Cutaneous manifestations of psychiatric disease that commonly present to the dermatologist--diagnosis and treatment

Evaluation and Management of Pruritus and Scabies in the Elderly Population

Pruritus is the most common dermatologic complaint in the geriatric population. Its growing prevalence coincides with the rapid growth of the elderly population (>65 years of age) in the United States. According to the US Census Bureau, 16.9% of the population, or more than 56 million adults 65 years and older, lived in the United States in 2022. Pruritus is a condition that accompanies a diverse array of underlying etiologic factors. The mechanism of normal itch impulse transmission has been recently elucidated. The itch sensation originates from epidermal/dermal receptors connected to unmyelinated, afferent C-fibers that transmit the impulse from the periphery.

Psychiatric Features in Neurotic Excoriation Patients: The Role of Childhood Trauma

INTRODUCTION

Neurotic excoriation is a psychodermatological disease of primary psychological/psychiatric genesis, responsible for self-induced dermatological disorders. Childhood traumatic events are closely related with self-injurious behaviors. The aim of this study is to evaluate the psychiatric features of neurotic excoriation and to investigate the effect of childhood traumatic events on the disease.

METHODS

Thirty-eight neurotic excoriation patients who did not receive any psychiatric treatment within the past year and 40 healthy individuals having similar sociodemographic features were included in the study. For clinical evaluation, the Structured Clinical Interview for DSM-IV Axis I Disorders, Beck Depression Inventory, Beck Anxiety Inventory, and Childhood Trauma Questionnaire-Short Form were applied to all the individuals.

RESULTS

In this study, we observed that 78.9% of neurotic excoriation patients were diagnosed with at least one Axis I psychiatric disorder, the most frequent diagnoses of which were major depressive disorders and anxiety disorders. The anxiety and depression levels were significantly higher in the patient group than in the healthy individuals. Regarding the Childhood Trauma Questionnaire, emotional neglect, emotional abuse, and physical abuse subscales and weighted average total scores were found to be significantly higher in the patient group (p<.05).

CONCLUSION

Our study has shown a close relationship between neurotic excoriation and childhood traumatic events as well as the accompanying psychiatric problems. We suppose that early interventions by both dermatologists and psychiatrists and especially a detailed investigation of childhood traumatic events by establishing a therapeutic collaboration are highly important and that using psychotherapeutic interventions can result in better treatment outcomes in many patients.

Understanding the pathophysiology of itch

Itch is the most common symptom described by our patients. Treating this symptom can be challenging. A revolution is ongoing in understanding the pathophysiology of itch and will allow this challenge to be met. The present authors review and update the current understanding of the pathophysiology of itch.

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.

Dermatitis artefacta: unusual appearance in an older woman

Dermatitis artefacta is a rare and difficult condition for diagnosis and treatment, with the highest incidence of onset in late adolescence to early adult life. Most patients are young women who have a personality disorder; borderline features are common and the patient's denial of psychological distress makes management and treatment difficult. Patients use a variety of means to cause the skin changes. Clinical presentation of the skin lesions does not conform to those of known dermatoses and are located on easily reached parts of the skin. We report an unusual case of a 72-year-old woman with symmetrical changes under the breasts and in the right inguinal region. The lesions were composed partly of haemorrhagic round lesions and partly of scars. A skin biopsy was taken and consultations with the psychiatrist, internist and the patient's family led to the diagnosis of self-induced dermatitis. The skin lesions were covered by occlusion techniques and the lesions improved very rapidly. The patient was discharged from the hospital under psychiatric and family care.

Expression of anger and alexithymia in patients with psychogenic excoriation: a preliminary report

OBJECTIVE

Psychogenic excoriation (PE), which is characterized by lesions formed by self-picking, has a significant place among the dermatoses related to psychological factors. Emotions, particularly anger that cannot be expressed, may be important in the etiology. The objective of this study was to evaluate the sociodemographic characteristics of patients with PE and with another psychodermatosis, and compare them in terms of anger, manner of anger expression, and alexithymia.

METHODS

Thirty-one consecutive subjects with PE and thirty-one patients with chronic urticaria were recruited from an outpatient dermatology clinic. All of the subjects completed Toronto Alexithymia Scale and Trait Anger and Anger Expression Scale.

RESULTS

PE patients had higher levels of anger (p < .01), tended not to show their anger (p < .05), and were more alexithymic (p < .05). There was also a positive correlation between anger and alexithymia scores (r = .49, p < .05).

DISCUSSION

PE, a severe and chronic psychiatric and dermatological problem, may be related to affect-regulation, particularly anger and alexithymia. Due to the fact that it has a different place among psychodermatoses, individuals with PE might benefit from learning how to regulate their affects other than by excoriation.

The relation of psychogenic excoriation with psychiatric disorders: a comparative study

Psychogenic excoriation (PE), characterized by excessive scratching or picking of the skin, is not yet recognized as a symptom of a distinct DSM-IV disorder. It is a chronic disorder with a high rate of psychiatric comorbidity. The purpose of this study was to compare patients diagnosed with PE and patients with another dermatological disease in terms of comorbid psychiatric disorders. Thirty-one consecutive subjects were recruited from an outpatient dermatology clinic. The control group was composed of 31 patients with chronic urticaria. All subjects were interviewed using the Structured Clinical Interview for DSM-III-R (SCID-I), Beck Depression Inventory (BDI), Hamilton Anxiety Rating Scale (HARS), and Yale-Brown Obsession and Compulsion Scale (Y-BOCS) and also completed a semistructured questionnaire. Current major depressive syndrome was the most common psychiatric disorder in the PE group. There was a statistically significant difference between the two groups in terms of current major depressive syndrome (PE group 58.1%, control group 6.5%, P<.01). In the PE group, 45.2% of subjects were diagnosed with obsessive compulsive disorder (OCD), while the rate of OCD was only 3.7% in the control group (P <.01). The PE group scored significantly higher on the BDI, HARS, and Y-BOCS. The results of this study point to the close relationship of PE to depression and OCD.

Behavioral dermatology

The practice of behavioral dermatology encompasses the management of any dermatologic condition for which there is a substantial behavioral or emotional component. Commonly recognized behavioral dermatoses such as acral lick dermatitis, psychogenic alopecia, and hyperesthesia are syndromes rather than discrete diagnoses. Successful patient management is dependent upon integrating physiological, social, and environmental factors which contribute to the clinical manifestation of behavioral dermatoses.

Skin picking in German students. Prevalence, phenomenology, and associated characteristics

Severe skin picking (SP) is a repetitive, intentionally performed behavior that causes noticeable tissue damage and results in clinically significant distress or impairment. To date, SP has received little attention in the psychiatric literature. This study was conducted to further investigate SP and its characteristics in a German student population. The participants (N = 133) completed various self-report questionnaires. More than 90% (n = 122) reported occasional SP, with six students (4.6%) endorsing significant impairment from recurrent, self-injurious SP. SP was triggered by specific cutaneous stimuli, situations, and emotions. The students primarily squeezed (85%) and scratched (77.4%) the skin, with a primary focus on the face (94.7%) and cuticles (52.6%). About 20% (n = 26) ate the picked tissue afterward. Results suggest SP is an underrecognized problem that occurs on a continuum ranging from mild to severe with generally stable clinical characteristics across cultures.

Nonpharmacologic treatments in psychodermatology

The author believes that psychocutaneous medicine has indeed come of age and is being incorporated into mainstream medical practice. Patients presenting to dermatologists today are more sophisticated and are frequently dissatisfied with traditional medical therapies. They actively seek alternative approaches and adjuncts to standard treatments. In contrast to many other "alternative" (or) "holistic" treatments offered through non-medical venues, dermatologists can assure their patients that controlled studies support the efficacy of psychocutaneous techniques in improving many dermatologic conditions. Psoriasis, rosacea, herpes simplex, body dysmorphic disorder, acne, eczema, urticaria, neurotic excoriations, excoriated acne, trichotillomania, dysesthetic syndromes, and delusions parasitosis are included in this incomplete list. The author believes it is helpful for both the patient and therapist to define concrete and realistic goals for psychocutaneous intervention. Concrete observable or measurable goals can help the patient and clinician gauge therapeutic progress and success. Specifically, goals can include reduction in pruritus (rating severity from 1-10), decreased scratching activity, decreased plaque extent or thickness, decreased number of urticarial plaques, decreased flushing, decreased anxiety, decreased anger, decreased social embarrassment, decreased social withdrawal, and improved sleep. More global goals can include an improved sense of well-being, increased sense of control, and enhanced acceptance of some of the inevitable aspects of a given skin disease. Cure should never be a goal, because most disorders amenable to psychocutaneous techniques are chronic in nature; thus, cure as an endpoint would only lead to disappointment. The author encourages dermatologists to align themselves with what he euphemistically calls "a skin-emotion specialist." The skin-emotion specialist may be a psychiatrist, psychologist, social worker, biofeedback therapist, or other mental health or behavioral specialist. Patients are more likely to accept a referral to a "skin-emotion specialist," because this term destigmatizes psychologic interventions. Incorporating these techniques and specialists into a clinical practice will expand therapeutic horizons and improve the quality of life of many of the patients afflicted with chronic skin disease. A final caveat must be offered about attempting to make prognostic statements regarding the likelihood of therapeutic success. Although all patients can potentially benefit from psychocutaneous interventions, those with severe psychopathology and poor pretreatment functional status are likely to be more difficult to treat and to achieve less optimal outcomes. Patients with personality disorders such as borderline, narcissistic, and schizotypal disorders, and patients with any active psychotic process certainly constitute a more resistant and difficult population with whom therapeutic success is less likely. These patients, however, are often the ones in the greatest subjective distress and certainly can profit from any of the described interventions. Quoting W. Mitchell Sams, Jr., "although the physician is a scientist and clinician, he or she is and must be something more. A doctor is a caretaker of the patient's person--a professional advisor, guiding the patient through some of life's most difficult journeys. Only the clergy share this responsibility with us." This commitment is and must always be the guiding force in the provision of comprehensive and compatient patient care.

Dermatitis artefacta: A review of 14 cases

BACKGROUND

Dermatitis artefacta (DA) is a self-inflicted dermatologic injury sometimes produced for secondary gains. Laboratory investigations, including histologic examination of lesional tissue biopsy, are usually negative and do not give a clue to the correct diagnosis.

PATIENTS AND METHODS

Over a five-year period, 14 patients were diagnosed with DA at King Fahad Hospital (KFH) in Al Baha during routine outpatient and inpatient dermatologic consultations. The diagnoses were based on vagueness of history given by the patients, and the presence of bizarre skin lesions distributed over sites accessible to the patientsA centAA hands. Investigations excluded the possibility of other diseases. In some cases, consultant psychiatric assessment was sought in order to identify possible underlying psychopathologic factors. Seven patients were hospitalized while the rest were managed as outpatients.

RESULTS

The 14 patients comprised 12 females and two males aged 12 to 71 (mean 25.9) years. All except one were Saudis. DA in the males was probably caused for secondary gains. The females, four of whom were married and eight single, were aged 12-36 (mean 21.8) years. Nine of the females (64%) had identifiable severe emotional or psychiatric problems. The remaining two were unmarried and had no identifiable underlying factors.

CONCLUSION

This study reveals that the presentation of DA in Saudi Arabia is essentially similar to what has been reported from other parts of the world. It brings into focus a medical problem which needs to be recognized, as greater awareness may bring about earlier correct diagnosis and treatment.

Factitial cheilitis in an adolescent

A 14-year-old adolescent girl presented with a 2-year history of an exquisitely tender, vegetating cheilitis. Because of this, she was unable to drink fluids and was repeatedly hospitalized for dehydration and pain management. Lip and skin biopsies, as well as multiple laboratory studies did not support a definitive diagnosis. After 2 years, a diagnosis of factitial cheilitis was finally established.

Psychotherapy for intractable inflammatory dermatoses

BACKGROUND

Most patients with inflammatory dermatoses respond to conventional treatment. Recalcitrance may indicate underlying emotional factors after infection, contact allergy, and noncompliance have been ruled out. Psychiatric treatment has been reported to be effective.

OBJECTIVE

The purpose was to determine whether insight-oriented psychotherapy, by effecting last change, would provide long-term cutaneous and psychiatric improvement.

METHODS

On the basis of emotional distress attributed to a recalcitrant inflammatory dermatosis, four patients were referred for psychiatric evaluation. The effect of adding insight-oriented psychotherapy as the only change in the treatment regimen of each patient was studied. Each patient served as his or her own control.

RESULTS

In each patient clearing of the previously recalcitrant dermatosis accompanied psychiatric improvement.

CONCLUSION

In selected cases of recalcitrant inflammatory dermatoses, insight-oriented psychotherapy may provide lasting cutaneous improvement and improved life adjustment and psychologic well-being.