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Psychocutaneous Disorders


Introduction

  • Psychodermatology refers to any aspect of dermatology in which psychological factors play a significant role.

  • Psychodermatologic disorders can be classified in two ways: (1) by the specific psychodermatologic condition or (2) by the underlying psychopathology ( Fig. 5.1 ).

    Fig. 5.1, Classification of psychodermatologic disorders.

  • Treatment is simplified by basing the choice of psychotropic medication or therapy on the underlying psychopathology ( Table 5.1 ).

    Table 5.1
    Psychotropic medications most commonly used in dermatology.
    Treatment of procedural anxiety in adults (prior to procedure)
    Benzodiazepines
    Diazepam: 10 mg orally 30 minutes prior
    Alprazolam: 0.5 mg orally 30–60 minutes prior
    Lorazepam: 2 mg orally 30–60 minutes prior

    • An approximate 50% dose reduction necessary for older (age >60) or debilitated adults, patients with low cardiac output or hepatic insufficiency

    • Repeated dose, 50–100% of initial dose, may be repeated in 30–60 minutes if initial dose has no effect

    • Patients must have a driver to take them home

    Treatment of obsessive compulsive disorder (OCD)
    Selective serotonin reuptake inhibitors (SSRIs) (in addition to cognitive behavioral therapy)

    SSRI Initial dose Maximum dose (via weekly dose escalation∗∗)
    Fluoxetine 10–20 mg/day 60 mg/day ∗
    Citalopram 10–20 mg/day 40 mg/day ∗∗
    Paroxetine 10–20 mg/day 50 mg/day
    Sertraline 25–50 mg/day 200 mg/day
    Escitalopram 10 mg/day 20 mg/day ∗∗

    • Clinical response may take 6–10 weeks to become apparent

    • Children, adolescents and young adults should be closely monitored for any suicidal ideation

    • N-acetylcysteine (up to 2400 mg/day) alone, or in combination with SSRIs has shown promise in treating OCD

    Treatment of delusions of parasitosis
    Antipsychotics
    Pimozide: initiate at 0.5–1 mg/day and gradually (every 2–4 weeks) titrate up to 2–6 mg/day, if needed
    Risperidone: initiate at 0.5 mg/day and titrate up to 1–4 mg/day, if needed Olanzapine: initiate at 2.5 mg/day and gradually titrate up to 5–15 mg/day, if needed

    • Response is often seen after ∼2 weeks and treatment should be continued for several months, followed by gradual tapering

    • Side effects include extrapyramidal symptoms, QTc prolongation (significant risk, pimozide; moderate risk, risperidone); tardive dyskinesia (pimozide, if prolonged use); metabolic syndrome (risperidone, olanzapine), weight gain (olanzapine), and hyperprolactinemia (risperidone). Baseline ECG recommended (pimozide) if history of arrythmia or cardiac conduction abnormalities.

    ∗ Make dose adjustments after several weeks of therapy

    ∗∗ Higher doses associated with QTc prolongation

  • The more commonly encountered primary psychiatric disorders in dermatology include body dysmorphic disorder, excoriation (skin-picking) disorder, acne excoriée, trichotillomania, other body-focused repetitive behavior disorders (BFRBD), delusions of parasitosis, dermatitis artefacta, and nonsuicidal self-injury.

  • Because many of these patients with primary psychiatric disorders present to the dermatologist and not the psychiatrist, it is important to establish the correct diagnosis and to offer appropriate treatment options.

The More Common Primary Psychiatric Disorders Seen in Dermatology

Obsessive–Compulsive and Related Disorders: General Features

  • Obsessions are recurrent and persistent thoughts, images, or urges that are intrusive and unwanted.

  • Compulsions are repetitive behaviors or mental acts that are performed in order to reduce anxiety or distress, especially that arising from obsessions.

  • In all of these disorders, the preoccupations and/or behaviors lead to significant distress or impairment in social, occupational, or other areas of functioning.

  • Some of these conditions feature body-focused repetitive behaviors (BFRB; e.g. hair-pulling, skin-picking; Table 5.2 , Fig. 5.2 ).

    Table 5.2
    Body-focused repetitive behaviors (BFRBs) and associated mucocutaneous findings.
    BFRBs occur on a chronic basis and present with characteristic mucocutaneous findings, depending on the body site and behavior type. These behaviors exist along a spectrum, with habits at one end and body-focused repetitive behavioral disorders (BFRBD) at the other end. The latter disorders continue despite repeated attempts to stop, and lead to impaired functioning (e.g. social, occupational) or to distress manifesting as feelings of loss of control, embarrassment, or shame.
    Body-focused repetitive behavior Associated mucocutaneous findings
    Lip licking Irritant contact dermatitis, secondary bacterial or yeast infections
    Lip picking or biting Multiple erosions or ulcerations, recurrent HSV
    Cheek chewing or biting Bite fibroma, morsicatio buccarum
    Cuticle pulling, picking, or biting (see Fig. 5.2 ) Paronychia, nail surface irregularities
    Nail biting (onychophagia) (see Fig. 5.2 ) Paronychia, nail dystrophy, subungual hemorrhages
    Nail picking or pulling (onychotillomania)
    Habit-tic deformity of the thumbnail Multiple midline Beau’s lines with prominent longitudinal central depression
    Thumb or finger sucking Skin maceration, dermatitis, secondary bacterial or yeast infections
    Nose picking (rhinotillexomania) Erosions, secondary bacterial infections
    Trichotillomania See text
    Excoriation (skin-picking) disorder See text

    Fig. 5.2, Body-focused repetitive behaviors.

  • BFRB become disorders (BFRBD) when the following criteria are met: (1) the repetitive behavior causes skin lesions; (2) there are repeated attempts to decrease or stop the behavior; (3) the behavior causes significant distress or impaired functioning; (4) there is no other underlying medical condition or mental disorder to explain the behavior.

Body Dysmorphic Disorder

  • Characterized by a distressing or impairing preoccupation with a nonexistent or slight defect in appearance.

  • On a psychiatric spectrum from obsessional to delusional.

  • Mean age of onset is 30–35 years; females = males; present in up to 10–15% of dermatologic patients.

  • Patients usually concerned with nose, mouth, hair, breasts, or genitalia.

  • Often adopt compulsive (e.g. numerous visits to physician for reassurance), ritualistic (e.g. excessive grooming routines), or delusional (e.g. multiple unnecessary surgeries) behaviors.

  • Consider and assess for this diagnosis in patients seeking multiple cosmetic procedures.

  • Rx: selective serotonin reuptake inhibitors (SSRIs) for obsessive–compulsive disorder (OCD) variant or antipsychotics for delusional variant.

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