent decades [3]. The diagnosis of atopic dermatitis is
usually based on several variables, including anamnestic
and clinical findings. The criteria of Hanifin and Rajka
[4] have been scientifically evaluated and can be applied
successfully in the clinical situation. Important trigger
factors are irritants, microbial agents, food, hormones
and stressful life events [5].
Emotional stress has a great influence on the immune
system and can be manifested in skin disease [6]. A
stress reaction is a nonspecific response of the organism
to any type of burden or threat. A stimulus is perceived
as stressful if the individual does not believe that he or
she can exercise any influence on the frequency and in-
tensity of the stimulus. It is a highly regulated, wide-
spread reaction and a number of hormones are activated
during a stress response.
Relaxation has been used to treat atopic eczema pa-
tients and dermatological treatment combined with mas-
sage [7,8] and behavioral therapy has been reported to be
an effective method [9].
The aim of the study was to examine a method of re-
laxation for this group of patients, who usually have
problems finding a way to relax by themselves, in order
to reduce chronic stress since stress is a worsening factor
for patients with AD. Subjective stress was investigated
by using a stress enquiry, and objective stress by using
cortisol as an indicator of chronic stress [10].
2. MATERIAL AND METHODS
2.1. Patients
Nine women with AD, with a mean age of 32 years
(range: 19 to 42) who had active atopic moderate to se-
vere dermatitis (as defined by the criteria of Hanifin and
Rajka [4]) were referred to the Neurocutaneous recep-
tion at Karolinska University Hospital in Solna, Sweden,
by other dermatologists. Each had a history of eczema
being aggravated by stress.
The patients evaluated their ongoing stress level and
the intensity of itching by using a Visual Analog Scale
from 0 to 100 (0 = nothing, 100 = worst) before and after
each treatment. They also evaluated the percentage of
body surface covered by eczema by using a Visual Ana-
log Scale from 0 to 100 and completed a “Dermatology

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Life Quality Index” (DQLI) before and after the treat-
ment period. Each patient received five individual treat-
ments, once a week. Each session lasted approximately
1.5 hours. The patients have their usual topical treatment
during the period of stress relaxation.
2.2. Salivary Cortisol Test
Salivary cortisol samples were obtained from all pa-
tients before and after the period of treatment. The
saliva samples were collected in plastic vials at 8.00
am on three consecutive days. At 10.00 pm on the last
day, 0.25 mg of dexametason was administered orally,
followed by a new cortisol test on the following
morning. The samples were stored at -20oC until
analysis and cortisol concentrations were determined
using a radioimmunoassay kit (Spectria Cortisol,
Orion Diagnostica, Espoo, Finland). The ratio of the
mean of the previous three values to the last cortisol
value was determined, with a low ratio being an indi-
cator of chronic stress [7].
2.3. The Dermatology Life Quality Index (DLQI)
The DLQI consists of ten items covering different as-
pects of skin disease-related symptoms during the pre-
vious week. There are four alternative responses to each
question: “not at all, “a little,” “a lot” and “very much,”
with corresponding scores of 0, 1, 2, 3, respectively. The
total score is calculated by adding the scores for each
question, and the total score ranges from a minimum of
0 to a maximum of 30, with a higher score indicating a
greater impact on quality of life. The Danish version of
the DLQI has previously been shown to have satisfac-
tory reliability and validity [11]
2.4. The Body Balance Relaxation Method
The Body Balance relaxation method is a program of
body awareness exercises designed to enhance mental
and physical awareness. The patient becomes more
aware of his or her body and emotions at the time of
treatment, which enhances his or her sense of self
awareness and relaxation. The exercises are done with
the patient in sitting and recumbent positions, and the
time required for the treatment is between sixty and
ninety minutes.
The Body Balance relaxation method divides the body
into seven different levels:
1) Pelvic floor, including legs and feet, 2) Pelvis, 3)
Solar plexus, 4) Thoracic cage, 5) Neck, 6) Forehead and
head, 7) Top of the head.
During the treatment, the patient is instructed to con-
centrate on one level at a time, focusing first on the pel-
vic floor in a sitting position and then the rest of the
program while lying down, continuing level by level to
the top of the head. Each level is treated as follows:
1) Movement: The patient makes slow cross-lateral
movements and rotations along and around the center
line of the body as well as movements between the upper
and lower parts of the body.
2) Breathing: The patient is instructed to inhale and
exhale in pace with the movements, and then to relax
and breathe freely. The exercises stimulate abdominal
breathing and the patient experiences a deepening of
breathing and an increased feeling of roominess in his or
her thoracic cage.
3) Sound: The patient also makes vowel sounds to-
gether with the movements, with different vowels used
for each level, for example, an “o” sound for the pelvic
floor.
4) Color: The patient is asked to visualize colors dur-
ing the program, with one color used for each level, for
example, visualizing red when concentrating on the pel-
vic floor.
Movements, breathing, sound and color help the
patient focus on one level of the program at a time.
Once the patient has focused on a particular part of
the body, he or she is instructed to lie back and relax.
During relaxation, the patient notes how the particular
part of the body feels and how mentally and physi-
cally relaxed he or she is at that time. With practice,
the patient can use this technique alone to achieve
relaxation and inner balance as well as to improve self
awareness.
2.5. Statistical Methods
The total sum of stress, skin symptoms and DQLI
scores for patients in the group was compared using
the Wilcoxon Signed Rank Test. The level of signifi-
cance was set at p0.05.
3. RESULTS
3.1. Extent of Eczema
The mean percentage of body surface covered by ec-
zema before the first session was 46, range 10-90, and
after the last session was mean 29, range 10-60, with a
strong tendency to a decrease (p=0.068) (Table 1 and 2).
3.2. Itching
Before the first session, the mean of itching scored on
the Visual Analog Scale was 39, range 9-73, and after
the last session 5, range 0-23, with a decrease (p
 0.01).
3.3. Stress Score
Before the first session, the mean of the subjective stress
score was 46, range 18-79, and after the last session,
mean 3, range 0-21, with a decrease (p0.01).
3.4. Cortisol Ratio
The mean of the cortisol ratio before the first session

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Table 1. Before the treatment.
Patient Extent Pruritus
Stress Cortisol ratio DLQI
46 22 0.8 10
70 49 1.3 11
22 24 0.8 19
4 20 9 18 2.7 10
5 20 13 32 0.4 2
6 1 80 69 1.9 13
7 2 70 60 0.2 4
8 3 60 63 0.4 8
9 10 49 79 1.2 7
Mean 46 39 46 1.0 9
Table 2. After the treatment.
Patient Extent Pruritus
Stress Cortisol ratio DLQI
1 30 7 0 2.0 8
2 40 0 0 5.2 12
3 60 23 3 10.4 17
4 20 2 1 6.9 10
5 20 0 0 3.1 1
6 30 2 21 2.0 17
7 20 0 0 3.6 1
8 30 10 0 5.7 10
9 10 0 1 5.3 4
Mean 29 5 3 4.9 9
was 1, range 0-3, and after the last session, mean 5,
range 2-10. Thus, there was an increase (p0.01), indi-
cating a lower level of chronic stress following treat-
ment.
3.5. DLQI
Before the first session, the mean of DLQI was 9, range
4-19, and after the last session being 9, range 1-17, with
no evident difference.
4. DISCUSSION
Personality and stress may play important roles in the
pathogenesis of AD [12]. AD can be induced or wors-
ened by stress, and all of the patients involved in the
study confirmed that stress is an initiating or exacerbat-
ing factor. We do not know exactly how many patients,
indicating that stress impairs their eczema, but all pa-
tients with AD who seeking to Karolinska Hospital may
offer to go on neurocutana reception, where stress man-
agement is part of the treatment. The atopic dermatitis
outpatients at the Neurocutaneous reception were re-
ferred in order to reduce their chronic stress levels. Some
of the patients had tried different types of relaxation be-
fore without success. All together, the components of the
program helped patients to reduce stress and increase
physical and mental awareness. In this limited study in
which women with stress-related atopic eczema partici-
pated, we have shown that this type of relaxation has
tended to reduce the inflammation of the skin. Unfortu-
nately, during this period, no men participate in the study,
but to reduce stress is important in the treatment of in-
flammatory diseases for all patient categories.
The body balance method stimulates several senses
and gradually improves physical and mental awareness.
The design of the movements and total focus on one part
of the body at a time make the method meditative, so it
is easy to let go of thoughts and stay focused on the body.
The movements reduce muscular tension along the spine
and provide physical relaxation. The patient also be-
comes more aware of the location of tension and tender
points in the back and how they change during treatment.
This increases the patient’s awareness of what is hap-
pening in his or her body.
During treatment, it was observed that the patients’
movements increased when they reported feeling
stressed or worried while their movements slowed and
became more rhythmical as they gradually began to re-
lax. Relaxation was enhanced through the vocalization
of sounds, which tended to reduce the tempo of the pa-
tients’ movements, and coordination was enhanced
through the synchronization of movement, breathing and
sound.
All of the patients in the study reported a reduction in
stress at each session and cited that they felt that they
were centered in the core of their bodies. Seven of the
nine patients reported that this feeling of being centered
lasted for some time after the sessions, from a couple of

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hours up to several days.
One patient, who had been on sick leave for approxi-
mately one year due to burnout and who experienced
bouts of anxiety especially in the evenings, found that
she felt less stressed and anxious at each session and
experienced less stress in daily life. She also reported
that her skin did not itch or burn as much or as often as
before. This patient was also able to reduce her anxiety
outside of the sessions by using the body balance
method. This positive effect was confirmed by an inde-
pendent psychologist who had been seeing the patient
for several months prior to the study.
The main symptoms of AD are dryness of the skin and
severe pruritus. This occurs episodically or persistently
in the eczematous areas and leads to vigorous scratching.
Unconscious scratching may be particularly severe dur-
ing the night, resulting in poor sleep. During the study,
the patients became relaxed during the sessions and their
skin reactions decreased. They reported less or no itch-
ing, burning or pain compared to before the sessions.
They also reported that they were able to maintain this
sense of relaxation for some time afterwards.
It is possible that the lack of impact on the DLQI
might be due to the rather short time period of the study,
with a latency in the recording of changes in this pa-
rameter. The patients may have adapted to their illness
and had a negative self-esteem and they may have
needed psychological counseling to reduce their avoid-
ance and helplessness [10]. For this reason, it would be
interesting to conduct a longer study on the body balance
method.
In this uncontrolled study, we have focused on relaxa-
tion with a body balance method. Though there was no
indication of an increased use of topical treatment, using
steroids, within the studied patients, it would be useful to
erform a similar controlled study. p
5. CONCLUSIONS
Stress management is an important part of the treatment
of stress-related eczema. Relaxation through body bal-
ance may be a method to reduce subjective and objective
stress and eczema in atopic eczema patients.
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