Delusions of parasitosis. A dermatologist's guide to diagnosis and treatment

A combined tropical medicine and psychiatry approach to patients with possible delusional infestation

BACKGROUND

Delusional infestation (DI) is a well-recognized delusional disorder presenting as the persisting belief of being infested. Combined clinics have been run by dermatology and psychiatry in a small number of centres. In this article we focus on our Liverpool University Hospitals NHS Foundation Trust clinic hosted at the Liverpool School of Tropical Medicine, UK, where we run a specialist clinic for DI.

METHODS

We describe the specific set-up and approach of our clinic as a guide for clinicians working in specialties likely to see patients with DI (including tropical medicine, infectious diseases and dermatology) who may either want to set up similar clinics or be better equipped to manage DI patients promptly within existing practice.

RESULTS

We describe the details of the clinic's approach. Between 2018 and 2023, the service saw 208 patients, of which 82.7% could be assessed and 55.7% had DI. The female:male ratio was 2:1.

CONCLUSION

Interdisciplinary combined clinics with medical and psychiatry consultants working together offer an approach to managing this rare, challenging and high-consequence condition.

State-of-the-Art Review: Evaluation and Management of Delusional Infestation

Delusional infestation is a condition encountered frequently by healthcare professionals across a variety of specialties in which patients have a fixed, false belief that they are infested with living creatures, such as bugs, parasites, worms, or mites, or nonliving objects, such as fibers. Delusional infestation can be debilitating for patients, who not only present with intense psychological distress and physical discomfort but are also at risk of developing numerous dermatological and psychiatric complications. This condition poses unique diagnostic challenges, as these symptoms can occur secondary to many metabolic or infectious causes, as well as unique treatment challenges, with patients frequently refusing psychiatric care and consequently seeking evaluation by other healthcare professionals. In this review, we aim to use existing literature to provide clinicians in infectious diseases or other specialties with sufficient clinical context and treatment guidance for the appropriate management of delusional infestation.

The Diagnostic Workup, Screening, and Treatment Approaches for Patients with Delusional Infestation

Delusional infestation (DI) is a psychiatric disorder defined by the fixed, false belief that one has been infested by an organism without evidence to support this. Patients may present with skin lesions and report abnormal cutaneous sensations. The diagnostic workup for patients presenting with delusional infestation is essential to ensuring accurate diagnosis in ruling out other explanations for symptoms and investigating potential secondary causes of DI. In addition to a comprehensive history and physical examination, laboratory workup should be considered depending on the clinical picture. Antipsychotic medications are the most common drugs used in management of adults with DI and tailor the choice of treatment according to patient characteristics. This article serves as a guide for dermatologists, psychiatrists, and other clinicians as it reviews the workup and screening that should be considered when managing a patient with delusional infestation and subsequent treatment protocols once the diagnosis has been made.

Delusional infestation: an interface with psychiatry

Delusional infestation (delusional parasitosis) is a relatively rare condition but it has been of interest to a wide range of professionals, including entomologists, zoologists and dermatologists, as patients predominantly seek help from specialties other than psychiatrists. The illness requires a multidisciplinary approach and a strong bond of trust between the treating clinician and the patient to ensure the best possible outcome. This article discusses how clinicians in all specialties should approach patients presenting with the disorder and outlines differential diagnosis and associated laboratory tests. It considers the evidence base for treatment and the success of psychodermatology clinics that provide a ‘neutral setting’ for consultation to address the problem of patients’ non-engagement. Such clinics are few, and there is a need to develop disease-specific pathways in primary care and hospital settings to improve prognosis.

Stimulant use in patients presenting with psychocutaneous disorders

BACKGROUND

Psychocutaneous disorders are often attributed to stimulant medications, yet this relationship has never been fully elucidated. Literature on psychocutaneous disorders largely focuses on clinical presentation and treatment rather than disease etiology or exacerbation.

OBJECTIVE

To determine whether patients presenting with psychocutaneous disorders display high rates of stimulant use and psychiatric comorbidity.

METHODS

We undertook a retrospective cohort study of patients with psychocutaneous disorders presenting to a single center. It was hypothesized that these patients would have high rates of stimulant use and psychiatric comorbidity. Following analysis of baseline demographics, the patients were assigned to 1 of 2 groups: those with a psychotic disorder and those with a neurotic disorder.

RESULTS

Sixty percent of the patients (n = 317) with psychocutaneous disease had recently used a stimulant and more than 80% (270 of 317) carried an additional psychiatric diagnosis. The neurotic disorder group (n = 237) was younger and had higher rates of stimulant use. The psychotic disorder group (n = 80) had higher rates of psychosis, medical comorbidity, and illicit stimulant drug use.

LIMITATIONS

The predominantly Caucasian population may limit generalizability of findings as may the retrospective nature.

CONCLUSIONS

Patients with psychocutaneous disease have high rates of stimulant use and most have at least 1 psychiatric comorbidity.

A comprehensive entomological survey and evaluation of the efficacy of different therapies on a suspected delusional parasitosis case

OBJECTIVE

Delusional parasitosis (DP) is one type of psychotic disorders. It is a multifactorial disorder with different etiologies. Given that very little attention is paid to entomological survey in these cases, a comprehensive study was designed and performed for the first time in Iran on a suspected DP case and its home from Shiraz during 2018-2019.

METHODS

In this study, entomological survey, dermatological studies, and psychological and psychiatric interventions were done respectively on a 40-year-old man who was referred to as a suspected case of DP.

RESULTS

No medical importance arthropods were collected from the patient's home. He was not infected with lice and other ectoparasites. Skin samples were negative for scabies, but he was infected with Demodex folliculorum at low level. Psychiatric studies showed that he was a secondary DP case with depression. No effect and partial remission were reported after treatment with risperidone (2-6 mg/d) and olanzapine (5 mg/d), respectively. Therapeutic effects of hypnotism were also not satisfactory.

CONCLUSIONS

In Iran, the most important challenges these patients faced with are as follows: the absence of a specific referral center, patients resort to self-treatment or traditional methods, and lack of a certain duration and dosage of antipsychotic for these cases. Comprehensive clinical trials should be done on this rare syndrome at the national level for better understanding the epidemiological profile of DP and finding the best method of treatment for Persian community.

Substance use disorders and chronic itch

Chronic pruritus is one dermatologic manifestation of an underlying substance use disorder. Recent literature has uncovered similarities between the general neurologic mechanisms of addiction and chronic itch, largely involving activation of the dopaminergic reward circuits within the brain and imbalances between mu and kappa opioid receptor activation. It is likely that the use of specific drugs, like central nervous system stimulants and opioids, results in further activation and imbalances within these pathways, perpetuating both addiction and pruritus simultaneously. Opioid users often present to dermatology clinics with a generalized pruritus, whereas individuals using central nervous system stimulants like cocaine and methylenedioxymethamphetamine (MDMA), as well as legally prescribed drugs like treatments for attention deficit hyperactivity disorder, frequently complain of crawling, delusional infestation-like sensations underneath the skin. Because of these overlapping mechanisms and similar clinical presentations to many other chronically itchy conditions, it is necessary for dermatologists to consider and investigate an underlying substance use disorder to effectively treat these patients.

Historical and clinical considerations on Ekbom's syndrome

Ekbom's syndrome represents a relatively uncommon neuropsychiatric condition characterized by the recurrent and bizarre fixed delusional belief to be infested by small organisms or even unanimated materials ('Morgellons disease'), without any objective evidence of infestation/parasitosis. The condition, mainly diagnosed in a nonpsychiatric setting, is supposed to be largely underestimated and, hence, undermanaged. The present comprehensive review aims at investigating Ekbom's syndrome, from a historical, epidemiological, clinical and therapeutic perspective, by providing diagnostic-treatment strategies in managing this condition in routine psychiatric clinical settings. The prototypical patient is a middle-aged woman (or a younger subject in those cases in which substance and/or alcohol abuse is implicated), often single, divorced or widowed (loneliness component and social withdrawal), who has already consulted several specialists due to skin lesions associated with a firm and delusional belief to be infested. The identification and diagnosis are challenging due to poor patient's insight, poor knowledge and collaboration between specialists and differential diagnoses to be considered before asking for a psychiatric referral. Management and treatment strategies mainly derive from isolated case reports or observational studies with a small sample size. Further randomized clinical trials should be performed to evaluate the efficacy of newer antipsychotic drugs, including long-acting injectable formulations.

A systematic review of antipsychotic agents for primary delusional infestation

BACKGROUND

Delusional infestation (DI) is a rare delusional disorder in which individuals have a false belief that they are infested with bugs, parasites, or insects, despite the lack of medical evidence that such an infestation exists. Data on the effectiveness of antipsychotics for DI are limited.

METHODS

We conducted a systematic review using EMBASE, MEDLINE, PsycINFO, and Cochrane Central Register of Controlled Trials from inception of the databases up until July 20, 2018. Studies examining typical or atypical antipsychotics for primary DI were included.

RESULTS

A total of 51 relevant articles were identified, primarily case reports/series. Overall response was favorable for both typical and atypical antipsychotics, but there was no strong evidence to suggest that any one antipsychotic agent was preferable to other agents. Pimozide (1-16 mg/day) and risperidone (0.5-8 mg/day) were the most commonly studied typical and atypical antipsychotics, respectively. Inconsistent reporting of treatment outcomes and variability in study designs limited the overall evaluation of the data.

CONCLUSIONS

There remains a lack of sound data supporting the effectiveness of antipsychotic treatment for primary DI. Further research is required to establish more definitive conclusions about the relative clinical utility of antipsychotic agents for DI.

Delusional infestation: a prototype of psychodermatological disease

Delusional infestation (DI) is a disorder in which patients express a firm, unwavering belief that they are infested with some type of organism but otherwise have a typical grasp on reality with relatively normal cognitive functioning. Although classified as a somatic delusional disorder, DI requires special consideration due to its complicated clinical presentation, requiring attention to several possible explanations for the symptoms the patients describe. The purpose of the current review is to first summarize the clinical background and features of the diagnosis then explore treatment options. DI is a rare disorder though has reported cases dating back to the 19th century and spanning across the globe. Patients often experience the disorder as secondary to a medical condition, including substance use/withdrawal. However, there have also been many reported cases of primary DI, occurring in the absence of any other psychiatric or medical disorder. Clinically, DI is a diagnosis of exclusion, where the physician must rule out other medical conditions, including genuine dermatological disorders or infestations, or contributions from medications or substances. Patients with the disorder more commonly present to nonpsychiatric healthcare providers, making it essential for all clinicians to be able to identify the disease. Treatment can include either first or second generation antipsychotics, but it is important to proceed tactfully in discourse with the patient, being careful to address patients in a straightforward manner without reinforcing or questioning the delusion and focusing conversation on what can be done for the symptoms. Future research can continue to evaluate pathophysiology underlying primary DI, which historically has been an under-studied topic.

Ectoparasite defence in humans: relationships to pathogen avoidance and clinical implications

Currently, disgust is regarded as the main adaptation for defence against pathogens and parasites in humans. Disgust's motivational and behavioural features, including withdrawal, nausea, appetite suppression and the urge to vomit, defend effectively against ingesting or touching sources of pathogens. However, ectoparasites do not attack their hosts via ingestion, but rather actively attach themselves to the body surface. Accordingly, by itself, disgust offers limited defence against ectoparasites. We propose that, like non-human animals, humans have a distinct ectoparasite defence system that includes cutaneous sensory mechanisms, itch-generation mechanisms and grooming behaviours. The existence of adaptations for ectoparasite defence is supported by abundant evidence from non-human animals, as well as more recent evidence concerning human responses to ectoparasite cues. Several clinical disorders may be dysfunctions of the ectoparasite defence system, including some that are pathologies of grooming, such as skin picking and trichotillomania, and others, such as delusory parasitosis and trypophobia, which are pathologies of ectoparasite detection. We conclude that future research should explore both distinctions between, and overlap across, ectoparasite defence systems and pathogen avoidance systems, as doing so will not only illuminate proximate motivational systems, including disgust, but may also reveal important clinical and social consequences.This article is part of the Theo Murphy meeting issue 'Evolution of pathogen and parasite avoidance behaviours'.

Reframing delusional infestation: perspectives on unresolved puzzles

Delusional infestation (DI), a debilitating psychocutaneous condition, featured as a false fixed belief of being infested accompanied by somatosensory abnormality, behavior alteration, and cognitive impairment. Although management of primary causes and pharmacotherapy with antipsychotics and/or antidepressants can help to alleviate symptoms in most patients, the underlying etiology of DI still remains unclear. Morgellons disease (MD), characterized by the presence of cutaneous filaments projected from or embedded in skin, is also a polemic issue because of its relationship with spirochetal infection. This review aims to discuss the following topics that currently confuse our understandings of DI: 1) the relationship of real/sham “infestation” with DI/MD; 2) behavior alterations, such as self-inflicted trauma; 3) neuroimaging abnormality and disturbance in neurotransmitter systems; and 4) impaired insight in patients with this disease. In discussion, we try to propose a multifactorial approach to the final diagnosis of DI/MD. Future studies exploring the neurobiological etiology of DI/MD are warranted.

Skin-transmitted pathogens and the heebie jeebies: evidence for a subclass of disgust stimuli that evoke a qualitatively unique emotional response

Skin-transmitted pathogens have threatened humans since ancient times. We investigated whether skin-transmitted pathogens were a subclass of disgust stimuli that evoked an emotional response that was related to, but distinct from, disgust and fear. We labelled this response "the heebie jeebies". In Study 1, coding of 76 participants' experiences of disgust, fear, and the heebie jeebies showed that the heebie jeebies was elicited by unique stimuli which produced skin-crawling sensations and an urge to protect the skin. In Experiment 2,350 participants' responses to skin-transmitted pathogen, fear-inducing, and disgust-inducing vignettes showed that the vignettes elicited sensations and urges which loaded onto heebie jeebies, fear, and disgust factors, respectively. Experiment 3 largely replicated findings from Experiment 2 using video stimuli (178 participants). Results are consistent with the notion that skin-transmitted pathogens are a subclass of disgust stimuli which motivate behaviours that are functionally consistent with disgust yet qualitatively distinct.

Children with a mother with delusional infestation--implications for child protection and management

Delusional infestation (DI) is a reportedly uncommon psychocutaneous condition in which an individual holds a fixed, false belief of pathogenic infestation of the skin or body contrary to medical evidence. There are reports of such a delusion being shared with family members or close friends (folie a deux/famillie), but the implications of DI induced in children have not been discussed. We describe the case of a mother with DI whose children subsequently shared her belief. Implications for child protection and management are explored.

Uncommon and/or bizarre features of dementia

This study aimed at describing uncommon or bizarre symptoms observed in patients suffering from dementia. Medline and Google scholar searches were conducted for relevant articles, chapters, and books published since 1967. Search terms used included uncommon presentation, behavioural and psychological symptoms, dementia, Alzheimer's disease, and fronto-temporal dementia. Publications found through this indexed search were reviewed for further relevant references. The uncommon symptoms are described as case-reports and there are no systematic investigations. Bizarre behaviours arising late in life should be thoroughly investigated as symptoms of dementia.

Neural correlates of delusional infestation responding to aripiprazole monotherapy: a case report

BACKGROUND

The pathophysiology and appropriate pharmacological interventions for delusional infestation remain unknown.

CASE PRESENTATION

Here, we report a case of primary delusional infestation successfully treated with aripiprazole. We performed functional magnetic resonance imaging (fMRI) to investigate brain structures and functional modifications. Before antipsychotic treatment, pre- versus post-treatment fMRI images revealed a marked increase in brain activation in the supplementary motor area (SMA).

CONCLUSION

Our results highlight the efficacy and safety of aripiprazole in the treatment of delusional infestation and the possible role of SMA dysfunction in delusional infestation. Indeed, our results suggest that psychiatric improvement of delusional infestation is associated with normalization of brain activity, particularly in the SMA.

Delusions of parasitosis

Patients with delusions of parasitosis (DOP) are more commonly recognized in dermatology practices today. However, dermatologists may feel uncomfortable treating these patients because of the psychiatric nature of their disorder. As a result of the fact that DOP patients strongly prefer to seek treatment from dermatologists rather than mental health professionals, it is important for dermatologists to be well equipped with a basic understanding of the disorder and with tools to assist this patient population. In this review, we discuss the epidemiology, presentation, differential diagnosis and treatment strategy for patients with DOP.

An oral ulceration associated with Morgellons disease: a case report

Morgellons disease is a psycho-dermatologic condition in which patients report fibers or filaments "growing" out of their skin. This case report highlights an oral ulceration in a young woman associated with Morgellons disease, a condition that has not been previously described in the dental literature. An increasing number of individuals are self-reporting this condition and oral health care providers must be familiar with this disorder.

Ekbom syndrome: a delusional condition of "bugs in the skin"

Entomologists estimate that more than 100,000 Americans suffer from "invisible bug" infestations, a condition known clinically as Ekbom syndrome (ES), although the psychiatric literature dubs the condition "rare." This illustrates the reluctance of ES patients to seek mental health care, as they are convinced that their problem is bugs. In addition to suffering from the delusion that bugs are attacking their bodies, ES patients also experience visual and tactile hallucinations that they see and feel the bugs. ES patients exhibit a consistent complex of attributes and behaviors that can adversely affect their lives.

Morgellons disease and delusions of parasitosis

Morgellons disease is a controversial and poorly defined symptom cluster of skin lesions and somatic symptoms, most notably 'fibers' in the skin. Because of widespread coverage in the media and on the Internet, there are an increasing number of patients presenting to dermatologists. We present three patients who believed that they had fibers in their skin. We offer a discussion of delusions of parasitosis to demonstrate similarities between these conditions. It has been suggested by a limited number of healthcare providers that an unknown infectious agent underlies this symptom complex yet no available evidence supports this assertion. Laboratory values that would be reflective of an infectious process (e.g. elevated white blood cells, sedimentation rate, C reactive protein) are routinely normal and biopsies often reflect only nonspecific findings such as acute and chronic inflammation with erosion or ulceration. Patients with Morgellons disease generally lack insight into their disease and reject the need for psychiatric help. The goal is to build trust and refrain from minimizing what the patient experiences. Attentive examination of the patient's skin and fragments they present is necessary to rule out a true underlying pathologic process and to establish a trusting relationship. A supportive, non-confrontational approach is ideal. The patient is best treated by a team of practitioners of several specialties, including dermatologists, psychiatrists, and counselors.

Morgellons: contested illness, diagnostic compromise and medicalisation

The case of Morgellons illustrates how the emergence of a new medically contested illness intersected with and impacted on the diagnostic processes of an existing uncontested psychiatric condition, Delusional Parasitosis (DP). More specifically, the sociopolitical processes at play in the contested illness, Morgellons, dubiously reflect patient empowerment, as well the resilience and power of medical jurisdiction. This research offers insights into the contested illness and medicalisation literatures, and aims to bridge these two approaches towards the relationship between patient empowerment and medical authority, which I do through the notion of doctor-patient compromise. The data for this research come from a comprehensive qualitative analysis of Morgellons discourse through four key sources: the pro-Morgellons website Morgellons.org; the anti-Morgellons website Morgellonswatch.com; the popular media's portrayal of Morgellons; and the DP and Morgellons articles published in peer-reviewed medical journals, as made available on PubMed.

Ekbom syndrome: the challenge of "invisible bug" infestations

Ekbom Syndrome is synonymous with delusory parasitosis, a belief that one's body is infested by invisible bugs. Persons suffering from this syndrome often claim to feel dermal sensations and to visualize the bugs, although no one else can see them. Ekbom Syndrome is a delusional condition; it is intractable and cannot be corrected by argument or evidence. Ekbom Syndrome sufferers exhibit a range of predictable behaviors in their attempts to eliminate their infestations, including seeking identifications and treatment from physicians and entomologists. Frequently they also experience comorbid psychological conditions. Because this is a delusional affliction, successful treatment typically requires neuroleptic medications, necessitating intervention by medical professionals.

Delusions of parasitosis

BACKGROUND

Delusions of parasitosis (DP) is a rare psychiatric disorder in which the patient has a firm belief that she or he is infected by parasites. Although it is a psychiatric disorder, these patients often present to an emergency physician because they are convinced that they have a severe skin problem.

TREATMENT

Patients with DP often reject psychiatric referral. The diagnosis of DP can usually be made based on history alone. However, it is important that the patient does not have an organic skin disorder and that the delusion is not secondary to another mental or physical illness. The current treatments of choice are the antipsychotic medications risperidone and olanzapine.

CONCLUSIONS

In our experience, patients with DP seen in the emergency department who are suspected of having this condition can be a challenging diagnostic and treatment problem because they usually do not have health insurance. Consequently, we find it difficult to get dermatologic and psychiatric consultation to treat their illness.

Morgellons in dermatology

Delusional parasitosis (DP) is the most frequent delusional disorder in dermatology. In DP there is a fixed belief of a usually skin-related invasion or infestation by a number of alleged infectious species (usually parasites and bacteria), whose identity has varied over the decades. Since 2002 worldwide an increasing number of patients have complained of unverifiable fibers and filaments in or on the skin, associated with numerous nonspecific complaints (arthralgias, altered cognitive function and extreme fatigue). This entity has been named "Morgellons disease" by the patients themselves, although medical evidence for its existence is lacking. As an example, we discuss a 55-year-old woman who complained of Morgellons disease and was treated as if she had DP. Currently the delusional assumption of infestation with Morgellons should be considered as a new type of DP with some kind of inanimate material. We therefore recommend in case of DP including Morgellons the use of the broader term "delusional infestation".

Delusional infestation

This papers aims at familiarizing psychiatric and nonpsychiatric readers with delusional infestation (DI), also known as delusional parasitosis. It is characterized by the fixed belief of being infested with pathogens against all medical evidence. DI is no single disorder but can occur as a delusional disorder of the somatic type (primary DI) or secondary to numerous other conditions. A set of minimal diagnostic criteria and a classification are provided. Patients with DI pose a truly interdisciplinary problem to the medical system. They avoid psychiatrists and consult dermatologists, microbiologists, or general practitioners but often lose faith in professional medicine. Epidemiology and history suggest that the imaginary pathogens change constantly, while the delusional theme "infestation" is stable and ubiquitous. Patients with self-diagnosed "Morgellons disease" can be seen as a variation of this delusional theme. For clinicians, clinical pathways for efficient diagnostics and etiology-specific treatment are provided. Specialized outpatient clinics in dermatology with a liaison psychiatrist are theoretically best placed to provide care. The most intricate problem is to engage patients in psychiatric therapy. In primary DI, antipsychotics are the treatment of choice, according to limited but sufficient evidence. Pimozide is no longer the treatment of choice for reasons of drug safety. Future research should focus on pathophysiology and the neural basis of DI, as well as on conclusive clinical trials, which are widely lacking. Innovative approaches will be needed, since otherwise patients are unlikely to adhere to any study protocol.

Morgellons disease?

Morgellons disease, a pattern of dermatologic symptoms very similar, if not identical, to those of delusions of parasitosis, was first described many centuries ago, but has recently been given much attention on the internet and in the mass media. The present authors present a history of Morgellons disease, in addition to which they discuss the potential benefit of using this diagnostic term as a means of building trust and rapport with patients to maximize treatment benefit. The present authors also suggest "meeting the patient halfway" and creating a therapeutic alliance when providing dermatologic treatment by taking their cutaneous symptoms seriously enough to provide both topical ointments as well as antipsychotic medications, which can be therapeutic in these patients.

Psychocutaneous syndromes: a call for revised nomenclature

We propose abandoning three outdated, pejorative diagnostic terms: 'trichotillomania', 'delusions of parasitosis', and 'neurotic excoriation'. These insensitive terms are offensive to patients and become a barrier to treatment. We suggest the following alternative patient-centred nomenclature: 'neuromechanical alopecia', 'pseudoparasitic dysaesthesia', and (simply) 'excoriation'. We briefly review clinical and historical aspects of these disorders.

Psychodermatology: a guide to understanding common psychocutaneous disorders

OBJECTIVE

This review focuses on classification and description of and current treatment recommendations for psychocutaneous disorders. Medication side effects of both psychotropic and dermatologic drugs are also considered.

DATA SOURCES

A search of the literature from 1951 to 2004 was performed using the MEDLINE search engine. English-language articles were identified using the following search terms: skin and psyche, psychiatry and dermatology, mind and skin, psychocutaneous, and stress and skin.

DATA SYNTHESIS

The psychotropic agents most frequently used in patients with psychocutaneous disorders are those that target anxiety, depression, and psychosis. Psychiatric side effects of dermatologic drugs can be significant but can occur less frequently than the cutaneous side effects of psychiatric medications. In a majority of patients presenting to dermatologists, effective management of skin conditions requires consideration of associated psychosocial factors. For some dermatologic conditions, there are specific demographic and personality features that commonly associate with disease onset or exacerbation.

CONCLUSIONS

More than just a cosmetic disfigurement, dermatologic disorders are associated with a variety of psychopathologic problems that can affect the patient, his or her family, and society together. Increased understanding of biopsychosocial approaches and liaison among primary care physicians, psychiatrists, and dermatologists could be very useful and highly beneficial.