Quack-induced dermatitis: A case report of two dermatitis artefacta induced by quacks advise

This report delineates two instances of dermatitis artefacta (DA), a psychodermatological condition marked by self-induced or exacerbated skin lesions. These cases, triggered by treatments from non-qualified practitioners, highlight the critical need for healthcare professionals to discern the potential repercussions of unsound medical guidance.

Anhedonia in Acne Vulgaris: A Cross-Sectional Study of 104 Consecutive Acne Patients

Background

Anhedonia is defined as a reduced ability to experience or even a total loss of pleasure.

Purpose

This study was undertaken to evaluate anhedonia in 104 consecutive acne patients.

Material and Methods

Acne severity was assessed with Investigator Global Assessment (IGA), anhedonia was studied with the Snaith-Hamilton Pleasure Scale (SHAPS), Anticipatory and Consummatory Interpersonal Pleasure Scale (ACIPS) and Temporal Experience of Pleasure Scale (TEPS). Moreover, the quality of life (QoL) and stigmatization, as well as depression and anxiety (Hospital Anxiety and Depression Scale - HADS), were additionally evaluated.

Results

Anhedonia was found in 20.19% of acne patients and was more common (p=0.007) in males (34.29%) than in females (13.04%). Based on SHAPS, males with acne showed significantly (p=0.049) higher levels of anhedonia (2.39 ± 3.18 points) than acne females (1.26 ± 2.36 points). Anhedonia significantly correlated with the clinical acne severity (SHAPS: r=0.205, p=0.038 and ACIPS: r=-0.222, p=0.026). Although the intensity of anhedonia did not show any relationship with QoL and stigmatization assessments, there was a significant correlation between anhedonia and depressive symptoms (SHAPS: r=0.310, p<0.001; ACIPS: r=-0.364, p<0.001). Such dependency was not documented for anxiety.

Conclusion

Anhedonia seems to be a common phenomenon in acne and should be considered in the holistic approach to acne patients.

The Prevalence of Clinically Undiagnosed Depression in Patients With Autoimmune Bullous Diseases Seen at Inkosi Albert Luthuli Central Hospital, Durban, South Africa

Background Chronic autoimmune bullous diseases have been associated with major depression in previous studies. This has been attributed to inflammatory cytokines, chronic pain, and the chronicity and debilitating nature of the disease. As no similar studies have been conducted in our setting, we aimed to determine the prevalence and severity of clinically undiagnosed depression in patients with autoimmune bullous diseases. Methodology We performed a cross-sectional study among outpatients managed in a bullous disease clinic at Inkosi Albert Luthuli Central Hospital, a quaternary provincial hospital in Durban, South Africa. Results A total of 44 participants were recruited and included in this study. The majority of the participants were females (29, 65.9%). The most common autoimmune bullous diseases were pemphigus vulgaris (19, 43.2%), bullous pemphigoid (18, 40.9%), and pemphigus foliaceus (5, 11.4%). The overall prevalence of at least mild and at least moderate depression in patients with autoimmune bullous diseases in our clinic was 52.3% and 20.5%, respectively. Pemphigus vulgaris showed the highest median Patient Health Questionnaire-9 score compared to other bullous dermatoses. Statistically significant differences were observed between females and males for the duration with the bullous disease (p = 0.014) and between intraepidermal and subepidermal disease for both the mean age (p = 0.038) and age at onset (p = 0.015). Conclusions Clinically undiagnosed depression is common in patients with autoimmune bullous disease. Its frequency and severity may differ depending on the underlying autoimmune bullous disease and possibly other factors. Dermatologists should always be alert to this fact and prompt psychiatric consultation as required to comprehensively manage these patients.

Factitious Disorder as a Skin Ulcer: A Case Report

Dermatitis artefacta (factitious dermatitis) is a dermatological disease of different types; it could appear on various parts of the body. It is associated with severe difficulties, such as psychic distress and negative feelings aroused in healthcare personnel or borderline personality disorder, and the long-term possibility of patient self-harm to create more symptoms, resulting in unnecessary medical procedures. This is a case of a 17-year-old girl who was hospitalized with a skin ulcer on her right ankle that proved to be a factitious disorder. She was experiencing severe symptoms of anxiety, such as feeling nervous, having trouble sleeping and concentrating, and an inability to control worry due to her preparation for university studies. She refused to see a mental health professional since the onset of anxiety symptoms, i.e., the last four months. Patients who present with factitious disorder deliberately create clinical signs of a somatic disease because they need warmth and attention in a medical environment. Symptoms offer no significant benefit, and the pathophysiological mechanisms are mainly psychological. The primary treatment for factitious disorder is psychotherapy while the management of the ulcer requires dermatosurgical treatment.

Histopathologic findings in ointment pseudo-cheilitis: An alert to dermatopathologists

Ointment pseudo-cheilitis is a recently recognized distinctive type of self-induced cheilitis. Lesions consist of a variable amount of crusts adhered to the vermilion. These crusts consist of dried saliva and dead cells mixed with applied medications attached to the lip surface. Patients are typically severely anxious or depressed; the condition impacts quality of life. Ointment pseudo-cheilitis is frequently misdiagnosed as exfoliative cheilitis or cheilitis glandularis. Biopsy reports are often non-revealing because there are no established histopathological criteria for this disease, and clinicians usually do not formulate the correct diagnostic hypothesis. Here, we present the histopathological findings of four cases of ointment pseudo-cheilitis. The most consistent finding was the presence of laminated parakeratotic material detached from the epithelium in biopsies that are devoid of other significant diagnostic changes. This material at the lip surface possibly represents physiologic labial desquamation mixed with dried saliva and applied medication. With this report, we intend to alert dermatopathologists to the diagnosis of ointment pseudo-cheilitis if they receive biopsies from patients who present clinically exuberant labial lesions that show only minimal histopathological changes.

Females May Have Less Severe Acne, but They Suffer More: A Prospective Cross-Sectional Study on Psychosocial Consequences in 104 Consecutive Polish Acne Patients

Acne is a common skin condition affecting both adolescents and adults, and it can profoundly impact patients' quality of life and mental well-being. This prospective cross-sectional study aims to explore the differences in psychosocial aspects between male and female acne patients in Poland. A total of 104 consecutive acne patients were included in this study. Clinical severity, patients' quality of life, stigmatization levels, and psychiatric disturbances were evaluated using the following instruments: Investigator Global Assessment (IGA), Dermatology Life Quality Index (DLQI), Cardiff Acne Disability Index (CADI), 6-Item Stigmatization Scale (6-ISS), and Hospital Anxiety and Depression Scale (HADS). This study found that female patients exhibited significantly less severe acne and experienced significantly decreased quality of life and increased levels of stigmatization. Furthermore, anxiety levels among female patients exceeded those observed in their male counterparts. Notably, no disparities in the severity of depression were observed between the two gender groups. Correlations were discerned among all psychosocial parameters in the entire study cohort and in the female subgroup, while such correlations were not uniformly observed among male participants. This study underscores the importance of considering psychosocial aspects and implementing routine measurements in the management of acne to improve patients' well-being.

The Mind Body Connection in Dermatologic Conditions: A Literature Review

Psychodermatology pertains to the relationship between the skin and brain. This review aims to summarize the evidence of the mind body connection in four psychophysiological conditions: rosacea, atopic dermatitis (AD), acne vulgaris (AV), and psoriasis. A literature search was conducted using several English language databases. All four conditions share similar psychiatric co-morbidities, including but not limited to anxiety, depression, and suicidality. In rosacea, the upregulation of transient receptor potential vanilloid type 1, Toll like receptor 2, and Th17 cells releases downstream products that are simultaneously implicated in mood disorders. Stress exacerbates AV through the hypothalamic-pituitary-adrenal (HPA) system, which alters functioning of sebocytes and Cutibacterium acnes. In AD and psoriasis, the HPA axis influences Th1, Th2, Th22, and Th1, Th17 immune mediated responses, respectively. This leads to the secretion of pro-inflammatory cytokines which are also involved in the pathogenesis of anxiety and depression. Neurotransmitters implicated in mental illness, such as gamma-aminobutyric acid and serotonin, may also play a role in the development of AD and psoriasis. The management of cutaneous disease may mitigate psychological distress, and future research may show the corollary to also be true.

Stigmatization among Patients with Plaque Psoriasis

The aim of the study was to analyze the level of stigmatization among patients with plaque psoriasis according to their demographic and clinical characteristics. The study included 122 patients who completed the 6-item and 33-item Feelings of Stigmatization Questionnaire and a sociodemographic survey. The analysis of the 6-item Stigmatization Scale showed a mean stigmatization score of 6.4 points. (Me = 6; s = 3.7); the mean score for the 33-item scale was 81.3 points (Me = 79.5; s = 19.9). Female patients felt stigmatized more often than males. Respondents living in the countryside had a stronger sense of stigmatization in the Sensitivity to Others' Attitudes (p = 0.0238) and Secretiveness (p = 0.0234) domains. The presence of psoriatic lesions across the entire body was the only explanatory variable significantly determining the level of stigmatization in the Positive Attitudes domain, either through the main effect or through the interaction with the patient sex. A highly significant difference was found for the feeling of being flawed domain (p = 0.044), with a mean score of 13.4 points. The issue of stigmatization in psoriasis deserves more attention, as the analysis of this problem may provide a better insight into the effect of the disease on the patient's condition, not merely in the context of its clinical manifestation.

Diagnosing the Dermatologic Blues: Systematic Review of the Rare Conundrum, Psychogenic Purpura

BACKGROUND

Psychogenic purpura is an idiopathic psychodermatologic condition of recurrent, painful purpura precipitated by psychological stress, predominantly affecting young females. Little consensus exists on the diagnostic guidelines for this rare condition, often resulting in costly, unnecessary, and stressful investigations as well as prolonged hospital admissions.

OBJECTIVE

With this first up-to-date systematic review of 134 cases of psychogenic purpura in over a decade, we aim to thoroughly investigate the diagnostic strategy and treatment regimens used in the last decade. With a sooner diagnosis, patient stress and nosocomial ecchymoses can be minimized, and treatment can be expedited.

METHODS

We conducted a literature review of 4 databases (PubMed, Ovid Embase, Ovid MEDLINE, and Web of Science) on October 5, 2022 that yielded 46 full-text articles, which were reviewed and extracted by 2 independent reviewers.

RESULTS

We analyzed a total of 134 cases, consisting largely of females (125/134, 93.3%) with purpura on the upper (103/134, 76.9%) or lower limbs (112/134, 83.6%). Apart from a paresthesia prodrome, patients commonly experienced headaches, malaise, and arthralgia or myalgia. Approximately 70% (95/134) of patients reported a physiological or psychological stressor or psychiatric diagnosis before the development of the purpura. Laboratory testing almost always revealed unremarkable results. The intradermal washed autoerythrocyte sensitization test was positive in 98% (42/43) of cases. Histopathology biopsy findings commonly revealed dermal erythrodiapedesis or hemorrhage (n=34) and perivascular inflammatory infiltrates (n=17). Approximately 42% (56/134) of patients received a novel psychiatric diagnosis, with depression being the most common (40/72, 56%). In both patients with and those without a novel psychiatric diagnosis, observation, counseling, treatment with antidepressants (ie, selective serotonin reuptake inhibitors), and psychotherapy (ie, cognitive behavioral therapy) prevailed in the resolution of the purpura.

CONCLUSIONS

Due to the unclear etiology and infrequent presentation of this condition, it remains a diagnosis of exclusion based on clinical suspicion evaluating the presence of stressors or psychiatric comorbidities and exclusion of systemic conditions. Clinical confirmation can be sought through a positive autoerythrocyte sedimentation test, characteristic histopathology findings, and remission of purpura after psychiatric treatment.

Attitudes towards COVID Vaccine and Vaccine Hesitancy in Dermatology: A Narrative Review

Vaccine hesitancy has been a contentious issue even before the pandemic. The COVID-19 crisis has further amplified vaccine hesitancy, with worries about adverse effects, cultural and religious beliefs, and misinformation on social media. In dermatology, patients with pre-existing skin conditions may have specific concerns about the impact of the vaccine on their skin health. Factors such as cutaneous reactions, potential flares of underlying conditions, and fears of psoriasis worsening post-vaccination contribute to vaccine hesitancy. Healthcare professionals, including dermatologists, play a crucial role in addressing vaccine hesitancy by providing accurate information, addressing concerns, and understanding the psychological impact on patients. The concept of vaccine fatigue is also explored, noting the challenges in sustaining vaccine acceptance over time, especially with regards to booster vaccinations. Overcoming vaccine hesitancy requires trust-building, effective communication strategies, and collaboration between healthcare workers and non-healthcare individuals to combat misinformation. By recognizing and addressing psychological factors, dermatologists can increase vaccine acceptance and improve public health efforts.

Plica Neuropathica as a Presenting Rare Dermatologic Symptom of Schizophrenia

Plica neuropathica (PN), also known as plica polonica, trichoma, matting, felting, or bird's nest hair, is a common but rarely reported hair disorder. It is characterized by the abrupt onset of irreversible hair entanglement, forming a densely matted hair mass. PN has been associated with the use of ionic or herbal shampoos, vigorous hair care practice, self-neglect, systemic infection, parasitic infestation, immunosuppressive drugs, and psychiatric conditions. However, literature supporting the coexistence of PN in psychiatric disorders is scarce. PN may be one of the presenting symptoms observed by physicians. In some cases of psychiatric illness, patients consult more readily with non-mental health professionals than psychologists or psychiatrists. To highlight this issue, we herein report a case of PN in a 32-year-old woman with a 1-month history of being unable to detangle her hair. The patient initially visited the dermatology department and was subsequently diagnosed with schizophrenia following psychiatric consultation. After establishing the fundamental diagnosis apparently underlying the PN, psychiatric treatment with antipsychotic medication and dermatological treatment of the hair condition were instituted. There was an improvement in both at the four-week follow-up. This case history highlights a rare presentation of schizophrenia.

Assessment of Frontal Hemispherical Lateralization in Plaque Psoriasis and Atopic Dermatitis

BACKGROUND

Each brain hemisphere plays a specialized role in cognitive and behavioral processes, known as hemispheric lateralization. In chronic skin diseases, such as plaque psoriasis (Pso) and atopic dermatitis (AD), the degree of lateralization between the frontal hemispheres may provide insight into specific connections between skin diseases and the psyche. This study aims to analyze the hemispherical lateralization, neurovegetative responses, and psychometric characteristics of patients with Pso and AD.

METHODS

The study included 46 patients with Pso, 56 patients with AD, and 29 healthy control (Ctrl) subjects. The participants underwent frontal electroencephalogram (EEG) measurement, heart rate variability (HRV) assessment, and psychological tests. Statistical analyses were performed using ANOVA, with Bonferroni correction applied for multiple comparisons.

RESULTS

This study shows a significant right-lateralized prefrontal activity in both AD patients (p < 0.001) and Pso patients (p = 0.045) compared with Ctrl, with no significant difference between the AD and Pso groups (p = 0.633). AD patients with right-hemispheric dominant prefrontal activation exhibited increased inhibition and avoidance markers, while Pso patients showed elevated sympathetic nervous system activity.

CONCLUSION

Psychophysiological and psychometric data suggest a shared prevalence of right-hemispheric dominance in both AD and Pso patient groups. However, the findings indicate distinct psychodermatological mechanisms in AD and Pso.

The vicious circle effect: stress as effect and cause in patients with psoriasis

Psoriasis is a common immune-mediated, chronic inflammatory disease, causing adverse effects on patients' quality of life and disease burden. In psychodermatology, psoriasis is included both in the group of dermatological diseases, in which the psychophysiological background plays a key role, and in dermatoses being a potential source of emotional disturbances or being a trigger for the development of secondary mental disorders. A comprehensive view of the patient with psoriasis, not only from the point of view of skin disease, but also as a result of a wide impact of stress, including low self-esteem and inappropriate social perception may have a key influence on improvement of quality of life of these patients.

Subliminal attentional bias modification training for itch

Introduction

Itch is unpleasant and induces the urge to scratch. This is adaptive to remove the itch-inducing stimulus from the skin. Accordingly, itch draws attention to protect our bodily integrity. Recent studies investigated whether attention is preferentially drawn towards its location, i.e., attentional bias (AB), and also whether this bias could be changed in healthy individuals. So far, results are mixed concerning the existance of an attentional bias towards itch stimuli in healthy individuals as well as the impact of modifications. However, available studies have typically focused on conscious processing and might miss preconscious aspects of attention and potential biases at these stages.

Methods

This study included 117 healthy individuals who underwent a subliminal Attentional Bias Modification (ABM)- training for itch based on a dot-probe paradigm with itch- related pictures. Participants were randomly assigned to a training towards itch group, a training away from itch group and a control group. This was done by manipulating the itch-target congruency of the dot-probe task during a training block. Pre- and post-training assessments were regular dot-probe tasks. Exploratorily, also attentional inhibition, cognitive flexibility and itch-related cognitions were assessed. Lastly, participants received an itchy stimulus on the inner forearm before and after the ABM-training to assess potential effects on itch sensitivity.

Results

Results showed no AB towards itch across groups at baseline, i.e., pre-training, but an AB away from itch, hence, avoidance of itch, post-training. Further analyses showed that this effect was driven by an attentional bias away from itch in the control group, while there were no significant effects in the experimental groups. There was no effect on itch sensitivity.

Conclusion

These findings are in line with recent studies on conscious ABM-training for itch and pain that also did not find significant training effects. Therefore, it is suggested that the field of AB might need to reconsider the current assessment of AB. Moreover, AB is probably a dynamic process that is highly dependent on current itch-related goals and relevance of itch in a specific situation. This suggests that processes probably differ in patients with chronic itch and that also ABM-training might work differently in these populations.

Clinical trial registration

https://trialsearch.who.int/Trial2.aspx?TrialID=NTR7561, identifier NTR7561.

A network analysis of psychological flexibility, coping, and stigma in dermatology patients

Introduction

Despite the negative effects of stigma in individuals with skin conditions, interventions to address its effects are rare. This might be in part due to a continued lack of understanding as to how individuals respond to stigma.

Methods

In this study, we employed a step-case analytic method, using traditional regression, moderation, and network analyses, to examine the role of psychological flexibility (PF) with stigmatized experiences, and stigma-related outcomes. We run a cross-sectional study (n = 105 individuals with various skin conditions) and analyzed stigma-related variables. We included variables examining perceived stigmatization (PSQ), anxiety (GAD-7), depression (PHQ-9), well-being (EQ5D5L), and variables stemming from the PF model (CompACT), presented as three coping with stigma responses, namely "open," "aware," and "active.".

Results

Using network analysis, the most influential or central variables that contributed to stigma were generalized anxiety, perceived stigmatization, and valued actions. In relation to PF, being open to the experience of stigma (as opposed to avoidance), keeping a distance from stigmatized thoughts (as opposed to self-stigmatizing), and bringing attention to value-based committed actions (as opposed to passivity) were all found to contribute to less stigmatized experiences.

Discussion

The results indicate that two of the three skills of the PF model ("open" and "active") may be important targets for interventions targeting stigma in people living with skin conditions.

How to Successfully Handle the Initial Encounter with a Delusional Infestation Patient

Managing a delusional patient is one of the most challenging situations experienced by dermatologists. This is exacerbated by the scarcity of psychodermatology training offered in residency and similar training programs. A few practical management tips can be easily employed in the initial visit to avoid an unsuccessful encounter. We highlight the most important management and communication techniques needed for a successful first encounter with this traditionally tricky patient population. Topics, such as diagnosing primary vs. secondary delusional infestation, how to prepare before entering the exam room, how to write the initial patient note, and when is the ideal time to introduce pharmacotherapy are discussed. Tips on preventing clinician burnout and creating a stress-free therapeutic relationship are reviewed.

Personality Disorders in Dermatology: a Review of Patient Characteristics, Associated Dermatologic Conditions, and Pearls for Management

Personality disorders are characterized by 'ego-syntonic' maladaptive behaviors that impair functioning. This contribution outlines the relevant characteristics and approach to patients with personality disorders pertaining to the dermatology setting. For patients with Cluster A personality disorders (paranoid, schizoid, and schizotypal), it is crucial to avoid being overly contradictory of eccentric beliefs and to take a straightforward, unemotional approach. Cluster B includes antisocial, borderline, histrionic, and narcissistic personality disorders. Promoting safety and boundaries is paramount when interacting with patients with an antisocial personality disorder. Patients with borderline personality disorder have higher rates of various psychodermatologic conditions and benefit from an empathetic approach and frequent follow-up. Patients with borderline, histrionic, and narcissistic personality disorders all have higher rates of body dysmorphia, and the cosmetic dermatologist needs to avoid unnecessary cosmetic procedures. Patients with Cluster C personality disorders (avoidant, dependent, and obsessive-compulsive) often have significant anxiety associated with their illness and may benefit from extensive and clear explanations of their condition and management plan. Due to the challenges posed by these patients' personality disorders, they are often undertreated or receive poorer quality care. While it is essential to acknowledge and address challenging behaviors, their dermatologic concerns should not be dismissed.

Psychiatric and psychologic aspects of chronic skin diseases

Chronic skin diseases can substantially impact a patient's physical, psychologic, and social well-being. Physicians may play a critical role in identifying and managing the psychologic sequelae of the most common chronic skin conditions. Acne, atopic dermatitis, psoriasis, vitiligo, alopecia areata, and hidradenitis suppurativa are chronic dermatologic diseases that put patients at high risk for symptoms of depression, anxiety, and decreased quality of life. Both general and disease-specific scales exist to assess the quality of life in patients with chronic skin disease, the most common being the Dermatology Life Quality Index. The general management approach to the patient with chronic skin disease should incorporate acknowledgment and validation of the patient's struggles, patient education on the potential impact of disease and prognosis; medical management of the dermatologic lesions; coaching on stress management; psychotherapy. Psychotherapies include talk therapy (i.e., cognitive behavioral therapy), arousal-reducing therapies (i.e., meditation, relaxation), and behavioral therapies (i.e., habit reversal therapy). Improved understanding, identification, and management of the psychiatric and psychologic aspects of the most common chronic skin conditions by dermatologists and other healthcare providers may positively affect patient outcomes.

Psychopharmacology in Dermatology: Five Common Disorders

Dermatologists often encounter a patient who presents with an illness that overlaps both psychiatric and dermatologic specialties. Psychodermatology patients range from straightforward (i.e., trichotillomania, onychophagia, excoriation disorder) to challenging (i.e., body dysmorphic disorder) to highly challenging (i.e., delusions of parasitosis). Many refuse to see psychiatrists. As such, the only chance that many of these patients will receive treatment is if the dermatologist is willing to prescribe psychiatric medications to them. We review five common psychodermatologic disorders and how to treat them. We discuss some commonly prescribed psychiatric medications and provide the busy dermatologist with a few psychiatric tools in the dermatologic toolbox.

Pharmacological Interventions for Primary Psychodermatologic Disorders: An Evidence Mapping and Appraisal of Randomized Controlled Trials

BACKGROUND

The lack of clinical guidelines for the treatment of primary psychodermatologic disorders (PPDs) hinders the delivery of optimal care to patients. The review aimed to identify, appraise, and summarize the currently available evidence about the safety and effectiveness of pharmacological management of PPDs through randomized controlled trials (RCTs).

METHODS

The Preferred Reporting Items for Systematic Review and Meta-Analyses (PRIMSA) statement and the Global Evidence Mapping Initiative guidance were followed. Medline, Embase, PsycInfo, Cochrane and Scopus were searched, and two reviewers independently completed article review, data extraction, and quality assessment.

RESULTS

Among 2618 unique studies, full texts of 83 were reviewed and 21 RCTs were included. Five PDDs were identified: trichotillomania (n = 12), pathologic skin picking (n = 5), nail biting (n = 2), delusional parasitosis (n = 1), and dermatitis from compulsive hand washing (n = 1). Seven different classes of medications were investigated: SSRIs (i.e., fluoxetine, sertraline, and citalopram), tricyclic antidepressants (i.e., clomipramine and desipramine), antipsychotics (i.e., olanzapine and pimozide), anticonvulsant (i.e., lamotrigine), N-acetylcysteine, inositol, and milk thistle. RCT-derived evidence supports the use of antidepressants in trichotillomania (sertraline and clomipramine), pathologic skin picking (fluoxetine), pathologic nail biting and dermatitis from compulsive hand washing (clomipramine or desipramine); antipsychotics in trichotillomania (olanzapine) and delusional parasitosis (pimozide); N-acetyl cysteine in trichotillomania and skin picking.

CONCLUSION

Few pharmacotherapies for primary psychodermatologic disorders are assessed through controlled trials in the literature. This review serves as a roadmap for researchers and clinicians to reach informed decisions with current evidence, and to build on it to establish guidelines in the future.

Manifestation of anxiety and depression among pediatric patients with psoriasis: A review

Psoriasis is a chronic, inflammatory skin disorder with manifestations extending beyond visual presentation to encompass psychological burden. Though the association between psoriasis and mental health disorders in adults is widely accepted, there is inadequate research to generalize these findings to pediatric populations. In this review of the literature, we discuss the prevalence of anxiety and depression among pediatric patients with psoriasis in hopes of raising awareness of these associations and advocating for psychological screening and intervention in dermatology practice.

The psychological consequences of androgenetic alopecia: A systematic review

INTRODUCTION

Androgenetic alopecia is the most common cause of hair loss in both males and females. In a society that places significant value on hair and associates it with attractiveness, a lack there of can have damaging psychological consequences. The psychosocial impact of hair loss is often overlooked due to the medically benign nature of offending conditions. Addressing the psychological aspects of androgenetic alopecia can improve holistic patient care and patient outcomes.

METHODS

A search was conducted in PubMed using the following search strategy: androgenetic alopecia AND anxiety OR depression OR psychological OR psychosocial OR self-esteem. Studies were excluded if they focused on any other type of alopecia or were published in a language other than English.

RESULTS

A total of 13 studies were retained after the initial search process. The included studies date from 1992 to 2021. They all conclude that androgenetic alopecia serves as a significant psychosocial stressor in the lives of those affected. It impairs quality of life according to multiple measures.

CONCLUSION

The data examined from these studies shed light on the increased need to attend to the psychosocial comorbidity associated with androgenetic alopecia. These hair-loss patients often present to dermatology clinics to seek treatment but would also benefit from psychological support.

Case report: Dermatosis neglecta mimicking pemphigus foliaceus in association with obsessive-compulsive disorder

Dermatosis neglecta (DN) is a frequently underrecognized skin disorder that occurs due to unconscious or conscious neglect of self-cleaning, causing the accumulation of keratin, sweat, sebum, and impurities. It is characterized by asymptomatic yellowish-to-brownish, waxy, adherent papules or plaques with cornflake-like scales that mimic several dermatological conditions. DN awareness is crucial for avoiding unnecessary invasive diagnostic procedures. Its lesions can be removed with some difficulty by ordinary cleansing and efficiently cleared with ethyl or isopropyl alcohol. Individuals with underlying physical or mental disabilities or psychiatric conditions are highly associated with DN. Nevertheless, supportive evidence for the coexistence of DN and psychological conditions is sparse, and most individuals with mental problems usually deny having psychiatric issues. Here, we present a case of DN resembling pemphigus foliaceus on the face with obsessive-compulsive disorder in a 16-years old male. The definitive diagnosis of DN in this patient was confirmed via histopathological examination. The lesions completely disappeared after appropriate facial cleansing and psychiatric management. DN may reveal underlying psychiatric disorders in patients.

Cognitive behavior therapy as dermatological treatment: a narrative review

Cognitive behavior therapy (CBT) is efficacious in treating numerous psychological disorders. It is also effective in combination with medication for chronic pain, diabetes, and other diseases. Patients with skin disease report high levels of stress, anxiety, and negative feelings.

Objective

To summarize the findings on the utility of CBT for the improvement of skin status and quality of life in patients with dermatological conditions.

Methods

PubMed and Google Scholar databases were searched for relevant articles from database inception to the time of search (October 20, 2021). A total of 30 included studies featured 10 on psoriasis, 11 on atopic dermatitis, 4 on vitiligo, 4 on acne, and 1 study on alopecia areata.

Results

Several studies, including randomized controlled trials with large study samples, support the effectiveness of CBT and Internet CBT for a number of dermatological conditions. Patients who completed CBT courses were less likely to rely on dermatological healthcare during follow-up.

Limitations

There are a limited number of studies discussing the implementation of CBT for alopecia, acne, and vitiligo.

Conclusion

Patients who underwent CBT or Internet CBT in addition to skin care demonstrated improvement with quality of life and severity of skin disease as compared to controls only receiving standard of care treatment.

A brief online writing intervention improves positive body image in adults living with dermatological conditions

Introduction

Dermatological conditions can affect how individuals feel about their bodies. This research therefore seeks to evaluate the potential for a brief writing intervention, focused on body functionality, to improve body image in adults living with a range of dermatological conditions.

Methods

As part of a parallel Randomised Controlled Trial, 451 adults living with a dermatological condition were randomized to either three functionality-based writing tasks or three creative writing tasks (control). Of these, 155 participants completed pre- and post-intervention measures of body appreciation, functionality appreciation, appearance anxiety, skin-related shame, and skin-related quality-of-life.

Results

For participants with relatively low or mid-range scores on baseline body appreciation and functionality appreciation, there were medium-to-large positive effects of the intervention. Effects were smaller, with all but-one remaining significant, at 1-month follow up and in intention-to-treat analyses. No between-group effects of the intervention were found for measures of appearance anxiety, skin-related shame, and skin-related quality-of-life.

Discussion

These findings suggest that a 1-week writing intervention has the potential to improve positive aspects of body image, but not appearance- and skin-related distress in adults living with a dermatological condition.

Clinical trial registration

[https://clinicaltrials.gov/ct2/history/NCT044459 74?V_3=View], identifier [NCT04445974].

Testing some psychometric properties of the Italian version of the Skin Cancer Index: A questionnaire for measuring quality of life in patients with non-melanoma skin cancer

OBJECTIVES

Non-melanoma skin cancers (NMSC) include two main types: basal cell carcinoma (BCC) and cutaneous squamous cell carcinoma (cSCC). Generic Health-Related Quality of Life (HRQoL) instruments revealed little to no HRQoL impairment in NMSC patients. Instead, the use of specific skin disease HRQoL tools contradicted those observations. For example, the Skin Cancer Index (SCI) was suggested as a validated instrument for the evaluation of the impact of skin cancers on HRQoL, and has already been validated in several languages, but not in Italian. The aim of this study is to testing some psychometric properties of the Italian version of the SCI questionnaire in a large sample of NMSC patients.

METHODS

This is a cross-sectional, single-center, observational study. Firstly, different factor models proposed in the literature were compared and the model with the best fit was identified. Secondly, the psychometric properties of the SCI, convergent validity and reliability, were evaluated.

RESULTS

The sample was composed of 371 NMSC patients. The factor analysis revealed that a revised version of the original model had the best fit [χ2(df = 85) = 354.53, p < 0.001, RMSEA = 0.09, CFI = 0.98, TLI = 0.97, SRMR = 0.03]. The SCI had satisfactory internal consistency for all subscales (Emotional subscale: ordinal alpha = 0.95; Social subscale: ordinal alpha = 0.94; Appearance subscale: ordinal alpha = 0.94). The convergent validity with Skindex-17 psychosocial subscale was adequate for all the SCI subscales (Emotional Subscale: rho = -0.50; Social Subscale: rho = -0.54; Appearance subscale: rho = -0.44; Total Skin Cancer Index: rho = -0.56; and p < 0.001).

CONCLUSION

The tested psychometric properties of the Italian version of the SCI may suggest that it is an appropriate tool to measure the HRQoL in NMSC patients, however, further studies are needed in order to confirm and tested other psychometric features of this tool.

Clinical profile of dermatitis neglecta with special emphasis on psychiatric comorbidities: A case series of 22 patients from Eastern India

Dermatitis neglecta (DN), first described by Poskitt et al. in 1995, is a dermatosis resulting from insufficient frictional cleansing of the skin. Lesions result from self-neglect and may have several underlying etiologies, including psychiatric conditions. There is a dearth of any formal study or large case series on this subject. Moreover, the psychological aspects of DN mostly remain unexplored. We report here the clinical profile and psychiatric comorbidities of a group of patients with DN from eastern India. Sporadic cases of underlying psychological problems like cognitive deficit and executive dysfunction, schizophrenia, severe anxiety disorder, and depression have been reported in the existing literature. Associated psychiatric disorder was present in 72.7% of the patients of this case series that include several underlying psychiatric disorders like depression, schizophrenia, somatic symptom disorder, social anxiety disorder, intellectual disability, bipolar disorder, Alzheimer's disease, and alcohol dependence. In this article we would like to emphasize that DN is frequently associated with psychiatric disorder and management of the underlying psychiatric condition with psychotropic medications; psychotherapy is of immense importance.

A pilot study of resilience and severity of depressive symptoms in patients with psoriasis

Background

Patients with psoriasis show an increased prevalence of depressive symptoms that worsen disease outcomes. This study investigated the effect of resilience and other sociodemographic/clinical variables on depressive symptoms' severity in patients with psoriasis.

Methods

This study included 58 psoriasis patients consecutively enrolled during the 14 months of the study. We evaluated psoriasis severity using the Psoriasis Area and Severity Index, Body Surface Area, and Physician Global Assessment. The psychometric assessment included the Resilience Scale and the Beck Depression Inventory-II (BDI-II). We divided participants into two subgroups based on the optimal BDI-II cut-off score (Group A: BDI-II ≤17; Group B: BDI-II >17). A stepwise regression analysis explored whether the variation in the BDI-II score could be predicted by a linear combination of sociodemographic and clinical variables.

Results

Psoriasis patients with more severe depressive symptoms (Group B patients) showed lower resilience levels than Group A patients (p <0.001). Moreover, depressive symptoms correlated only with resilience levels (p <0.001), with a negative correlation. The stepwise regression analysis revealed that resilience explained 37.1 % of the variance in BDI-II scores, whereas resilience, gender, and comorbidity with other physical illnesses combined explained 51.3 % of the variance.

Conclusion

Resilience may alleviate depressive symptoms in psoriasis patients. This study underscores the importance of resilience-building interventions for these patients. HIPPOKRATIA 2022, 26 (4):131-137.

New Insights into Delusional Infestation

The recently proposed Koo-Brownstone staging system for Delusional Infestation (DI) is a large step forward in Dermatology. It proposes that patients' presentations can be separated into various categories along a spectrum, and that each of these categories are approached differently. This system explains longstanding variation in the reported response to treatment of patients who present with concerns of infestation. To develop a consensus across the medical community, the authors propose that the terms are discussed in a larger forum of national experts. The authors also suggest the avoidance of the term "Morgellons" within this staging system.

The Impact of COVID-19 Pandemic on Dermatological Conditions: A Novel, Comprehensive Review

Background: The earliest cases of Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) emerged in Wuhan, China, in December 2019. Since the declaration as a pandemic on 11 March 2020, further dermatological conditions continue to be documented. We herein present a novel literature review of dermatological manifestations associated with the Coronavirus Disease 2019 (COVID-19) pandemic. To date, this literature review is the first broad-spectrum examination that analyzes a range of dermatological manifestations related to the COVID-19 pandemic: infection, vaccinations, personal protective equipment (PPE), and psychosocial factors. Methods: A detailed literature search was conducted using key terms for cutaneous manifestations associated with the scope of this review. The search retrieved 2199 articles. Results: The COVID-19 pandemic has triggered a significant range of dermatologic sequela. Etiologies of lesions continue to be investigated. Proposed mechanisms include inflammatory response to spike protein, vitamin D deficiency, ACE2 receptor activation, androgen levels, and increased psychological stress. One prominent mechanism describes viral spike protein invasion into the dermis by binding to the angiotensin-converting enzyme 2 (ACE-2) receptors in keratinocytes, with a secondary immunological response. Conclusions: Dermatologists play an integral role in the proper diagnosis and treatment of COVID-related lesions. Early treatment regimens and timely prophylaxis have been shown to safely reduce infection-related dermatological sequelae. Additional investigations and data collection can reduce disease burden and improve overall prognosis.

Pediatric skin picking disorder: A review of management

Skin picking disorder (SPD) commonly presents in childhood; often, families will first turn to dermatologists for evaluation. It is imperative that dermatologists accurately diagnose and treat the disorder as children are vulnerable to face significant negative psychosocial impacts. This article reviews the limited literature on the management of SPD in pediatric patients to better prepare dermatologists for educating families and recommending treatment options. We discuss studies evaluating behavioral and pharmacologic therapies, as well as emerging skin barrier treatments.

Experiences of Blogging About Visible and Long-term Skin Conditions: Interpretative Phenomenological Analysis

BACKGROUND

Skin conditions can detract from people's quality of life, much like conditions such as cancer, chronic pain, and depression. Visible skin conditions can lead to risk of stigmatization. It is acknowledged that there is a lack of available psychosocial support for people living with chronic skin conditions. One way in which individuals with long-term conditions are self-managing and providing peer support is through blogging and exchanging information on the web. To date, no research has specifically investigated how individuals with skin conditions experience the use blogging for self-management.

OBJECTIVE

This study sought to investigate the experiences of individuals with visible, long-term skin conditions when blogging about their conditions.

METHODS

A systematic blog search and a short survey were used for recruitment. A total of 4 participants took part in email interviews, which were analyzed using interpretative phenomenological analysis (IPA). Skin conditions included alopecia, psoriasis, and hirsutism. The content of these individuals' blogs was also analyzed using a qualitative template method derived from the IPA analysis.

RESULTS

The interviews and accounts revealed a clear sense of uncertainty about the course of the bloggers' skin conditions. This appeared to be associated with feelings of distress and isolation, searching for treatments, and ultimately a sense of defeat. The data revealed that blogging provided a space where this sense of defeat was managed and challenged. Posting on the web facilitated connection with others and enabled support networks to be established that assisted in challenging the feelings of isolation experienced. The data demonstrate the important role that blogging played for these participants in developing a sense of acceptance of their condition.

CONCLUSIONS

Blogging may provide a way for individuals to self-manage distress associated with visible skin conditions. It may provide similar benefits to those known to be derived from emotional disclosure that occurs during writing, with an added peer support dimension. Blogging has occurred naturalistically on web-based forums, and this study demonstrates how this form of interaction may warrant adaptation for use with web-based psychosocial interventions for people living with skin conditions. This study had a limited sample of 4 bloggers; therefore, further exploration would be needed to consider the utility of this approach.

19th Congress of the European Society for Dermatology and Psychiatry (ESDaP) and 2nd Brain Skin Colloquium Conference (BSC), June 11-13, 2021, London

The Congress of the European Society for Dermatology and Psychiatry (ESDaP), held in conjunction with the 2nd Brain Skin Colloquium (BSC) Conference, hosted over 60 speakers delivering 47 oral presentations, 41 poster presentations and 5 keynote talks via 2 simultaneous livestream platforms. The 2-day conference, held biennially, was due to be hosted in London, but was converted to a virtual format due to the Covid-19 pandemic. This report presents a synopsis of the conference.

Post-Traumatic Stress in Vitiligo Patients: A Neglected but Real-Existing Psychological Impairment

Background

Vitiligo is the most common depigmentation disorder. This disease causes disfiguration and induces psychological burdens, leading to significantly impaired quality of life. Limited research about disease-related post-traumatic stress (PTS) has been conducted in vitiligo patients.

Objective

To evaluate the prevalence, severity, and risk factors of post-traumatic stress in vitiligo patients.

Methods

This case-control study was performed from January 2021 to April 2021. A survey questionnaire including baseline information, post-traumatic stress symptoms evaluation, life quality evaluation was conducted. According to the severity of post-traumatic stress symptoms, patients were grouped and compared. The logistic regression model was conducted to analyze the risk factors for post-traumatic stress disorder (PTSD).

Results

A total of 337 patients were included. A 30.3% of vitiligo patients (102/337) in present cohort had PTS and 12.5% patients (42/337) were confirmed for developing into PTSD. The multivariate logistic regression revealed educational level<university (OR=2.32, 95% CI=1.97–2.93, P=0.003), vitiligo in face and neck (OR=2.65, 95% CI=2.08–3.12, P=0.008), vitiligo in feet and hands (OR=1.86, 95% CI=1.54–2.12, P<0.001) and surgical treatment (OR=3.53, 95% CI=3.12–4.02, P<0.001) were risk factors for PTSD. PTS severity was significantly associated with vitiligo disease activity score (rho=0.54, R2=0.29, P=0.002), vitiligo area scoring index score (r=0.55, R2=0.30, P=0.012), and dermatology life quality index score (r=0.61, R2=0.37, P=0.004).

Conclusion

Vitiligo-related PTS is prevalent in vitiligo patients and causes psychological impairment. Dermatologists should realize and identify this condition carefully and offer proactive intervention to improve patients’ quality of life.

The Importance of Exploring the Role of Anger in People With Psoriasis

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Internalized skin bias: Validation study to explore the impact of the internalization of social stigma on those with hidradenitis suppurativa

BACKGROUND

Hidradenitis suppurativa (HS) is a chronic auto-inflammatory disease that is highly associated with adverse psychopathology and impaired body image. Previous studies show that patients with HS are also impacted by social stigma associated with their skin disease. Over time, these experiences can influence the way in which patients feel about themselves, leading to internalized skin bias (ISB).

OBJECTIVES

To evaluate the validity and reliability of the Internalized Skin Bias Questionnaire (ISBQ) in an HS population, and to determine the association of this instrument with markers of HS severity.

METHODS

A cross-sectional survey with 72-hour retest was sent to adult patients with HS from March to November 2021. Reliability for the ISBQ was evaluated using Cronbach's alpha and the Concordance Correlation Coefficient (CCC). Construct validity was evaluated using Pearson Correlation Coefficients with similar measures.

RESULTS

Internal consistency for the ISBQ instrument was 0.89 with a CCC of 0.88. The ISBQ had moderate correlation (r = 0.63) with the experienced skin stigma questionnaire as well as the BDI-II (r = 0.66) and the psychosocial subscale of the HiSQOL (r = 0.65). ISBQ scores differed significantly across different stages of disease severity (p=0.04). There was no significant difference between those with different durations of disease (p=0.47).

CONCLUSIONS

This study shows that the ISBQ is a valid and reliable instrument that can be used to assess the psychosocial construct of ISB especially in a population of HS patients. Further, ISB places a prevalent negative impact on the psychopathology of patients with HS.

Depression and suicidality in patients with psoriasis and the role of psoriatic arthritis; a cross-sectional study in a tertiary setting

BACKGROUND

Depression is overrepresented in psoriasis. However, it is not clear whether the presence of psoriatic arthritis (PsA) independently increases patients' depressive burden. Furthermore, current evidence regarding suicidality risk of psoriasis populations is conflicting and the role of PsA on suicidality outcomes in psoriasis is unknown.

OBJECTIVES

(i) To test whether PsA is associated with depression and lifetime suicidal ideation among patients with psoriasis; (ii) to capture different suicidal phenomena in these patients; and (iii) to investigate whether suicidality and depressive symptom severity are associated with clinical markers of psoriasis severity and chronicity.

METHODS

A cross-sectional survey of tertiary patients (n=219, aged 18-65 years) with dermatologist-confirmed chronic plaque psoriasis, of whom 84 had rheumatologist-confirmed PsA, was undertaken. The Hospital Anxiety and Depression Scale and Sheehan-Suicidality Tracking Scale were used to assess depression and lifetime suicidality respectively.

RESULTS

PsA presence was associated with depression in patients with psoriasis, independently of other physical comorbidities (adjusted Odds Ratio 2.92, 95% Confidence Interval 1.53-5.68). Furthermore, patients with PsA experienced significantly higher levels of anhedonia and anxiety, after controlling for psychiatric history. 48.8% of all participants reported lifetime suicidal ideation with or without intent; 21.3% reported suicidal planning and 9.4% suicide attempts. Lifetime suicidality prevalence did not differ between patients with and without PsA. Depressive symptom severity and lifetime suicidality scores were not associated with objective measures of psoriasis severity or treatment group.

CONCLUSION

These data suggest that joint involvement in psoriasis is associated with higher depressive burden. There is a need for routine depression screening among patients with psoriasis, in particular when PsA is present. Anhedonia appears to be a particularly relevant symptom in the depression phenotype of this population. We did not find a statistically significant association between PsA and suicidality. Nevertheless, suicidality rates in tertiary patients with psoriasis appear to be higher than in the general population. Suicidality monitoring is recommended to help in reducing future psychiatric morbidity and mortality in patients with psoriasis.

Patients With Hidradenitis Suppurativa Negatively Perceive Both Medical and Euphemistic Appellations of Their Disease: A Study From Turkey

Background

The use of medical terms and folk names (euphemisms) affect a patient's understanding of diseases and perceptions of severity.

Objectives

We determine the psychological effects on patients with hidradenitis suppurativa of medical and folk names of their disease.

Methods

This was a cross-sectional and exploratory study conducted at a tertiary referral university hospital in Turkey. A questionnaire on the medical and folk names of hidradenitis suppurativa was administered to 31 males and 25 females.

Results

The patients expressed that they found the medical term hidradenitis suppurativa to be incomprehensible because it is a foreign term. When hearing it for the first time, it evoked negative responses such as confusion and worry about their health. Half of the patients preferred their doctors to use a more understandable and pronounceable name. More than 80% of patients expressed feeling depressed and stigmatized by the folk name of their disease. They preferred the terms boils, abscesses, or hidradenitis when referring to their disease.

Conclusion

Both medical and folk names for hidradenitis suppurativa have negative effects on patients, and most patients feel stigmatized by either term.

Illness Acceptance as the Measure of the Quality of Life in Moderate Psoriasis

Introduction

Psoriasis is a chronic disease with intermittent flares and remissions. Each individual perceives the disease, its somatic effects, resultant dysfunction and related problems differently. This attitude is primarily determined by one’s characterological traits and type of illness. A primary response to the diagnosis can be denial, underestimation, acceptance or overestimation of the disease. The aim of the study was to analyze the level of illness acceptance and its effect on the quality of life in moderate psoriasis depending on sociodemographic and clinical characteristics of the patients.

Materials and Methods

The study included 186 patients with plaque psoriasis with Psoriasis Area Severity Index (PASI) scores ≤10. The inclusion criteria of the study were duration of psoriasis >2 years, age ≥18 years, and lack of other somatic or mental disorders during three months preceding the study. The study participants completed the Acceptance of Illness Scale (AIS), Dermatology Life Quality Index (DLQI) as well as an original survey containing questions about their sociodemographic characteristics and information about their disease.

Results

Mean AIS score for the study group was 24.3 pts. Patients older than 40 years presented with lower levels of illness acceptance than younger persons (p = 0.0311). Also, patients’ sex and duration of psoriasis significantly affected the acceptance of the illness, with lower AIS scores found in women (p = 0.0092) and persons with a longer history of the disease (p = 0.0362). Mean DLQI score for the study group was 13.3 pts. A lower level of illness acceptance turned out to exert an unfavorable effect on the quality of life (QOL) in psoriasis (p = 0.0015; R = −0.33).

Conclusion

In this study, patients with psoriasis presented with a moderate level of the illness acceptance, and a significant correlation was found between this parameter and QOL.

Alopecia areata: A psychodermatological perspective

BACKGROUND

Alopecia Areata (AA) is an autoimmune dermatological disease that could be influenced by psychological factors as part of the pathophysiology of the illness.

AIMS

This review article aims to report on psychodermatological and psychopathological aspects involved in the etiopathogenesis and comorbidities of AA, as well as on the psychiatric and psychological management of affected patients.

METHODS

We conducted a literature search on PubMed and Google Scholar from January 1980 to May 2021 employing the search terms of alopecia areata, psychological factors, psychological impact, psychodermatology, and psychopathology. All lists of references from the identified articles were screened for further relevant studies. The search was limited to English and Spanish language articles and was supplemented with themed books and book chapters. No specific quality criteria were used for the studies selection.

RESULTS

Several authors have found a high comorbidity rate between AA and mental disorders, concluding that stress and psychological factors are involved in both the development and exacerbation of the illness. More evidences are needed in order to describe the associations between the immune response, stress, and the physiological factors observed in AA patients.

CONCLUSION

AA is a complex illness characterized by multifactorial etiology. An interaction between genetic, autoimmune, hormonal, neural, and psychological factors is supposed. Psychopathological aspects of illness need to be better described and considered in the clinical setting.

Delusional infestation in clinical practice over a period of two decades

Introduction

Patients presenting with cutaneous symptomatology may in fact suffer from underlying psychiatric conditions. Individuals diagnosed with delusional infestation (DI) have a fixed false belief of being infested with certain organisms or objects.

Aim

To analyse clinical features of subjects with DI who were admitted to the tertiary dermatology ward.

Material and methods

A retrospective analysis concerning DI patients hospitalized between 1997 and 2019 was carried out. The emphasis was put on the duration of symptoms, psychiatric symptomatology (including the "specimen sign"), comorbidities as well as therapy.

Results

We gathered data regarding 21 consecutive patients with DI. The mean age of subjects was 65.2 ±13.3 years, the majority were females (76.2%). The mean time span between the disease onset and diagnosis was 1.9 ±1.7 years. Previous psychiatric consultations were attended by 57.0% of patients. The specimen sign was present in 47.6% of cases, whereas the most common suspected causative factors were described as worms (52.4%), unspecified parasites (42.9%), "something" (33.3%) and flies (19.0%). Primary delusional disorder was diagnosed in 76.2%, followed by shared delusional disorder and secondary delusional disorder of organic origin (9.5% each). Risperidone monotherapy was initiated in 61.9% of patients. In total, only 33.3% of patients attended the follow-up visit.

Conclusions

DI features a wide spectrum of clinical signs and symptoms. Risperidone remains the drug of choice in the majority of cases. Successful management of each DI case requires collaboration between dermatologists and psychiatrists and still remains a major challenge.