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.

A prospective randomized controlled trial of Psychodermatology on the efficacy of Rilastil Difesa Sterile® cream in the hand eczema of healthcare workers during the COVID-19 pandemic

Hand eczema is one of the most frequent dermatological diseases, with an incidence increased during the COVID-19 pandemic. The impact on life quality is considerable, giving rise to the need for a psycho-dermatological approach. This is a Randomized Control Trial (RCT) evaluating, either by the dermatological or psychological point of view, the effectiveness of an emollient and rehydrating topical product (Rilastil Difesa Sterile® cream) versus a standard treatment (i.e. moisturizing basic cream) in a group of 51 healthcare workers suffering from hand eczema during the COVID-19 pandemic. The enrolled subjects were randomized into a treatment or a control arm, treated for 8 weeks, and monitored through a clinical score (HECSI) and questionnaires evaluating the impact of the pathology and treatment on quality of life (DLQI and QOLHEQ). A psychometric evaluation was performed using the SCL-90 R, OCI-R, and CPDI scales. Our data, despite not reaching the statistical significance, demonstrated that both the clinical and psychological scores decreased mostly in patients treated with Rilastil Difesa Sterile® cream when compared to those treated with simple topical emollients. Moreover, we observed a high level of psychic suffering in dermatological patients and a parallel change in dermatological and psychological indicators, thus confirming their connection.

Associations of Atopic Dermatitis with Attention Deficit/Hyperactivity Disorder and Autism Spectrum Disorder: A Systematic Review and Meta-Analysis

BACKGROUND

Atopic dermatitis (AD) shares similarities with attention deficit/hyperactivity disorder (ADHD) and autism spectrum disorder (ASD) regarding pathogenesis involving neuroinflammation and genetics. Nevertheless, evidence on the associations of AD with ADHD and/or ASD is inconclusive. This study aimed to systematically examine the existing evidence on the associations between AD, ADHD, and ASD.

METHODS

The Meta-Analysis of Observational Studies in Epidemiology guideline was followed. We searched MEDLINE, Embase, Cochrane Library, and Web of Science databases from their respective inceptions to March 4, 2022. Observational studies providing adjusted estimates and/or prevalences for ADHD and ASD in patients with AD were enrolled. A random-effects model meta-analysis was conducted to calculate pooled odds ratios (ORs) and confidence intervals (CIs). Subgroup analyses according to AD severity, age, geographic location, and study design were performed.

RESULTS

Overall, a total of 24 studies with 71,373,639 subjects were enrolled. Our meta-analysis demonstrated significant associations of AD with ADHD (pooled OR: 1.28; 95% CI: 1.18-1.40) and ASD (pooled OR: 1.87; 95% CI: 1.30-2.68). Subgroup analyses revealed that the associations for ADHD were the most prominent in studies evaluating severe AD patients as well as in studies focusing on school-age children and adolescents. Among patients with AD, the pooled prevalence of ADHD was 6.6%, and the respective prevalence of ASD was 1.6%.

CONCLUSION

The evidence to date suggests significant associations of AD with ADHD and ASD. Psychiatric consultation and an interdisciplinary approach would benefit patients with AD presented with behavioral symptoms suggestive of ADHD or ASD.

A survey on knowledge, awareness, and practice patterns in Lithuanian dermatovenereologists

The aim of this study was to evaluate the knowledge, awareness, and practice patterns of Lithuanian dermatovenereologists regarding psychocutaneous medicine. An online survey questionnaire was distributed to the members of the Lithuanian Association of Dermatovenereologists and to dermatovenereologists through public and private healthcare institutions in Lithuania. The questionnaire consisted of questions related to dermatovenereologists' awareness, knowledge, experience, and training needs regarding psychocutaneous disorders. 50% of respondents reported having a good or excellent understanding and knowledge of psychodermatology, and 42% feel prepared to consult psychodermatology patients. 54% of doctors rated their preparedness to prescribe psychopharmacological treatment as poor. The most frequent diagnoses referred to mental health professionals were dermatitis artefacta, acne excoriée, other self-inflicted dermatoses, trichotillomania, and pruritus. The most common course of action with patients at high risk of suicide or other acute psychiatric condition was trying to provide psychological support during dermatovenereology consultation. The most frequent management tactic for patients with chronic psychological problems was a referral to a psychiatrist. 85% of all respondents would participate in educational events about psychodermatology. 70% expressed interest in events about psychopharmacological treatment in dermatology. Lithuanian dermatovenereologists have a good understanding and knowledge of psychodermatology and are willing to further their education in this field. However, some gaps remain. Many doctors reported feeling poorly prepared to administer psychopharmacological treatment to their patients and there seems to be a lack of formal training in psychodermatology in Lithuania.

Factitial dermatitis in the hospital setting

Factitial Dermatitis (FD) is a notoriously difficult disease to diagnose, as patients produce self-induced cutaneous lesions and provide an inadequate or inaccurate history. We performed a cross-sectional study, querying an inpatient consultation database of all patients admitted to the Ohio State University Wexner Medical Center from 2012 to 2017 with a dermatologic ICD as a discharge diagnosis. Our exhaustive keyword search produced 189 candidates. Consult notes were thoroughly examined, and 32 patients were found to meet case definition of FD. Our analysis of this cohort revealed a significantly greater proportion of cases in the female population. Lesions were more often found to involve the skin on the upper extremities. Isolated secondary skin changes such as erosions, ulcers and excoriations in the absence primary morphologies were also significant in our cohort. As FD is difficult to identify, further understanding of its presentation pattern will decrease time to diagnosis and improve both hospital resource allocation and patient care.

The Association of Alopecia Areata-Related Emotional Symptoms with Work Productivity and Daily Activity Among Patients with Alopecia Areata

INTRODUCTION

Patients with alopecia areata (AA) experience psychological and psychosocial symptoms including depression, anxiety, anger, social withdrawal, embarrassment, and low self-esteem. While multiple studies have measured the detrimental emotional impact of AA on patient quality of life, evidence of its effect on work productivity loss (WPL) and daily activities is limited. This study aimed to assess the extent of AA-related emotional symptom (ES) burden on work productivity and activity impairment.

METHODS

A cross-sectional survey of dermatologists and their adult patients with AA was conducted in the USA in 2019. Dermatologists provided assessments of patients' clinical characteristics, while patients completed sociodemographic questionnaires along with two validated patient-reported outcome measures of the Work Productivity and Activity Impairment (WPAI) and the AA Patient Priority Outcomes (AAPPO) ES subscale. The WPAI assessed AA-related WPL (employed respondents) and activity impairment (all respondents), and the AAPPO-ES assessed AA-related frequency of feeling self-conscious, embarrassed, sad, or frustrated. Multiple linear regression models were fitted to both WPAI scores with the AAPPO ES as an independent variable.

RESULTS

A total of 242 patients with a mean (SD) age of 39.2 (13.3) years, treated by 59 dermatologists, were evaluated. Mean (SD) ES score was 2.0 (1.1). Mean (SD) work productivity loss [n = 170] and activity impairment [n = 242] were 12.2% (17.4%) and 13.3% (18.3%), respectively. After adjusting for covariates, WPL increased by 4.1% [95% confidence interval (CI) 1.6-6.7%; p = 0.002] and activity impairment increased by 3.1% (95% CI 0.7-5.4%; p = 0.010) for every 1-point increase in ES. For an average patient, a 1-SD decrease (about 1 point) on the ES scale substantially reduced WPL and activity impairment (by at least 25%).

CONCLUSIONS

Patients with AA reported significant increases in WPL and activity impairment associated with worsening AA-related ES. These findings underscore the substantial emotional and psychosocial burden among patients with AA and a need for improved treatment options.

Tattoos: Demographics, Motivations, and Regret in Dermatology Patients

Background

Tattoos are very popular in today's world. Objectives: The aim of this study was to determine the demographics, the characteristics of tattoos, motivations for getting tattoos, tattooing practices and tattoo regret.

Materials and Method

This multi-centre, cross-sectional study was conducted among. 302 patients attending to the dermatology outpatient clinics and having at least one tattoo. A questionnaire form including all needed data about patients, tattoo characteristics and possible reasons for obtaining tattoos was designed and applied to all participants.

Results

Of 302 patients, 140 (46,4%) were females and 162 (53,6%) were men. The mean age was28,3 ± 8,1 years (min-max, 16-62) for all study group, 53% of participants (n = 160) had at least one tattoo involving letters or number, 80 participants (26%) stated regret for at least one of their tattoos, and 34 of them (42,5%) had their unwanted tattoo removed or camouflaged with a new tattoo. The most common reason for regret was 'not liking the tattoo anymore'. The most common motivations for having tattoos were 'to feel independent', 'to feel better about himself/herself' and 'to look good'. Women had higher scores than men regarding tattoo motivations of 'to be an individual' and 'to have a beauty mark'.

Conclusion

Given the rates, tattoo regret is a significant issue and as motivations differ between genders, age groups and other demographic characteristics; tattoos are not just an ink or drawing on the body, but a tool for individuals to express themselves and to construct self-identity. Tattoos have deep symbolic meanings for emotions, and they may be a clue for behavioural patterns of individuals.

Psychiatric Consequences of Skin Conditions: Multiple Case Study Analysis with Literature Review

This review of current literature demonstrates the psychological implications of skin conditions. Skin conditions of varying severity can impact the quality of patients' lives and have psychiatric consequences. This impact provides a need for healthcare providers to consider the psychological implications of one's skin conditions and their effect on quality of life. The psychological challenges that arise from varying skin conditions show the potential need for both dermatological and psychiatric interventions. The following literature review details the psychiatric consequences of skin conditions under various conditions. It first looks at literature highlighting the psychiatric consequences experienced through various age ranges, from adults to adolescents and children. The paper then explores multiple skin conditions and their psychological effect before highlighting some of the interactions that stress has on the skin that could further exacerbate one's condition. Finally, it examines how patients characterize their experience with their skin condition and goes into some clinical case studies of patients with psychological implications as a result of their skin disorder. The paper also highlights the magnitude of dermatologic patients experiencing psychological conditions in conjunction with their skin conditions.

Risk Factors for Nonattendance in Delusional Infestation: A Multicenter Observational Study

BACKGROUND

Nonattendance is common among patients suffering from delusional infestation (DI) with a risk factor for poorer patient outcomes.

OBJECTIVE

The aim of this study was to determine the incidence rate and predictors of nonattendance among patients presenting to a psychodermatology department with DI and the subsequent effect on the success of prescribing new antipsychotics.

METHODS

Data of 265 patients were reviewed of the Amsterdam UMC, the Erasmus University Medical Center, the Royal London Hospital, and the Liverpool School of Tropical Medicine between January 2008 and October 2019.

RESULTS

We observed that among the patients who attended the first consultation, 57% (n = 144) did not attend their second visit. Recreational drug use was significantly higher in the nonattendance group compared to the attendance group (25% against 18%). Patients who had a history of previously prescribed antipsychotics at the time of the first consultation were less likely to get prescribed antipsychotics from the psychodermatology departments for DI; however, prescribing antipsychotic drugs by the psychodermatology department did not influence nonattendance significantly.

CONCLUSIONS

People suffering from DI are at high risk of nonattendance, even in specialist settings. Patients with current illicit drug use and younger patients are particularly at risk of this.

Alexithymia and Cutaneous Disease Morbidity: A Systematic Review

BACKGROUND

Alexithymia is a psychological construct that describes one's difficulty in understanding and describing their own emotions as well as differentiating feelings from bodily signals of arousal. In the general population, alexithymia's prevalence is approximately 10%. Alexithymia may act as a triggering factor for many medical and psychiatric disorders. In patients with physical disease, alexithymia's prevalence reaches up to 63%. Additionally, alexithymia is associated with worse outcomes and heightened psychosocial comorbidities.

OBJECTIVE

This review continues where an earlier review (Willemsen, 2008) left off to (1) clarify alexithymia's prevalence in dermatology patients and (2) further investigate alexithymia's impact on disease burden, psychosocial comorbidities, and treatment.

METHODS

Systematic searches on alexithymia and dermatologic conditions were conducted using PubMed, Embase, PsycInfo, and Web of Science databases from March 8, 2021, to March 12, 2021. Data from eligible publications, which were full-text, clinical studies published after September 1, 2008, and available in English, were extracted by two medical students and summarized.

RESULTS

Despite a small number of publications (n = 37), data showed a markedly greater prevalence and severity of alexithymia in patients with alopecia, vitiligo, psoriasis, hidradenitis suppurativa, atopic dermatitis, chronic idiopathic urticaria, and primary focal hyperhidrosis compared to healthy controls. Further, data consistently demonstrate a complex interplay between alexithymia, disease burden, and psychosocial comorbidity.

CONCLUSIONS

Identifying and addressing alexithymia in dermatology patients may improve treatment outcomes, associated comorbidities, and health-related quality of life.

More than a skin disease: stress, depression, anxiety levels, and serum neurotrophins in lichen simplex chronicus

BACKGROUND

Lichen simplex chronicus is a dermatological condition due to excessive scratching, with few studies on psychoneuroimmunology.

OBJECTIVE

We aimed to estimate the levels of stress, depression, and anxiety, and to measure serum levels of neurotrophins in patients with lichen simplex chronicus, and to correlate these parameters with the severity of the disease and pruritus.

METHODS

Thirty-six patients with lichen simplex chronicus and 36 age- and sex-matched healthy controls were included. Each participant was administered the Hospital Anxiety and Depression Scale and Perceived Stress Scale questionnaires, along with a visual analog scale for pruritus. Levels of neurotrophins (brain-derived neurotrophic factor, neurotrophin-3, nerve growth factor, glial cell line-derived neurotrophic factor) were determined by ELISA assays.

RESULTS

The scores of Perceived Stress Scale-10, Hospital Anxiety and Depression Scale were statistically higher in patients (p < 0.05 for all). The serum levels of all neurotrophins were significantly lower in patients compared to healthy controls (p < 0.05 for all). Disease severity showed no correlation with all four neurotrophins. In linear regression models applied for increased visual analog scale-pruritus scores and disease severity these two variables were statistically significant predictors (p = 0.043).

STUDY LIMITATIONS

A direct causal relationship was not addressed.

CONCLUSION

Lichen simplex chronicus patients are at risk of increased levels of stress, anxiety, depression, and present decreased levels of neurotrophins, that may suggest a role in the pathophysiology of this disorder.

Striae Distensae: A Cross-Sectional Study of Risk Factors and Quality of Life among Nigerians

BACKGROUND

Striae distensae is a common affliction of darkly pigmented skin. The pattern, risk factors and impact of striae distensae on the Quality of Life (QoL) have not been widely examined.

OBJECTIVE

To document the prevalence, pattern, risk factors and impact of striae distensae on the QoL of sufferers.

METHODS

520 adults were included through a crosssectional design. Demographic and striae distensae-related clinical parameters were documented and QoL evaluated using Skindex-29 and DLQI.

RESULTS

Mean age of participants was 24.10±5.44years. Participants with striae distensae were significantly females (71.9% vs 28.1%, p<0.001) and mild (61.9%) and moderate (32.5%) striae distensae were prevalent. Higher total mean ± SD and mean ranked scores correlated with single status (p<0.001 and p=0.017) and striae distensae severity (p<0.001 and p=0.035) on Skindex and DLQI, respectively. Singles with striae distensae had significantly higher scores on symptom/feeling (p<0.001), daily activities (p=0.003), relationship (p=0.043), leisure (p=0.004), treatment (p=0.011) and work/school (p=0.014) on DLQI. Striae distensae was associated with higher emotion (p<0.001) and functioning (p<0.001) scores on Skindex-29. In regression analysis, age < 30years OR-1.219 (CI: 1.062, 1.400, p=0.005), was a predictor of severe QoL impairment on Skindex-29 and age <30 years OR-1.130 (CI: 1.022, 1.250, p=0.017), obesity OR=1.091, 95% (CI 1.008;1.181, p=0.032) and concern about striae distensae OR-2.482 (CI: 1.392, 4.425, p=0.002) on DLQI.

CONCLUSION

Psychologic evaluation might be indicated in cases of singles with moderate-severe striae distensae and impaired QoL. Predictors of impaired QoL include young age, high BMI, and concerns about striae distensae.

The association between alopecia areata and anxiety, depression, schizophrenia, and bipolar disorder: a population-based study

Although Alopecia areata (AA) has been found to be associated with psychological distress, the scope and nature of this association has not been fully delineated. The current study sought to examine the association of AA with anxiety, depression, schizophrenia, and bipolar disorder, utilizing a large-scale matched controlled cohort design. Patients suffering from AA (n = 41,055) were matched to control cases (n = 41,055) by age, sex, and socioeconomic status (SES). The prevalence of the four major mental disorders was assessed while stratifying the sample by age and sex, and after adjusting for marital status, smoking, BMI, hypertension, and diabetes. Data were accessed via the Clalit Health Services (CHS) database, a comprehensive health registry utilized by the largest managed healthcare company in Israel. Anxiety was independently and positively associated with AA (OR 1.22, 95% CI 1.13-1.31, p < 0.001), across all age groups above 30, with similar rates in males and females. Depression was also independently and positively associated with AA (OR 1.09, 95% CI 1.01-1.17, p < 0.005), particularly in the 30-49 age group, with a higher association among females. A negative association was found between AA and schizophrenia (OR 0. 71, 95% CI 0.61-0.83, p < 0.001). No association was found between AA and bipolar disease. Patients with AA are at risk for anxiety and depression, with female patients, and patients in the 30-49 age group being particularly vulnerable to develop a co-occurring mental disorder. Medical treatment should therefore include psychiatric evaluation and appropriate care.

Treatment of tardive dyskinesia: a review and update for dermatologists managing delusions of parasitosis

INTRODUCTION

This article introduces to the dermatology provider two medications for the treatment of tardive dyskinesia (TD), which were the first medications approved by the US FDA specifically for the treatment of TD. In addition to describing these two new medications, this article will also provide a focused review of the pathogenesis of TD, as well as non-FDA-approved treatments, which have been tried prior to the advent of these medications.

METHODS

A PubMed search was conducted and articles were reviewed by the senior authors and included if they were relevant for dermatologists regarding etiology, symptoms, risk, and treatment of TD.

RESULTS

One of the most widely accepted explanations of TD involves the concept of 'dopamine receptor hypersensitivity state.' There are several other less well substantiated proposed pathogenic pathways of TD. The clinical manifestation is characterized by involuntary movements. Prevention includes switching to a 2nd generation agent or using the lowest dose possible for the shortest amount of time. Two new FDA-approved medications for TD are also discussed and reviewed.

CONCLUSION

TD now has FDA-approved medications for treatment. Now, there is even more reason for the dermatologist to have increased confidence when treating delusions of parasitosis (DOP) with antipsychotic agents.

[Screening for mental comorbidities in dermatology : Successful implementation of a screening for mental comorbidities in the field of inpatient dermatological treatment]

BACKGROUND

Anxiety and depression are common in the field of inpatient somatic treatment. Especially in dermatology in which the treatment of chronic diseases is very common and the risk of stigmatization by society is particularly high, mental disorders appear in every third patient. Dermatological diseases and mental disorders often negatively interact with each other leading to increased morbidity. Dermatological guidelines recommend early detection, but this is often not adequately done in practice.

MATERIALS AND METHODS

We present the implementation of an easy screening for mental comorbidities in the field of inpatient dermatological treatment by using a short questionnaire. This so-called Patient Health Questionnaire‑4 (PHQ-4) consists of four questions regarding anxiety disorders and depression. Upon reaching a certain number of points, a psychosomatic consult is automatically requested. As a result the patient's stress is relieved and the necessary holistic treatment becomes possible.

RESULTS

In 2019, 83% of inpatients in our clinic were screened using the PHQ‑4; 98 psychosomatic consults were performed.

CONCLUSION

Our findings so far have shown the benefit of the screening with a minimal investment of time. We recommend its comprehensive use in the field of inpatient dermatological treatment.

Development and Evaluation of the Psychosocial Adaptation Questionnaire among Patients with Chronic Skin Disease

BACKGROUND/OBJECTIVE

Chronic skin disease (CSD) often has physiological, psychological, and social impacts, which requires the patient to adjust to achieve psychosocial adaptation (PSA). As a standardized assessment instrument was lacking, we developed a PSA questionnaire for patients with CSD (PSAQ-CSD).

METHODS

According to the steps of questionnaire development, a systematic process of scoping review, qualitative research, content validity expert review, testing in a sample of 321 adults, item analysis, and classical test theory methods were applied.

RESULTS

Following item analysis and exploratory factor analyses, 18 items were eventually entered into the model of confirmatory factor analyses, with a cumulative contribution of 65.435%. Three subscales were developed: emotional, self-cognitive, and social dimensions. Item analysis, exploratory factor analyses, and content validity expert review narrowed the subscales to 8, 6, and 4 items, respectively.

CONCLUSIONS

The 18-item PSAQ-CSD has been confirmed to have good internal consistency reliability and convergent and discriminant validity. It may be a useful tool to evaluate the PSA among patients with CSD and provide a basis for further research.

Dermatologists' perceptions of suicidality in dermatological practice: a survey of prevalence estimates and attitudes in Austria

Background

Chronic illnesses belong to suicide risk factors. The goal of the current study was to estimate the rate of suicide-related behaviors in patients with atopic dermatitis, psoriasis, or acne from a third-person perspective (namely, Austrian dermatologists).

Methods

A link to a questionnaire specially developed for this study was emailed to 450 self-employed dermatologists in Austria, from which a total of 45 participated.

Results

Three dermatologists reported more than five patients with atopic dermatitis, psoriasis, or acne who committed suicide in 2017. Seven doctors treated between 1 and 10 such patients suffering from suicidal ideation. These results are suggestive for a low rate of suicidal ideations in Austrian dermatology ordinations. The majority of dermatologists in the sample (82%) knew that these patients are at higher suicide risk. 60% of participants also believed that it rather would not be a problem for them to recognize suicidal ideation. When facing patients in a suicide crisis, reported intervention steps were: referring them to a specialist in psychiatry, or having a conversation about it. In the sample, most challenging about suicide was lack of time and lack of knowledge. Dermatologists were also interested in cooperating with mental health professionals and in the implementation of new prevention strategies (e.g., suicide-related training programs). Analysis revealed that private specialists, as compared with contract physicians, had fewer patients, but spent more time with them. Yet, these differences did not appear to influence the quality of treatment they provided. Treatment quality was defined as the extent to which doctors tell their patients that additional psychological treatments could be helpful and asking them about their emotional state. Female gender and a professional background in psychology impacted positively on treatment quality.

Conclusions

Possible explanations for the low rate of suicidal ideations reported include the advanced Austrian health care system and dermatologists’ underestimation of the problem. Implications of the study are to promote cooperation between dermatologists and mental health professionals and to address patient suicidality from a first-person perspective (i.e., the patients).

Anxiety sensitivity and social anxiety in adults with psychodermatological symptoms

Many dermatology patients experience social anxiety symptoms; however, few studies have investigated vulnerabilities contributing to this distress. Anxiety sensitivity (AS), or the fear of the consequences of anxiety, warrants consideration given its association with social anxiety and dermatological symptoms, respectively. The purpose of this investigation was to investigate the role of AS in social anxiety symptoms in two samples of adults with psychodermatological conditions. AS social, but not physical or cognitive, concerns were hypothesized to demonstrate unique associations with social anxiety symptoms after controlling for relevant variables. Participants completed self-report measures online (Study 1) or in-person (Study 2). Study 1 included 164 participants with active skin conditions (M_age = 31.88; 69.5% female; 83.5% White), and Study 2 included 63 dermatology outpatients (M_age = 51.49; 70.7% female; 65% White). Results revealed AS social concerns was a unique factor contributing to social anxiety symptoms in both samples. This study demonstrates replication, and the findings suggest heightened concerns about the negative consequences related to visible skin conditions may worsen social anxiety symptoms in individuals with psychodermatological conditions. Despite limitations, this study informs the conceptualization of co-occurring psychological and dermatological conditions and highlights the need to evaluate the efficacy of brief AS interventions among patients with psychodermatological conditions.

The Sense of Stigmatization in Patients with Plaque Psoriasis

BACKGROUND

Psoriasis is a systemic inflammatory disease capable of creating stigmatization in the form of social exclusion and decrement of psychological conditions.

AIM

The aim of the study was to determine the level of stigmatization in patients with plaque psoriasis.

METHODS

The study included 166 patients with plaque psoriasis (55.6% women and 44.3% men) with Psoriasis Area and Severity Index scores ≤10. The age of the study patients ranged between 18 and 72 years (arithmetic mean = 37.4; median = 38; standard deviation [SD] = 11.0). The mean age at the diagnosis of psoriasis was 21.5 years (median = 20; SD = 9.1) and disease duration varied from 2 to 59 years (arithmetic mean = 15.8; median = 15; SD = 11.3). The study patients completed the Polish version of the 6-item Stigmatization Scale and the 33-item Feelings of Stigmatization Questionnaire and a survey developed by the authors of this study, containing questions about the participants' sociodemographic characteristics (sex, age, place of residence, marital status, education, employment status) and information about their disease (location of psoriatic lesions, time elapsed since the diagnosis of psoriasis).

RESULTS

The mean score for the 6-item Stigmatization Scale for the whole study group was 7.6 out of 18 points (median = 7; SD = 3.8; minimum = 0; maximum = 17). The average score for the 33-item Stigma Feelings Questionnaire in our series was 84.5 out of 165 points (median = 88; SD = 20.9; minimum = 30; maximum = 136). A statistically significant sex-related difference was observed in the 6-item Stigmatization Scale scores, with higher stigmatization levels found in men than in women (p = 0.0082). Moreover, significantly higher levels of stigmatization were observed in countryside dwellers (p = 0.0311) and unmarried persons (p = 0.0321). Patients with a longer history of the disease (≥15 years) scored significantly higher on the 6-item Stigmatization Scale (p = 0.0217) than those in whom psoriasis lasted less long, and presented with higher, at the threshold of statistical significance, scores for the 33-item Feelings of Stigmatization Questionnaire.

CONCLUSIONS

Stigmatization awareness should be promoted among physicians and psoriatic patients to improve psoriasis management.

Climate change and pediatric skin health

Children are known to disproportionately bear the health impacts of climate change, particularly children living in impoverished areas. Owing to their developing physiology and immature metabolism, distinct exposure behaviors, and reliance on adults for care and protection, children are uniquely susceptible to the adverse effects of our warming planet. Herein, we summarize the known impacts of climate change on pediatric skin health, including its effects on atopic dermatitis, vector-borne and other infectious diseases, nutritional deficiencies, and psychodermatoses.

Psychological aspects of aesthetic and cosmetic surgery: Clinical and therapeutic implications

Recently there is a surge in cosmetic and aesthetic surgery procedures. Several patient seeking various cosmetics procedures present to aesthetic surgery clinics and demanding procedures which are out of proportion. Several of these patients have under-recognized or untreated psychiatric disorders. Proper screening and evaluation of these patients could save money and resources. This brief review focuses on current trends, clinical and psychological assessment and expectations on the part of patients and recommendations regarding management of these patients.

"Psychodermatology" knowledge, attitudes, and practice among health care professionals

Psychiatric disorders are prevalent in dermatology patients. Psychodermatology is the body of knowledge at the intersection of psychiatry and dermatology practice. The purpose of this literature review was to assess the knowledge, attitudes, and practices of health care professionals regarding psychodermatology. A search of relevant articles was conducted in PubMed, CINAHL, ERIC, and PsychInfo databases using a comprehensive set of search terms. Studies were included if (1) study participants were health care professionals, (2) studies contained data that could be extracted, and (3) studies were published in peer-reviewed journals. A review of study findings was conducted. A total of nine studies were included in the review. Studies were conducted in several countries. Findings from the review confirmed that providers frequently reported psychocutaneous disorders in their practice. There were, however, gaps and variations in providers' knowledge base and level of comfort treating these patients. Further, providers acknowledged a lack of training in the practice of psychodermatology. The findings from this review suggest that health care professionals from multiple areas of the world may lack a full understanding, level of comfort, and proper training in psychodermatology. Improving the knowledge base and increasing level of comfort in treating psychodermatological disorders can improve the practice of psychodermatology amongst providers. Further, addressing knowledge and comfort level among providers through training and continuing education may improve outcomes for patients with psychocutaneous disorders.

Skin Diseases in Patients with Primary Psychiatric Disorders

OBJECTIVE

The few psychodermatological studies of primary psychiatric populations so far suggest that parasitic-infectious skin diseases are the most common dermatological comorbidity in more than 70% of psychiatric patients, which should be studied here in a large data bank outside dermatological treatment facilities.

METHODS

In a descriptive-explorative and retrospective study, more than 17,000 patients with primary psychiatric disorders were examined to investigate dermatological comorbidities.

RESULTS

The proportion of patients with primary mental disorders and additional dermatological disease was 1.24% (n=212). Here, psoriasis (35.4%) and atopic dermatitis (22.6%) were the most frequent dermatological diseases among these 212 patients. Infectious-parasitic skin diseases were present in 13.2% of comorbid patients. The most common mental disorder was a depressive illness, seen in 42.5% (n=90) of patients.

CONCLUSION

Our results confirmed the frequent association of depression with psoriasis and atopic dermatitis, indicating the need for the early detection and treatment of such comorbid patients. In contrast, psychiatric inpatients do not appear to suffer from predominantly infectious-parasitic dermatoses.

Hidradenitis Suppurativa and Bipolar Disorders: A Population-Based Study

BACKGROUND

Psychological comorbidities have been reported in patients with hidradenitis suppurativa (HS), yet only a few studies have investigated the possible association between HS and severe psychiatric disorders. The current study aimed to assess the association between HS and bipolar disorder, a major, chronic, psychiatric disease.

METHODS

A nationwide, population-based study was performed utilizing data from the Clalit Health Services (CHS) database in Israel. The study included 4,191 HS patients and 20,941 age- and gender-matched controls. A multivariate binary logistic regression, adjusted for demographic and behavioral risk factors, was performed.

RESULTS

A higher proportion of bipolar disorders was found among HS patients compared to controls (0.7 vs. 0.1%, respectively). There was an increased proportion of active smokers among HS patients than among controls (53.4 vs. 13.5%, respectively). In the multivariate analysis, adjusting for age, sex, and smoking, HS was found to be independently and positively associated with bipolar disorders (OR 2.12, 95% CI 1.21-3.27, p < 0.01), yet after controlling for body mass this association became nonsignificant.

CONCLUSIONS

Bipolar disorders are associated with HS. Future studies should explore whether cardiometabolic deficiencies might account for this association. Healthcare providers should consider this potential co-occurrence as it may impede patient compliance and require appropriate screening and treatment. Results also stress the need for a multidisciplinary approach to optimize management of the disease and its associated comorbidities.

Current Understanding and Approach to Delusional Infestation

Delusional infestation is a psychiatric condition defined by a fixed belief of infestation despite contrary evidence. Diagnosis includes exclusion of organic etiologies. Treatment with antipsychotics is effective and safe in the majority of patients. Patients are characteristically reluctant to pursue psychiatric evaluation and may resist discussing their disease in psychiatric terms. Strategies to strengthen the provider-patient therapeutic alliance facilitate communication around appropriate treatment. Without antipsychotic medications, patients can become heavy utilizers of care and practice self-destructive behaviors in attempts to clear their perceived infestation.

[German version of the Skin Shame Scale (SSS-24) : Validation with dermatological patients and dermatologically healthy individuals]

BACKGROUND

Skin shame plays an important role in the psychological distress of dermatological patients. However, it is rarely examined in research or clinical practice due to the lack of availability of a robust measure of skin shame. This study sought to adapt and validate the Skin Shame Scale (SSS-24) for use in the German-speaking population.

METHODS

The SSS-24 questionnaire was completed by 488 dermatologically healthy (DH) individuals (66.6% women) and 339 dermatological patients (DP; 66.7% women). Participants also completed measures of general shame (SHAME) and of psychological distress (BSI[Brief Symptom Inventory]-18).

RESULTS

The SSS-24 showed adequate psychometric properties and a high internal consistency in both samples (DH: α = 0.91; DP: α = 0.95). DP reported more skin shame than DH (p < 0.001) but in both samples more skin shame was associated with more general shame and more psychological distress (p < 0.001).

CONCLUSIONS

Overall, the psychometric properties of the English original version were replicated in the German version of the SSS-24. Due to the strong associations with general shame and psychological distress, skin shame should be considered an important parameter in psychodermatology. The SSS-24 enables further research into the role of shame in skin conditions and provides a useful tool for identifying patients who might benefit from psychosocial interventions.

Association of GA genotype of SNP rs4680 in COMT gene with psoriasis

Psoriasis is a multigene and multifactorial skin disease with heterogeneous genetic inheritance. Mental disorders participate in the development of psoriasis as predisposing factors; a correlation of dermatological diseases with pathological anxiety and stress was shown. Meanwhile, there are no studies describing molecular mechanisms of the linkages between psycho-emotional disorders and skin diseases. The aim of this study is to find the associations between SNP in genes COMT (rs4680), DBH (rs141116007), CCKAR (rs1800857) and CCKBR (rs1805002), and psoriasis. Patients were selected according to the 10th revision of International Classification of Diseases (L-40). The sample size was 88 patients. The size of the control sample (population control) was 365 people. Genotyping was performed using PCR-RFLP and real-time PCR. Statistical analysis was performed using WinPepi software. Identification of complex genotypes was performed by the Monte Carlo method using APSampler 3.6.1 algorithm. Among the studied genes, only GA genotype of COMT gene is significantly associated with psoriasis [χ² = 19.163 (p = 1.3E-5), F (p) = 1.2E-5, OR 3.47 (CI 99% = 1.61-7.91)]. At the moment, the functional significance of this phenomenon is difficult to explain.

Onychotillomania: A Chameleon-Like Disorder: Case Report and Review of Literature

Onychotillomania, or nail-picking disorder, is an uncommon and misdiagnosed behavioral pattern focused on the nail apparatus. It is demarcated by the compulsive or irresistible urge in patients to constantly injure their own nails, with the fingers or tools, inflicting noticeable or even irreversible self-destruction of the nail unit. Despite its rarity, this self-injurious coercion often poses a diagnostic and therapeutic challenge. Not only do many patients deny nail manipulation, but also the disorder has long been recognized to present itself with a wide range of clinical features, which hampers early and indisputable diagnosis. Furthermore, onychotillomania constitutes a persistent and hardly manageable problem, mostly because of its psychocutaneous nature as well as its high propensity to coexist with underlying neuropsychiatric illnesses or other behavioral disorders. However, the medical literature concerning obsessive nail picking still remains relatively scarce. Herein, we present an extraordinary, yet very intriguing case of a Caucasian patient with onychotillomania and onychophagia coexistence masquerading a weird inflammation-like lesion.

Impact of Folliculitis Decalvans on Quality of Life and Subjective Perception of Disease

Folliculitis decalvans (FD) is a primary neutrophilic scarring alopecia characterized by perifollicular papules, crusts, and pustules frequently located on the vertex. FD may affect young men and women. Since it may lead to hair loss, it can have a negative impact on patients' quality of life. Nevertheless, studies have focused on clinical, prognostic, and therapeutic aspects without considering the psychological impact of FD. In our study, we found that FD patients experienced a considerable impact on their quality of life. Interestingly, almost half of the patients considered that their alopecia was related to a poor medical care in their past. To our knowledge, this is the first description of the impact of FD on patients' quality of life, and it highlights the importance of psychological support for these patients.

Psychoneurocutaneous medicine: past, present and future

Psychoneurocutaneous medicine is an important and rapidly growing field. It is an integrative science created to address the interaction between the mind, nervous system and skin. Four major fields are involved: psychiatry, psychology, neurology and dermatology. The history of psychoneurocutaneous medicine is old and fascinating. Even though it is a young science only established in the last century, allusions to the nervous system and diseases of the skin can be traced back thousands of years in the literature. Characteristically, the last two centuries were of special importance for the development of this field in Europe, lately in America, with great effort placed on research and publications. More recently, the creation of associations, work groups and the merging of subspecialties dedicated exclusively to study the psychological impact of skin disorders in subpopulations of patients have helped to give momentum to psychoneurocutaneous medicine. Further development of this field will shed light on the appropriate diagnosis and treatment of psychodermatologic disorders, enhancing the functionality and quality of life of patients. This paper presents a summary of the most influential facts in the history of psychoneurocutaneous medicine, its present and future perspectives.

A mixed methods survey of social anxiety, anxiety, depression and wig use in alopecia

OBJECTIVES

This study aimed to examine levels of social anxiety, anxiety and depression reported by people with alopecia as a result of a dermatological condition and associations with wig use. The study also sought to report on experiences of wearing wigs in social situations and the relationship with social confidence.

DESIGN

A cross-sectional survey was sent by email to the Alopecia UK charity mailing list and advertised on social media.

PARTICIPANTS

Inclusion criteria were a diagnosis of alopecia, aged 13 or above and sufficient English to complete the survey. Exclusion criteria included experiencing hair loss as a result of chemotherapy treatment or psychological disorder. Participants (n=338) were predominantly female (97.3%), Caucasian (93.5%) and aged between 35 and 54 years (49.4%) with a diagnosis of alopecia areata (82.6%).

MAIN OUTCOME MEASURES

The Social Phobia Inventory measured symptoms of social anxiety, and the Hospital Anxiety and Depression Scale was used to measure symptoms of anxiety and depression. Survey questions were designed to measure the use of wigs. Open-ended questions enabled participants to comment on their experiences of wearing wigs.

RESULTS

Clinically significant levels of social anxiety (47.5%), anxiety (35.5%) and depression (29%) were reported. Participants who reported worries about not wearing a wig reported significantly higher levels of depression: t(103)=3.40, p≤0.001; anxiety: t(109)=4.80, p≤0.001; and social anxiety: t(294)=3.89, p≤0.001. Wearing wigs was reported as increasing social confidence; however, the concealment it afforded was also reported as both reducing fear of negative evaluation and maintaining anxiety.

DISCUSSION

Overall, 46% of participants reported that wearing a wig had a positive impact on their everyday life with negative experiences related to fears of the wig being noticed. Psychological interventions alongside wig provision would be beneficial for people living with alopecia.

[Dermatological diseases and their importance for psychiatry]

The relationship between skin and psychiatric disorders is not an uncommon occurrence in the clinical practice; however, there are only a few systematic studies and in addition knowledge about the neurobiological and immunological mechanisms is lacking. Impairments and disorders of the skin are often an (early) sign of a psychiatric disorder. In the sense of true psychosomatics, psychiatrists should also be aware of this relationship as far as possible. This review article focuses on the most important dermatological diagnoses in relation to the respective psychiatric comorbidities and presents the most important aspects of epidemiology, symptomatology, pathophysiology and treatment options.

History of Morgellons disease: the same name for different psychodermatologic diseases?

"Morgellons disease" has been a controversial topic in the history of psychodermatology. The most consensual scientific opinion is that it is a primary psychiatric disorder, particularly, a delusional disorder, although others were also pointed out. Some authors have suggested that it may correspond to a common dermatosis with secondary psychopathology. The Morgellons Research Foundation has advocated that it is "an emerging infectious" entity. This paper intends to critically review the main ideas and controversies, since its first description.

Psychosocial aspects associated with use of sunscreen, natural sunlight exposure, and artificial tanning

Natural and artificial tanning have become very popular in Western culture, yet at the same time, there is still a psychodermatology concern for this activity. Not much has been examined with the psychological aspects of tanning and sunscreen use. The purpose of this study is to examine the psychosocial effects associated with sun protection, natural, and artificial tanning among individuals 18 years old or older visiting the University of Miami Dermatology Outpatient Clinic. We distributed a survey on tanning and sunscreen use to 150 dermatology outpatients, hospital employees, and hospital visitors for three weeks during June/July 2015 asking about how often they tan, use sunscreen, and how they feel about this topic. Demographics, such as gender, ethnicity, and education were taken into consideration to examine the different responses in each category. Our results suggest that people's perception to tanning and sunscreen use have evolved over time. Most people in South Florida nowadays feel guilty when exposed to natural sunlight without sunscreen and do not tan frequently. The majority of the people, specifically women, utilize the recommended amount of sunscreen with a sun protection factor of 30-50. However, we can conclude that communication between social media and the general public can affect people's decision-making on tanning and sunscreen use with physician advice being the most effective method of encouraging people to use sunscreen. This study will add to the growing knowledge about psychodermatology.

Psycho-Neuro-Endocrine-Immunology: A Psychobiological Concept

Psycho-Neuro-Endocrine-Immunology (P.N.E.I.) is a scientific field of study that investigates the link between bidirectional communications among the nervous system, the endocrine system, and the immune system and the correlations of this cross-talk with physical health. The P.N.E.I. innovative medical approach represents a paradigm shift from a strictly biomedical view of health and disease taken as hermetically sealed compartments to a more interdisciplinary one. The key element of P.N.E.I. approach is represented by the concept of bidirectional cross-talk between the psychoneuroendocrine and immune systems. The Low Dose Medicine is one of the most promising approaches able to allow the researchers to design innovative therapeutic strategies for the treatment of skin diseases based on the rebalance of the immune response.

Burnout Syndrome and Demotivation Among Health Care Personnel. Managing Stressful Situations: The Importance of Teamwork

Almost one-third of our lives is spent in the workplace, where much of our interaction with others takes place and where we are exposed to stressful situations. Work-related stress has consequences for the individual's physical and mental health. Stress and professional burnout syndrome are the main consequences of work situations characterized by a constant state of tension. Stress is the second leading cause of absenteeism in the European Union, and around 12% of European workers are currently affected by burnout syndrome. It is therefore vital to identify demotivated and stressed staff in both large organizations (hospitals and clinics) and smaller centers (private practices) so as to facilitate preventive measures and ensure early intervention in situations of stress, with a view to improving the performance of work teams.

Obsessive-compulsive behaviour related cutaneous ulcers: two cases with therapeutic considerations

Obsessive-compulsive-related cutaneous disease most often includes trichotillomania, neurotic excoriations and nail biting. In this report, we present two cases of self-inflicted severe wounds that were diagnosed as secondary to obsessive-compulsive behaviour. Patients were middle-aged females who presented with deep cutaneous ulcers that were acknowledgedly maintained through repetitive manipulation. Obsessive-compulsive-related cutaneous disease is better treated with serotonin reuptake inhibitor antidepressants in higher dosages than those used to treat depression. Both patients were treated with fluoxetine 60-80 mg that resulted in adequate healing of the ulcers; relapses were observed during attempts to taper fluoxetine dosage. An adequate psychic diagnosis is required if an effective therapeutic response to self-inflicted cutaneous lesions is desired, because clinically identical lesions can also be caused as a result of distinct mental mechanisms: anxiety, depression, psychosis, obsessive-compulsive disorder and classic dermatitis artefacta.

Dermatological manifestations of stress in normal and psychiatric populations

This article explores the way stress affects the skin, both at the molecular level, where the skin has an intricate connection to the neurocutaneous and immune systems, and at the clinical level. The concept of psychodermatology is reviewed with regard to the way skin reacts to stress, how stress is a trigger for several common skin diseases, and how neuropsychiatric disorders may have skin manifestations. The article is directed at making the dermatologist, the psychiatrist, the psychologist, and the primary physician familiar with the brain-skin mechanisms involved in stress and the resultant clinical expressions on the skin.

Unnecessary surgical treatment in a case of olfactory reference syndrome

We present a case of olfactory reference syndrome (ORS) with complaints of bromhidrosis. This patient underwent a lumbar sympathectomy to correct the imagined body odor problem. The patient reported experiencing an improvement after surgery, but later, the olfactory symptoms returned. The main objective with ORS patients should be to begin psychiatric treatment early. Other treatments usually appear to be ineffective and cause great dissatisfaction.