Vol. 32. No. 2


In a busy dermatology practice, we frequently encounter patients whose psychological problems appear just as important as their dermatological ones. Some examples include patients with delusion of parasitosis (Morgellons syndrome), neurotic excoriations, trichotillomania, cutaneous sensory disorder and any patient whose skin condition is worsened with emotional stress. Studies have shown that as many as one-third of dermatology patients have a significant psychological issue in connection with their skin complaint. Therefore, it is helpful in clinical practice to know as much as possible about the management of psychological issues in dermatology. On the other hand, despite its high relevance to our practice, psychodermatology is rarely covered in dermatology residency programs. In this issue of Seminars in Cutaneous Medicine and Surgery, we provide a rare opportunity to learn about psychodermatology. You will find the papers presented herein to be concise and clinically useful. This issue covers many important topics such as the optimal approach to the psychodermatology patient, the role of emotional stress in worsening skin conditions, and the impact of disfiguring skin disorders on quality of life. We also review the diagnosis and management of well-known psychodermatological disorders, such as delusional disorders, cutaneous sensory disorders, body dysmorphic disorders, obsessive-compulsive disorders in dermatology, trichotillomania, onychophagia, and neurotic excoriations. Lastly, both pharmacologic and nonpharmacologic approaches to the management of psychodermatology patients are discussed. We hope that you find this issue easy to comprehend and practical. Now that you have a compendium of psychodermatology in your hands, you are about to embark on an exciting journey. As you flip through the pages of this issue, you will uncover some fascinating topics in psychodermatology written by well-known experts in dermatology and psychiatry from around the world.


Alde Carlo Gavino, MD | Michelle Magid, MD | Monica Huynh, BA
Trichotillomania (TTM) is an impulse disorder in which patients chronically pull out hair resulting in noticeable hair loss. TTM is reported to affect as much as 4% of the population with the highest incidence in childhood and adolescence. The diagnostic criteria for TTM is likely to be revised in the planned fifth edition of the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders (DSM-V) to remove the requirement that the patient has “tension” followed by “relief” or “gratification” after hair pulling. First-line therapy is cognitive behavioral therapy, with strongest support for the subtype habit reversal training. Among pharmacologic therapy, clomipramine has been most effective in clinical trials. However, selective serotonin reuptake inhibitors are most commonly prescribed despite the lack of data supporting their efficacy. This article reviews the clinical features and treatment options for TTM to enhance knowledge and clinical management of TTM. Semin Cutan Med Surg 32:88-94 © 2013 Frontline Medical Communications

Neurotic Excoriations and Dermatitis Artefacta

Caroline S Koblenzer, MD | Rishu Gupta, BS
Neurotic Excoriations is a psychocutaneous disorder that is characterized by an uncontrollable urge to pick at normal skin or skin with mild irregularities. Dermatitis Artefacta is another psychocutaneous disorder that consists of self-induced skin lesions often involving a more elaborate method for damaging the skin, such as the use of a sharp instrument. Both neurotic excoriations and dermatitis artefacta cause significant disfigurement and anxiety for the patient. Since patients often present to dermatologists first, it is important for dermatologists to be aware of the nature of each condition and the available treatment options. This article provides an update on the clinical features, diagnosis, and treatment options for neurotic excoriations and dermatitis artefacta. Semin Cutan Med Surg 32:95-100 © 2013 Frontline Medical Communications

Quality-of-Life Effects of Common Dermatological Diseases

Ammar Ahmed, MD | Argentina Leon, MD | Daniel C Butler, BS | Jason Reichenberg, MD
Chronic skin conditions can impact a patient’s quality of life beyond the skin. This manuscript gives an overview of the negative impact of common chronic skin conditions, such as psoriasis, vitiligo, acne, and eczema measured by the validated quality of life instruments. Literature has shown that patients with vitiligo and acne are mostly affected by their psychosocial wellbeing, whereas psoriasis and atopic dermatitis patients are affected by both physical and psychosocial well-being. Effective treatments of the above skin conditions correlate with positive quality of life outcomes. Further studies are recommended to better understand factors affecting quality of life. Semin Cutan Med Surg 32:101-109 © 2013 Frontline Medical Communications

Cutaneous Sensory Disorder

Aditya K Gupta, MD, PhD, FRCPC | Madhulika A Gupta, MD, FRCPC, FAASM
Cutaneous sensory disorder (CSD) represents a heterogeneous clinical situation where the patient presents with either disagreeable skin sensations (ie, itching, burning, stinging) or pain (ie, allodynia) and/or negative sensory symptoms (ie, numbness, hypoaesthesia). These patients have no apparent diagnosable dermatologic or medical condition that explains the cutaneous symptom, and typically have negative findings upon medical workup. Skin regions that normally have a greater density of epidermal innervation tend to be more susceptible to the development of CSD. CSDs can affect any body region but generally tend to be confined to the face, scalp and perineum, and have been referred to in the literature with region-specific terms such as burning mouth syndrome, glossodynia and vulvodynia. Symptoms such as pruritus with unexplained hyperhidrosis may occur during sleep, as a result of heightened sympathetic tone. Sleep deprivation and insomnia can play a moderating role in CSD. Somatization and dissociation can play a central role in the pathogenesis of CSDs. A review of the literature suggests that CSDs represent a complex, and often poorly understood interplay between neurobiological factors associated with neuropathic pain, neuropathic itch and neurologic/neuropsychiatric states (eg, radiculopathies, stroke, depression and posttraumatic stress disorder). These neurologic/neuropsychiatric states can modulate pain and itch perception by potentially affecting the pain and itch pathways at a structural and/or functional level. Semin Cutan Med Surg 32:110-118 © 2013 Frontline Medical Communications

Nonpharmacologic Management of Psychodermatologic Conditions

Richard G Fried, MD, PhD
Nonpharmacologic management of psychodermatologic conditions includes both structured and unstructured interventions that may ameliorate skin disorders, reduce psychological distress, and improve the functional status of the affected individual. Nonpharmacologic techniques are often referred to as psychocutaneous interventions. This article will review the data on psychocutaneous conditions that have been shown to improve with nonpharmacologic interventions. Suggested clinical approaches to facilitate the implementation of these modalities will be discussed. Semin Cutan Med Surg 32:119-125 © 2013 Frontline Medical Communications