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Unformatted text preview: Mohammad Jafferany Psychodermatology: A Guide to Understanding Common Psychocutaneous Disorders Mohammad Jafferany, M.D. Objective: This review focuses on classification and description of and current treatment recommendations for psychocutaneous disorders. Medication side effects of both psychotropic and dermatologic drugs are also considered. Data Sources: A search of the literature from 1951 to 2004 was performed using the MEDLINE search engine. English-language articles were identified using the following search terms: skin and psyche, psychiatry and dermatology, mind and skin, psychocutaneous, and stress and skin. Data Synthesis: The psychotropic agents most frequently used in patients with psychocutaneous disorders are those that target anxiety, depression, and psychosis. Psychiatric side effects of dermatologic drugs can be significant but can occur less frequently than the cutaneous side effects of psychiatric medications. In a majority of patients presenting to dermatologists, effective management of skin conditions requires consideration of associated psychosocial factors. For some dermatologic conditions, there are specific demographic and personality features that commonly associate with disease onset or exacerbation. Conclusions: More than just a cosmetic disfigurement, dermatologic disorders are associated with a variety of psychopathologic problems that can affect the patient, his or her family, and society together. Increased understanding of biopsychosocial approaches and liaison among primary care physicians, psychiatrists, and dermatologists could be very useful and highly beneficial. (Prim Care Companion J Clin Psychiatry 2007;9:203–213) Received Sept. 9, 2006; accepted Oct. 10, 2006. From the Division of Child and Adolescent Psychiatry, University of Washington School of Medicine, Children’s Hospital and Regional Medical Center, Seattle. The author greatly acknowledges Bryan H. King, M.D., Head, Division of Child and Adolescent Psychiatry, and Vice Chair, Department of Psychiatry and Behavioral Sciences, University of Washington School of Medicine, Seattle, Wash., for his valuable suggestions and for reviewing and editing the final manuscript. Dr. King is an unpaid consultant for Forest, Abbott, Neuropharm, and Seaside Therapeutics. Dr. Jafferany reports no financial or other relationship related to the subject of this article. Corresponding author and reprints: Mohammad Jafferany, M.D., Division of Child and Adolescent Psychiatry, University of Washington School of Medicine, Children’s Hospital and Regional Medical Center, 4800 Sand Point Way NE., M/S W3636, Seattle, WA 98105 (e-mail: mohammad.jafferany@seattlechildrens.org). 203 204 P sychodermatology addresses the interaction between mind and skin. Psychiatry is more focused on the “internal” nonvisible disease, and dermatology is focused on the “external” visible disease. Connecting the 2 disciplines is a complex interplay between neuroendocrine and immune systems that has been described as the NICS, or the neuro-immuno-cutaneous system. The interaction between nervous system, skin, and immunity has been explained by release of mediators from NICS.1 In the course of several inflammatory skin diseases and psychiatric conditions, the NICS is destabilized. In more than one third of dermatology patients, effective management of the skin condition involves consideration of associated psychologic factors.2 Dermatologists have stressed the need for psychiatric consultation in general, and psychological factors may be of particular concern in chronic intractable dermatologic conditions, such as eczema, prurigo, and psoriasis.3–5 Lack of positive nurturing during childhood may lead in adulthood to disorders of self-image, distortion of body image, and behavioral problems.6 The emotional problems due to skin disease include shame, poor selfimage, and low self-esteem. The psychosocial impact depends upon a number of factors, including the natural history of the disease in question; the patient’s demographic characteristics, personality traits, and life situation; and the meaning of the disease in the patient’s family and culture.7 Hostile personality characteristics, dysthymic states, and neurotic symptoms have been frequently observed in common skin conditions like psoriasis, urticaria, and alopecia.8 It has been reported that female dermatology patients and widows/widowers exhibit a higher prevalence of associated psychiatric comorbidity.9 It has been reported that psychologic stress perturbs epidermal permeability barrier homeostasis, and it may act as precipitant for some inflammatory disorders like atopic dermatitis and psoriasis.10 Patients with psychocutaneous disorders frequently resist psychiatric referral, and the liaison among primary care physicians, psychiatrists, and dermatologists can prove very useful in the management of these conditions. Although there is no single universally accepted classification system of psychocutaneous disorders and many of the conditions are overlapped into different categories, the most widely accepted system is that devised by Koo Prim Care Companion J Clin Psychiatry 2007;9(3) Psychodermatology: Guide for Psychocutaneous Disorders Table 1. Classification of Psychodermatologic Disorders Psychophysiologic disorders Psoriasis Atopic dermatitis Acne excoriee Hyperhidrosis Urticaria Herpes simplex virus infection Seborrheic dermatitis Aphthosis Rosacea Pruritus Psychiatric disorders with dermatologic symptoms Dermatitis artefacta Delusions of parasitosis Trichotillomania Obsessive-compulsive disorder Phobic states Dysmorphophobia Eating disorders Neurotic excoriations Psychogenic pruritus Dermatologic disorders with psychiatric symptoms Alopecia areata Vitiligo Generalized psoriasis Chronic eczema Ichthyosiform syndromes Rhinophyma Neurofibroma Albinism Miscellaneous Cutaneous sensory syndromes Glossodynia Vulvodynia Chronic itching in scalp Psychogenic purpura syndrome Pseudopsychodermatologic disease Suicide in dermatology patients and Lee11: (1) psychophysiologic disorders, (2) psychiatric disorders with dermatologic symptoms, and (3) dermatologic disorders with psychiatric symptoms (Table 1). Several other conditions of interest can be grouped under a heading of miscellaneous, and medication side effects of both psychotropic and dermatologic drugs should also be considered. A search of the literature from 1951 to 2004 was performed using the MEDLINE search engine. Englishlanguage articles were identified using the following search terms: skin and psyche, psychiatry and dermatology, mind and skin, psychocutaneous, and stress and skin. PSYCHOPHYSIOLOGIC DISORDERS Here psychiatric factors are instrumental in the etiology and course of skin conditions. The skin disease is not caused by stress but appears to be precipitated or exacerbated by stress.11 The proportion of patients reporting emotional triggers varies with the disease, ranging from approximately 50% (acne) to greater than 90% (rosacea, alopecia areata, neurotic excoriations, and lichen simplex) and may be 100% for patients with hyperhidrosis.12 Stress Prim Care Companion J Clin Psychiatry 2007;9(3) management, relaxation techniques, benzodiazepines, and selective serotonin reuptake inhibitors (SSRIs) have been found useful in these disorders. Psoriasis Onset or exacerbation of psoriasis can be predated by a number of common stressors. Stress has been reported in 44% of patients prior to the initial flare of psoriasis, and recurrent flares have been attributed to stress in up to 80% of individuals.13,14 Early onset psoriasis before age 40 years may be more easily triggered by stress than late onset disease, and patients who self-report high levels of psychologic stress may have more severe skin and joint symptoms.15–17 The most common psychiatric symptoms attributed to psoriasis include disturbances in body image and impairment in social and occupational functioning.18 Quality of life may be severely affected by the chronicity and visibility of psoriasis as well as by the need for lifelong treatment. Five dimensions of the stigma associated with psoriasis have been identified: (1) anticipation of rejection, (2) feelings of being flawed, (3) sensitivity to the attitudes of society, (4) guilt and shame, and (5) secretiveness.19 Depressive symptoms and suicidal ideation occur more frequently in severe psoriasis compared with controls.20 Depression may modulate itch perception, exacerbate pruritus, and lead to difficulties with initiating and maintaining sleep. In a study21 of 217 psoriasis patients with associated depression, 9.7% acknowledged a “wish to be dead,” and 5.5% reported active suicidal ideation. Psoriasis also affects sexual functioning. In one study,22 30% to 70% of patients reported a decline in sexual activity, and these patients more frequently reported joint pains, psoriasis affecting the groin region, scaling, and pruritus compared with patients without sexual complaints. These patients also had higher depression scores, greater tendency to seek the approval of others, and a marginally greater tendency to drink alcohol.22 Psychophysiologically, neuropeptides such as vasoactive intestinal peptide and substance P may have a role in the development of psoriatic lesions.23 Imbalance of vasoactive intestinal peptide and substance P has been reported in psoriasis, and there may be an associated increase in stress-induced autonomic response and diminished pituitary-adrenal activity.24,25 Biofeedback, meditation, hypnosis-induced relaxation, behavioral techniques, symptomcontrol imagery training, and antidepressants are important adjuncts to standard therapies for this disease.18,26–28 Atopic Dermatitis Stressful life events preceding the onset of disease have been found in more than 70% of atopic dermatitis patients.29 Symptom severity has been attributed to interpersonal and family stress, and problems in psychosocial adjustment and low self-esteem have been frequently 205 204 Mohammad Jafferany noted.30,31 Dysfunctional family dynamics may lead to lack of therapeutic response as well as to developmental arrest.32,33 Williams34 found that 45% of children with atopic dermatitis whose mothers received counseling were clear of lesions versus only 10% in the group receiving conventional (nonpsychosocial) therapy alone. Chronic infantile eczema has been shown to respond when parental education was added to conventional treatment.33,35 Psychologic interventions, such as brief dynamic psychotherapy, biofeedback, cognitive-behavioral therapy, relaxation techniques, and hypnosis, can be important adjuncts to treatment.36–40 Benzodiazepines and antidepressants are frequently used for treatment.41 Acne Excoriee The habitual act of picking at skin lesions, apparently driven by compulsion and psychologic factors independent of acne severity, has been reported in the perpetuation of self-excoriation.42 Most patients with this disease are females with late onset acne. Psychiatric comorbidity of acne excoriee includes body image disorder, depression, anxiety, obsessive-compulsive disorder (OCD), delusional disorders, personality disorders, and social phobias.43–47 Immature coping mechanisms and low self-esteem have also been associated. Interesting gender differences have been observed in this disease. In men, self-excoriation is exacerbated by a coexisting depression or anxiety, while in women this behavior may be a manifestation of immature personality and serve as an appeal for help.48 SSRIs, doxepin, clomipramine, naltrexone, pimozide, and habitreversal behavior therapy have been used in the treatment of this condition, and recent reports suggest that olanzapine (2.5–5 mg daily for 2–4 weeks) may also be helpful.49–51 Hyperhidrosis With this disease, persistent sweating is brought on by emotional stimuli. These patients have social phobic and avoidance symptoms, sometimes leading to devastating consequences at work and social activities. States of tension, fear, and rage are common. The psychopathologic characteristics of patients with essential hyperhidrosis have been categorized into 3 groups: (1) objectifiable hyperhidrosis due to a psychosomatic disorder like atopic dermatitis; (2) objectifiable hyperhidrosis with secondary psychiatric sequelae like social phobia, anxiety, and depression as a consequence of chronic skin disease; and (3) delusional hyperhidrosis without any objective evidence of hyperhidrosis.52 This last category has been increasingly observed in patients with body dysmorphic disorder.53 Patients with hyperhidrosis have poorer coping ability and more emotional problems compared to patients with other dermatology problems.54 The SSRIs and benzodiazepines have been used with variable success in the treatment of hyperhidrosis associated with social anxiety disorder.55 205 206 Urticaria Severe emotional stress may exacerbate preexisting urticaria.56 Increased emotional tension, fatigue, and stressful life situations may be primary factors in more than 20% of cases and are contributory in 68% of patients. Difficulties with expression of anger and a need for approval from others are also common.57,58 Patients with this disorder may have symptoms of depression and anxiety, and the severity of pruritus appears to increase as the severity of depression increases.59,60 Cold urticaria may be associated with hypomania during winter and recurrent idiopathic urticaria with panic disorder.61,62 Doxepin, nortriptyline, and SSRIs have been reported to be useful in the management of chronic idiopathic urticaria.63,64 Recurrent urticaria associated with severe anxiety disorders has been treated successfully with fluoxetine and sertraline.62 Individual and group psychotherapies, stress management, and hypnosis with relaxation may also be useful in these patients.65,66 Herpes Simplex Virus, Herpes Zoster, and Human Papillomavirus Infections There is increasing evidence that stress has a role in recurrent herpetic infection. In one study, 67 experimentally induced emotional stress led to herpes simplex virus reactivation. Other studies have demonstrated an inverse correlation between stress level and present CD4 helper/ inducer T lymphocytes, thus contributing to herpes virus activation and recurrences.68,69 It has also been suggested that stress-induced release of immunomodulating signal molecules (e.g., catecholamines, cytokines, and glucocorticoids) compromises the host’s cellular immune response leading to reactivation of herpes simplex virus.70 Relaxation treatment and frontalis electromyographic biofeedback may reduce the frequency of recurrences.71 Herpes zoster has been associated with chronic child abuse, and severe psychologic stress of any sort may depress cell-mediated immune response, predisposing children to the virus.72 Effects of hypnotherapy on common warts have been well documented in the literature.73,74 Feelings of depression, anger, and shame and the negative effects on sexual enjoyment and activity associated with human papillomavirus infections have also been reported.75 Other disorders in which psychologic factors are important in the genesis and course of disease include seborrheic dermatitis, aphthosis, rosacea, pruritus, and dyshidrosis. PSYCHIATRIC DISORDERS WITH DERMATOLOGIC SYMPTOMS These disorders have received little emphasis in the psychiatry or dermatology literature, even though they may be associated with suicide and unnecessary surgical Prim Care Companion J Clin Psychiatry 2007;9(3) Psychodermatology: Guide for Psychocutaneous Disorders procedures. Most of these disorders occur in the context of somatoform disorder, anxiety disorder, factitious disorder, impulse-control disorder, or eating disorder. Dermatitis Artefacta A form of factitious disorder, dermatitis artefacta involves self-inflicted cutaneous lesions that the patient typically denies having induced. The condition is more common in women than in men (3:1 to 20:1).76 The lesions are usually bilaterally symmetrical, within easy reach of the dominant hand, and may have bizarre shapes with sharp geometrical or angular borders, or they may be in the form of burn scars, purpura, blisters, and ulcers. Erythema and edema may be present. Patients may induce lesions by rubbing, scratching, picking, cutting, punching, sucking, or biting or by applying dyes, heat, or caustics. Some patients inject substances, including feces and blood. Reported associated conditions include OCD, borderline personality disorder, depression, psychosis, and mental retardation.77,78 In one survey, dermatitis artefacta was found in 4% of 457 institutionalized children and adolescents with mental retardation.79 Physical and sexual abuse must be considered in the differential diagnosis as well as psychosocial stressors.80,81 Malignant transformations of dermatitis artefacta lesions sometimes resulting in death have been reported.82 Hypnosis can be useful in the evaluation of suspected cases. Direct confrontation of the patient should be avoided, and a supportive, nonjudgmental approach is the mainstay of management. Patients should be seen on an ongoing basis for supervision and support, whether or not lesions remain present.83 Relaxation exercises, antianxiety drugs, antidepressants such as SSRIs, and low-dose atypical antipsychotics might also be useful.84,85 In some case reports, an excellent clinical response has been observed with lowdose olanzapine.86 Associated psychiatric conditions may include anxiety, depression, dementia, mental retardation, mood or adjustment disorder, comorbid substance abuse, and eating disorder.78,94,95 The patients experience an increasing sense of tension immediately before an episode of hair pulling and when attempting to resist the behavior; they feel relief of tension and sometimes a feeling of gratification after hair pulling.96 This dynamic highlights similarities and differences between trichotillomania and OCD and tic disorder. Specifically, the behavior may not be regarded as egodystonic, but it does share many emotional factors with compulsions. Interestingly, many treatments for trichotillomania are similar to those utilized in OCD. Thus, along with symptomatic treatment, fluoxetine, paroxetine, sertraline, clomipramine, lithium, buspirone, risperidone, cognitive-behavioral therapy, habit-reversal therapy, and hypnotherapy have been reported to be beneficial.97,98 Obsessive-Compulsive Disorders Patients usually present to dermatologists because of skin lesions resulting from scratching, picking, and other self-injurious behaviors. They typically have an increased level of psychiatric symptomatology compared with age and sex matched controls taken from the general population of dermatology patients, and many patients experience negative stigmatization in their daily life.99–101 Common behaviors include compulsive pulling of scalp, eyebrow, or eyelash hair; biting of the nails and lips, tongue, and cheeks; and excessive hand washing. In one report,102 the most common site involved was the face, followed by back and neck. Koo and Smith103 have found that OCD in child and adolescent dermatology patients most commonly presents as trichotillomania, onychotillomania, and acne excoriee. SSRIs, clomipramine, behavior modification, and psychodynamic psychotherapy have been reported to be effective.87 Delusions of Parasitosis DSM-IV-TR defines delusions of parasitosis as delusional disorder of somatic type. Patients believe that organisms infest their bodies; they often present with small bits of excoriated skin, debris, insects, or insect parts that they show as evidence of the infection. Pimozide, 1 to 10 mg/day, has been the treatment of choice in past87–89; risperidone, trifluoperazine, haloperidol, chlorpromazine, and electroconvulsive therapy are among other treatments reported to be useful.90–92 Phobic States Among the commonly feared conditions for people with phobic states are sexually transmitted diseases, cancer, acquired immunodeficiency syndrome (AIDS), and herpes. Phobias about dirt and bacteria may lead to repeated hand washing, resulting in irritant dermatitis. In some cases, patients mutilate themselves in an attempt to remove pigmented nevi that they believe are related to possible cancer.104 Cognitive-behavioral therapy plays a major role in treatment. Trichotillomania Trichotillomania is the recurrent pulling out of one’s hair, resulting in noticeable hair loss. In the DSM-IV-TR, trichotillomania is classified as a disorder of impulse control; however, many dermatologists regard this behavior as quite compulsive. Childhood trauma and emotional neglect may play a role in the development of this disorder.93 Dysmorphophobia This condition is also called body dysmorphic disorder or dermatological non-disease.105 Patients with this condition are rich in symptoms but poor in signs of organic disease. Self-reported “complaints” or “concerns” usually occur in 3 main areas: face, scalp, and genitals. Facial symptoms include excessive redness, blushing, scarring, Prim Care Companion J Clin Psychiatry 2007;9(3) 207 206 Mohammad Jafferany large pores, facial hair, and protruding or sunken parts of face. Other symptoms are hair loss, red scrotum, urethral discharge, and herpes and AIDS phobia. Strategies to relieve the anxiety due to the perceived defects may include camouflaging the lesions, mirror checking, comparison of “defects” with the same body parts on others, questioning/reassurance seeking, mirror avoidance, and grooming to cover up “defects.”106 Women are more likely than men to be preoccupied with the appearance of their hips or their weight, to pick their skin, to camouflage defects with makeup, and to have comorbid bulimia nervosa. Men are more likely than women to be preoccupied with body build, genitals, and hair thinning and to be unmarried and to abuse alcohol.107 Patients with body image disorders, especially those involving the face, may be suicidal.108 Associated comorbidity in dysmorphophobia may include depression, impairment in social and occupational functioning, social phobias, OCD, skin picking, marital difficulties, and substance abuse.109,110 SSRIs, clomipramine, haloperidol, and cognitive-behavioral therapy have been used in this condition with variable success.111,112 Eating Disorders Dermatologic signs and symptoms in anorexia nervosa and bulimia nervosa are primarily the result of starvation and malnutrition or self-induced vomiting and the use of laxatives, emetics, or diuretics. The skin changes are more frequently seen when body mass index reaches 16 kg/m2 or less. The skin signs associated with eating disorders are summarized in Table 2.113–119 Other than weightrelated body image issues, patients’ most common concerns relate to skin, teeth, jaws, nose, and eyes. The high prevalence of skin involvement has been linked to core “ego deficits” and may be an index of severity disturbance in overall body image; acne may also be a risk factor for anorexia nervosa.118,119 Antidepressants, cognitivebehavioral therapy, psycho-educational approaches, and family therapy have been employed in the treatment of eating disorders.120–122 Neurotic Excoriations As per DSM-IV-TR classification an impulse-control disorder not otherwise specified, neurotic excoriations are self-inflicted lesions that typically present as weeping, crusted, or lichenified lesions with postinflammatory hypopigmentation or hyperpigmentation. The preferred term for this disorder is pathologic skin picking.123 Usual sites are the extensor aspects of extremities, scrotum, and perianal regions. Repetitive scratching, initiated by an itch or an urge to excoriate a benign skin lesion, produces lesions. The behaviors of these patients sometimes resemble those with OCD. Psychopathologically, patients with neurotic excoriations have personalities with compulsive and perfectionist traits. Common concurrent psychiatric diagnoses are 207 208 Table 2. Dermatologic Signs of Eating Disordersa Lanugo-like body hair Brittle nails and hair Gingivitis Sjögren syndrome–like changes Acrocyanosis Carotenodermia Hyperpigmentation Factitious dermatitis Poor wound healing Russell’s sign Dry scalp hair Onychophagia Asteatotic skin Hard calluses Cheilitis Acne Hypertrichosis Generalized pruritus Striae distensae Seborrheic dermatitis Melasma Alopecia Periungual erythema Acquired pili torti a Information based on references 113–119. OCD and other anxiety disorders, mood disorders, body dysmorphic disorders, substance abuse disorders, eating disorders, trichotillomania, compulsive-buying disorder, and personality disorders (obsessive-compulsive and borderline personality disorder).124–127 The extent and degree of self-excoriation has been reported to be a reflection of the underlying personality. Family- and work-related stress has also been implicated. Phenomenologically, there is an overlap between trichotillomania and pathologic skin picking; both conditions are similar in demographics, psychiatric comorbidities, and personality traits.128 In rare cases, there are medical complications, such as epidural abscess with subsequent paralysis, as a result of compulsive picking.129 SSRIs, doxepin, clomipramine, naltrexone, pimozide, olanzapine, benzodiazepines, amitriptyline, habit-reversal behavioral therapy, and supportive psychotherapy have been used in the treatment.123,129–131 Psychogenic Pruritus In this disorder, there are cycles of stress leading to pruritus as well as of the pruritus contributing to stress. Psychologic stress and comorbid psychiatric conditions may lower the itch threshold or aggravate itch sensitivity.132 Stress liberates histamine, vasoactive neuropeptides, and mediators of inflammation, while stress-related hemodynamic changes (e.g., variation in skin temperature, blood flow, and sweat response) may all contribute to the itch-scratch-itch cycle.133 Psychogenic pruritus has been noted in patients with depression, anxiety, aggression, obsessional behavior, and alcoholism. The degree of depression may correlate with pruritus severity.134 Habitreversal training, cognitive-behavioral therapy, and antidepressants may be beneficial.130 DERMATOLOGIC DISORDERS WITH PSYCHIATRIC SYMPTOMS This category includes patients who have emotional problems as a result of having skin disease. The skin disease in these patients may be more severe than the psychi- Prim Care Companion J Clin Psychiatry 2007;9(3) Psychodermatology: Guide for Psychocutaneous Disorders atric symptoms, and, even if not life threatening, it may be considered “life ruining.”87 Symptoms of depression and anxiety, work-related problems, and impaired social interactions are frequently observed.135 Psoriasis, chronic eczema, various ichthyosiform syndromes, rhinophymas, neurofibromas, severe acne, and other cosmetically disfiguring cutaneous lesions have grave effects on psychosocial interactions, self-esteem, and body image; major depression and social phobia may develop. and often believe that they do not receive adequate support from providers.145 Younger patients and individuals in lower socioeconomic groups show poor adjustment, low self-esteem, and problems with social adaptation.146,147 Most patients with vitiligo report a negative impact on sexual relationships and cite embarrassment as the cause.148 Alopecia Areata Alopecia areata is a nonscarring type of hair loss on any hair-bearing area of the body. The influence of psychologic factors in the development, evolution, and therapeutic management of alopecia areata is well documented. Acute emotional stress may precipitate alopecia areata, perhaps by activation of overexpressed type 2 β corticotropinreleasing hormone receptors around the hair follicles, and lead to intense local inflammation.136 Release of substance P from peripheral nerves in response to stress has also been reported, and prominent substance P expression is observed in nerves surrounding hair follicles in alopecia areata patients.137 Substance P-degrading enzyme neutral endopeptidase has also been strongly expressed in affected hair follicles in the acute-progressive as well as the chronic-stable phase of the disorder. Comorbid psychiatric disorders are also common and include major depression, generalized anxiety disorder, phobic states, and paranoid disorder.138,139 A very strong family history and concurrent atopic and associated autoimmune diseases are common in alopecia areata patients.140 In a study141 with 31 patients, 23 patients (74%) had lifetime psychiatric diagnoses. Major depression and generalized anxiety disorder may occur in as many as 39% of patients, and those with patchy alopecia areata may be more likely to have generalized anxiety disorder. Increased rates of psychiatric diseases in firstdegree relatives of patients with alopecia areata have also been noticed, including anxiety disorder (58%), affective disorder (35%), and substance abuse (35%).141 This group includes disorders or symptoms that are not otherwise classified. Vitiligo Vitiligo is a specific type of leukoderma characterized by depigmentation of the epidermis. It is associated with more psychosocial embarrassment than any other skin condition. In some studies, patients with vitiligo have been found to have significantly more stressful life events compared with controls, suggesting that psychologic distress may contribute to onset.142 Links between catecholaminebased stress, genetic susceptibility, and a characteristic personality structure have been postulated.143 Psychiatric morbidity is typically reported in approximately one third of patients,142 but, in one study, 56% of the sample had adjustment disorder and 29% had depressive disorders.144 Patients with vitiligo are frightened and embarrassed about their appearance, and they experience discrimination Pseudopsychodermatologic Disease These patients may have bizarre skin symptoms without obvious physical findings or a subclinical skin disease that has been eradicated or modified by scratching. Psychodermatologic disease can mimic other skin disorders, and medical disorders can mimic psychodermatologic conditions. Localized bullous pemphigoid lesions, for example, have been mistaken for dermatitis artefacta; multiple sclerosis, folliculitis, hypothyroidism, and vitamin B12 deficiency have been initially diagnosed as delusions of parasitosis.152 Prim Care Companion J Clin Psychiatry 2007;9(3) MISCELLANEOUS Cutaneous Sensory Syndromes Patients with these syndromes experience abnormal skin sensations (e.g., itching, burning, stinging, and biting or crawling) that cannot be attributed to any known medical condition. Examples include glossodynia, vulvodynia, and chronic itching in the scalp. These patients often have concomitant anxiety disorder or depression.149 Psychogenic Purpura Syndrome This condition, also known as autoerythrocyte sensitization syndrome (Gardner-Diamond syndrome), is seen primarily in emotionally unstable adult females. These patients present with bizarre, painful, recurrent bruises on extremities, frequently after trauma, surgery, or severe emotional stress. The exact mechanism is unclear; however, hypersensitivity to extravasated red cells, autoimmune mechanisms, and increased cutaneous fibrinolytic activity has been implicated in the pathogenesis. These patients may have overt depression, sexual problems, feelings of hostility, obsessive-compulsive behavior,150 borderline personality disorder, and factitious dermatitis.151 Without a correct diagnosis, these individuals can receive treatments that are neither necessary nor effective. The diagnosis can be made in a patient who has atypical history and clinical picture of the syndrome and in whom a skin test with use of the patient’s blood reveals a positive reaction. Suicide in Dermatology Patients Suicide has been reported in patients with longstanding debilitating skin diseases and must be considered 209 208 Mohammad Jafferany when evaluating these patients. Even clinically mild to moderate severity skin disease may be associated with significant depression and suicidal ideation.153 Cotterill and Cunliffe154 reported suicides in 16 patients (7 men and 9 women) with body image disorder or severe acne. THERAPEUTICS Realistic goals in the treatment of psychodermatologic diseases include reducing pruritus and scratching, improving sleep, and managing psychiatric symptoms such as anxiety, anger, social embarrassment, and social withdrawal. Nonpharmacologic management may include psychotherapy, hypnosis, relaxation training, biofeedback, operant conditioning, cognitive-behavioral therapy, meditation, affirmation, stress management, and guided imagery.* The cutaneous side effects of common psychiatric drugs are shown in Table 3. The common skin disorders in which cognitive behavioral methods, hypnosis, and biofeedback have proven useful are listed in Table 4.155,156 The choice of psychopharmacologic agent depends upon the nature of the underlying psychopathology (e.g., anxiety, depression, psychosis, compulsion). The efficacy of the tricyclic antidepressants probably is related to antihistaminic, anticholinergic, and centrally mediated analgesic effects. They have been successfully used in chronic urticaria, nocturnal pruritus in atopics, postherpetic neuralgia, psoriasis, acne, hyperhidrosis, alopecia areata, neurotic excoriations, and psychogenic pruritus.157 SSRIs may be beneficial in body dysmorphic disorders, dermatitis artefacta, OCDs, neurotic excoriations, acne excoriee, onychophagia, and psoriasis.158 Cutaneous reactions to these drugs are rare, but toxic epidermal necrolysis, Stevens-Johnson syndrome, leukocytoclastic vasculitis, and papular purpuric erythema on sun-exposed areas have been reported with fluoxetine, fluvoxamine, and paroxetine.159–162 The atypical antipsychotics have been used as an augmentation strategy in the treatment of several psychocutaneous disorders. The development of diabetes, hyperlipidemia, and weight gain due to certain atypical antipsychotics should be closely monitored and managed accordingly. Recently mirtazapine, a noradrenergic and serotonergic drug, has been reported as useful in chronic itch and several itchy dermatoses.163 Other psychiatric drugs used in dermatology include gabapentin (postherpetic neuralgia and idiopathic trigeminal neuralgia), pimozide (delusions of parasitosis), topiramate and lamotrigine (skin picking), and naltrexone (pruritus).157,164 A variety of cutaneous side effects have been attributed to lithium.165 It has been associated with both the onset and exacerbation of psoriasis, triggering localized or general- *References 27,37,38,46,49,64,70,82,86,89,120,122,137,154. 209 210 Table 3. Cutaneous Side Effects of Psychiatric Drugs Antipsychotics Blue-grey discoloration of skin Photosensitivity Lupus-like syndrome Erythematous maculopapular rash Contact dermatitis Seborrheic dermatitis SJS/erythema multiforme Purpura Urticaria Palmar erythema Anxiolytics Exacerbation of porphyria Fixed drug eruption Hyperpigmentation Bullous lesions Maculopapular rash Photosensitivity Urticaria Erythema multiforme Erythema nodosum Antidepressants Maculopapular, pustular rash Urticaria Petechiae Photosensitivity Vasculitis Leukonychia Acne Alopecia Erythema multiforme Pustular psoriasis Barbiturates Precipitation/exacerbation of porphyria Bullous lesions Fixed drug eruption Maculopapular rash Acneiform rash Erythema multiforme TEN Purpura Lupus-like syndrome Photosensitivity Anticonvulsants Maculopapular rash Hypersensitivity reactions Exfoliative dermatitis Systemic lupus erythematosus Alopecia Erythema multiforme/SJS/TEN Urticaria Hair color changes Scleroderma Vasculitis Lithium Psoriasiform lesions Acneiform lesions Vaginal and other mucosal ulcerations Hidradenitis suppurativa Follicular hyperkeratosis Exacerbation of Darier’s disease Lichenoid stomatitis Erythematous maculopapular rash Hair loss Increased growth of warts Geographical tongue Abbreviations: SJS = Stevens-Johnson syndrome, TEN = toxic epidermal necrolysis. Prim Care Companion J Clin Psychiatry 2007;9(3) Psychodermatology: Guide for Psychocutaneous Disorders Table 4. Nonpharmacologic Treatments of Some Common Skin Disordersa Biofeedback Hyperhidrosis Raynaud’s disease Psoriasis Atopic dermatitis Herpes simplex a Cognitive-Behavioral Methods Acne excoriee Atopic dermatitis Factitious cheilitis Hyperhidrosis Lichen simplex Onychotillomania Prurigo nodularis Trichotillomania Urticaria Body dysmorphic disorder Neurotic excoriations Hypnosis Acne excoriee Alopecia areata Atopic dermatitis Ichthyosis Erythroderma Dyshidrotic eczema Glossodynia Herpes simplex Hyperhidrosis Lichen planus Nummular eczema Postherpetic neuralgia Pruritus Psoriasis Rosacea Trichotillomania Urticaria Common warts Vitiligo Information based on references 155 and 156. ized forms of pustular psoriasis.166 Suggested mechanisms for these effects include lithium’s role in regulating the second-messenger system (cyclic adenosine monophosphate [cAMP] and phosphoinositides), and its inhibition of adenyl cyclase (leading to decreased levels of cAMP) and inositol monophosphatase (increasing total circulating neutrophil mass).167 An in vitro study demonstrated that lithium influences the cellular communication of psoriatic keratinocyte with HUT 78 lymphocyte by triggering the secretion of TGF α, Il-2, and IFN γ.168 Other cutaneous manifestations attributed to lithium include acneiform lesions,169 vaginal ulcerations,170 mucosal ulcerations,171 hidradenitis suppurativa,172 follicular hyperkeratosis,173 exacerbation of Darier’s disease,174 lichenoid stomatitis,175 erythematous maculopapular rash,176 diffuse and localized hair loss, increased growth of warts, palmoplantar hyperkeratosis with ichthyosiform features,177 geographical tongue,178 and follicular mycosis fungoides.179 Interestingly, topical lithium has been used in the treatment of seborrheic dermatitis at various centers in Europe.180 Corticosteroids are among the dermatologic agents most often associated with psychiatric symptoms, which include cognitive impairment, mood disorders, depression, delirium, and psychosis.181 Isotretinoin has been implicated in depression, suicidal ideation, and mood swings.182 There are conflicting reports about the relationship between isotretinoin and depression and suicide, but, since its approval in 1982, it has ranked among the top 10 in number of reports to the U.S. Food and Drug Administration about suicide.183,184 Many investigators have found no causal connection, however, and most of the published case reports do not meet the established criteria for establishing causality.185,186 Other drugs associated with de- Prim Care Companion J Clin Psychiatry 2007;9(3) pression include dapsone, acyclovir, metronidazole, and sulfonamides.187,188 SUMMARY AND CONCLUSION Psychodermatology has evolved as a new and emerging subspecialty of both psychiatry and dermatology. The connection between skin disease and psyche has, unfortunately, been underestimated. More than just a cosmetic disfigurement, dermatologic disorders are associated with a variety of psychopathologic problems that can affect the patient, his or her family, and society together. Increased understanding of these issues, biopsychosocial approaches, and liaison among primary care physicians, psychiatrists, and dermatologists could be very useful and highly beneficial. The value of shared care of these complex patients with a psychiatrist is highly recommended. Creation of separate psychodermatology units and multicenter research about the relationship of skin and psyche in the form of prospective case-controlled studies and multisite therapeutic trials can provide more insight into this interesting and exciting field of medicine. Drug names: acyclovir (Zovirax and others), buspirone (BuSpar and others), chlorpromazine (Thorazine, Sonazine, and others), clomipramine (Anafranil and others), doxepin (Sinequan, Zonalon, and others), fluoxetine (Prozac and others), gabapentin (Neurontin and others), haloperidol (Haldol and others), isotretinoin (Claravis and Amnesteem), lamotrigine (Lamictal and others), lithium (Eskalith, Lithobid, and others), metronidazole (Flagyl, Metrocream, and others), mirtazapine (Remeron and others), naltrexone (Vivitrol, ReVia, and others), nortriptyline (Pamelor and others), olanzapine (Zyprexa), paroxetine (Paxil, Pexeva, and others), pimozide (Orap), risperidone (Risperdal), sertraline (Zoloft and others), topiramate (Topamax), trifluoperazine (Stelazine and others). REFERENCES 1. Misery L. Neuro-immuno-cutaneous system (NICS). Pathol Biol (Paris) 1996;44:867–874 2. Savin JA, Cotterill JA. Psychocutaneous disorders. In: Champion RH, Burton JL, Ebling FJG, eds. Textbook of Dermatology. 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