PSYCHODERMATOLOGY
Jun
2013
Vol. 32. No. 2
Introduction
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.
Trichotillomania
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
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Neurotic Excoriations and Dermatitis Artefacta
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
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Quality-of-Life Effects of Common Dermatological Diseases
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
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Cutaneous Sensory Disorder
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
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Nonpharmacologic Management of Psychodermatologic Conditions
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
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