18 KEY REFERENCES

14. Stander S et al: Clinical classification of itch: A position

paper of the International Forum for the Study of Itch.
Acta Derm Venereol 87(4):291-294, 2007
Full reference list available at [Link] 70. Yosipovitch G et al: Itch. Lancet 361(9358):690-694, 2003
113. Yosipovitch G, Samuel LS: Neuropathic and psychogenic
DVD contains references and additional content itch. Dermatol Ther 21(1):32-41, 2008
124. Wang H, Yosipovitch G: New insights into the patho-
2. Davidson S, Giesler GJ: The multiple pathways for physiology and treatment of chronic itch in patients with
itch and their interaction with pain. Trends Neurosci end-stage renal disease, chronic liver disease, and lym-
33(12):550-558, 2010 phoma. Int J Dermatol 49:1-11, 2010
4. Patel T, Yosipovitch G: Therapy of pruritus. Expert Opin
Pharmacother 11(10):1673-1682, 2010
5. Weisshaar E, Dalgard F: Epidemiology of itch: Add-
ing to the burden of skin morbidity. Acta Derm Venereol
89(4):339-350, 2009
Section 18

Chapter 104 :: Psychocutaneous Skin Disease

::
Neurocutaneous and Psychocutaneous Skin Disease

:: Evan Rieder & Francisco A. Tausk

in turn, are perceived by it. When these perceptions
PSYCHOCUTANEOUS DISEASES go awry, great distress may result. When the skin is
AT A GLANCE markedly affected by a primary dermatologic condi-
tion, psychological sequelae in the form of comorbid-
Primarily Psychiatric Disorders ity often follow, greatly impacting patient quality of
life.
Delusional: Delusions of Parasitosis, The central nervous system (CNS) can influence
Body Dysmorphic Disorder. the health of other organ systems, including the
skin. Psychophysiologic mechanisms for this inter-
Factitial: Dermatitis Artefacta, Dermatitis action range from the stress responses mediated by
Para-Artefacta (Trichotillomania, Skin neuroadrenal connections and associated changes
Picking), Malingering. in immunologic function, to the systemic and local
action of various neuropeptides and neurohor-
Somatoform: Body Dysmorphic Disorder, mones.1,2
Atypical Pain/burning, Hypochondriasis,
Somatization.

Obsessive Compulsive Disorders.

ROLE OF THE DERMATOLOGIST
Affecting approximately 5% of dermatology Between 20% and 40% of patients seeking treatment
for skin complaints have some type of psychiatric
patients.
or psychological problem causing or complicating
the presenting symptoms.3,4 A large number of these
Variable degree of insight, mostly poor.
patients lack insight into the possible psychogenic
origin of their symptoms and are often reluctant to
Mostly self-induced lesions.
accept any kind of psychiatric referral. Therefore, in
the absence of a psychiatry liaison clinic in the der-
Poor prognosis if untreated.
matologic setting,4 the dermatologist must be familiar
with the most common of these diagnoses, their clini-
Quality of life severely deteriorated.
cal manifestations (both psychological and dermato-
logic), and the basic principles of treatment. When
approaching these issues, it is important to explore
Scientific advances are shedding new light on the psychiatric, and particularly psychotic, symptoms as
understanding and treatment of long-recognized con- well as compliance with medications. Collateral infor-
ditions located at the interface of dermatology and mants such as family members can be quite helpful
psychiatry. Both arising from ectoderm, the skin and if the patient grants permission. Lastly, the effects of
the nervous system are connected by more than just patient symptoms on familial and social life can be
their common origins. The skin is one of the major of much assistance in understanding the issues to be
1158 avenues by which humans perceive the world, and, addressed.
CLASSIFICATION OF
Box 104-1  Classification of the
18
PSYCHOCUTANEOUS DISEASES Primary Psychocutaneous Diseases6
Following the original description of C. Koblenzer,5 Delusional Delusion of parasitosis
psychocutaneous diseases can be classified on the Body odor delusion
basis of their primary etiology as: Hypochondriacal syndrome
Primary psychogenic disorders, which can present Body dysmorphic disorders
with a variety of symptoms and behaviors, usu- (BDDa)—somatic form
ally characterized by self-injury, that can lead to Factitious Dermatitis para-artefacta syn-
perceived or actual dermatologic conditions, or drome
Primary dermatologic disorders that can be either Dermatitis artefacta syndrome
triggered or amplified by contextual causes (e.g.,
Malingering
life stresses or interpersonal relationships) that may

Chapter 104
lead to psychiatric comorbidities such as, anxi- Somatoform BDD
ety, depression, and distress through their impact Cutaneous dysesthesias
on physical appearance and well being. In some Somatization syndrome
instances, the psychiatric comorbidities are not Compulsive Compulsive washing
merely the result of the detrimental aspects of skin, Lichen simplex chronicus
but are associated to the pathophysiology of the

::
BDD
dermatological disease itself. An example of the lat-

Psychocutaneous Skin Disease

a
ter is the association of psoriasis with depression, in BDD is classified by the DSM-IV as a somatoform disorder,
although some patients may be classified as having obsessive-
which both conditions share common inflammatory
compulsive disorders (OCD) and others as delusional.
pathways.
The classification can guide in implementing an
effective treatment approach including dermatologic,
psychiatric, and contextual aspects of the disease by the larger cultural, ethnic, or religious community.
aimed to interrupt the circular reinforcement of pathol- Patients’ unshakeable beliefs frequently coexist with a
ogy. In this chapter, we focus on the description of the fairly intact character and personality structure. The
most frequent primary psychogenic disorders that present most frequent form of this condition seen by dermatol-
to the dermatologist, and require acknowledgement ogists is delusion of parasitosis8 in which patients mani-
and treatment. fest the belief of being infested with parasites. Because
this is frequently the only overt manifestation of the
subject’s psychosis, these patients most often pres-
PRIMARY PSYCHOGENIC ent to dermatologists and entomologists rather than
to psychiatrists. Although we will describe below the
DISORDERS more common form of delusions of parasitosis, there are
other more rare forms of delusions such as hypochon-
Frequently, these diseases are manifested by self- driacal, where patients believes that they are afflicted
inflicted dermatosis. The most significant difference by a particular disease (such as AIDS, cancer, etc.), or
between them is the degree of insight or conscious delusions of body odor. In many instances, patients
perception of autoinjury. The classification of these with body dysmorphic disorder (BDD) may have the
disorders as delusional, factitial, somatoform, or compul- unshakeable delusional conviction that they have a
sive is adapted for the clinical dermatological practice, severe physical disfigurement.
following the one described in Clinical Management
in Psychodermatology6 with the understanding that in EPIDEMIOLOGY. This disease predominates in
many instances, disorders may span through various middle aged to elderly females with premorbid social
categories (Box 104-1), and may differ conceptually isolation. In approximately 12% of patients, the delu-
from the DSM-IV (Diagnostic and Statistical Manual of sion of infestation is shared or at least endorsed by a
Mental Disorders, published by the American Psychiat- family member (folie a deux).9,10
ric Association), which is directed towards the psychi-
atric practitioners7 and clinical studies. CLINICAL FINDINGS. Patients with delusional
parasitosis frequently present to the clinician in an
anxious, ruminative, overwhelmed state, with a his-
DELUSIONAL DISORDERS tory of visits to multiple physicians without satisfac-
tion. In addition to proffering a long and detailed
DELUSION OF PARASITOSIS history that includes visual or tactile hallucinations
of the organisms, the patient also frequently provides
Subjects with delusional disorders present with somatic “evidence” of the parasitic infection in the form of
complaints, no insight into the involved psychological clothing lint, skin crusts, or other debris, the so-called
issues, and encapsulated monosymptomatic delusions. “matchbox sign”11 (these items are collected in a
Delusions are fixed, false beliefs that are not endorsed matchbox to be presented to the physicians), which is 1159
18

A B

Figure 104-1  Delusions of parasitosis. A. Excoriations secondary to the attempt to provide an exit route for the parasites.
B. After 2 months of treatment with aripiprazole.
Section 18

delusionally misinterpreted as entire organisms, body sation of crawling, biting and stinging, but lacks the
parts, larvae, or ova. Skin manifestations can be quite fixed unshakeable conception that the skin sensations
variable, if present. Lesions ranging from mild excoria- are induced by parasites.
::

tions (Fig. 104-1A) to large ulcers may reflect patients’

unsuccessful attempts at treating the perceived infesta- PROGNOSIS AND CLINICAL COURSE.
Neurocutaneous and Psychocutaneous Skin Disease

tion.12 Because this is a monosymptomatic delusional Although often regarded as chronic, unremitting,
disorder, some patients have a well-organized train of and difficult to treat, these patients have an improved
thought and normal outward appearance and behav- recovery rate following appropriate pharmacologic
ior, resulting in the conviction by those surrounding therapy.
them that the subject has a true infestation. The delu-
sion becomes apparent to the physician when the sub- TREATMENT. The critical tenet of treatment is to
ject is approached. keep the patient engaged. Empathetic listening, state-
ments of concern, and examinations of the mate-
DIFFERENTIAL DIAGNOSIS. Actual infesta- rial that patients brings in help to establish rapport.
tion and underlying skin or systemic disorders must Because these patients will frequently reject psychiat-
be ruled out (see Box 104-2). Subsequently, the dif- ric referrals,13 various authors have suggested means
ferential diagnosis of psychosis must be considered, of increasing trust, thus paving the road towards
distinguishing between the primary psychiatric condi- psychiatric evaluation.13,14 It is critical that the derma-
tions that manifest with delusions of infestation. True tologist avoids confronting the patient directly, and
monosymptomatic hypochondriasis represents a form exhibits interest in the chief complaint patiently. After
of delusional disorder characterized by a discrete, a few visits, the physician may carefully introduce the
circumscribed delusional belief with possible associ- notion that the parasites may not be present, or that
ated hallucinations without clear syndromic changes the patient is so distressed by this condition, that the
in affect or personality.7 On the contrary, patients with prescription of psychotropic medication could be war-
uni- or bipolar depressive psychosis will describe ranted. Targeted therapy is undertaken with antipsy-
predominantly classic changes in mood, motivations, chotic medications (Fig. 104-1B).15 Pimozide has been
sleep, and appetite. Schizophrenic patients may have used historically as the drug of choice,16,17 although it is
a history of previous psychotic episodes and often now being replaced by atypical antipsychotics, which
show deterioration in global functioning, impaired are associated with a more favorable side effect profile
social relatedness, thought disorder, paranoid traits, (eBox 104-2.1 in online edition).14,18 The clinician needs
and more bizarre and extensive delusions and hallu- to be aware of the need for monitoring for metabolic
cinations. In arriving at the diagnosis, it is critical that syndrome characterized by abdominal obesity, insulin
the clinician differentiate true delusions of parasitosis resistance and impaired glucose tolerance, disturbance
from formication, which involves the cutaneous sen- in lipid metabolism, hypertension, and weight gain.

Box 104-2  Differential Diagnosis of Delusions of Parasitosis

DERMATOLOGIC SYSTEMIC PSYCHIATRIC
Chronic folliculitis Dementia Cocaine use
Insect bite reactions Malignancy (brain) Amphetamine use
Dermatitis artefacta Cerebrovascular disease Psychotic-spectrum illness
Dermatitis para-artefacta Vitamin B12 deficiency Affective disorders
1160
In many instances, the psychotropic medication needs
to be introduced by the dermatologist, and only when
18
the patient begins to respond favorably is it possible to
obtain a referral to a psychiatrist.

FACTITIOUS DISORDERS
This group of syndromes is characterized by self-
inflicted dermatological disease; they are mostly
differentiated based on the degree of insight or con-
sciousness of their behavior.

DERMATITIS ARTEFACTA

Chapter 104
Figure 104-2  Dermatitis artefacta. Linear, sharply bor-
Dermatitis artefacta is a form of factitious disorder dered ulcer.
in which patients intentionally feign symptoms and
produce signs of disease in an attempt to assume the
titious behavior. Occlusive dressings (e.g., an Unna
patient role.6 Unlike patients with malingering who
boot) or other means of preventing manipulation by
engage in similar behavior for external or “secondary

::
the patient lead to healing of the lesions and are often
gain” (such as monetary reward or relief from occu-
helpful strategies in clarifying the diagnosis.

Psychocutaneous Skin Disease

pational or other social responsibilities), the factitious
patient seeks the “primary gain” of the emotional and
psychological benefits that accrue to those who are
TREATMENT. A supportive, nonconfrontational,
empathic approach to the patient is indicated ini-
“ill.” Patients with borderline personality disorder
tially. Immediate confrontation regarding the suspi-
also frequently exhibit self-mutilatory behavior19 as do
cion that the patient’s lesions are self-induced can be
patients who consume cocaine or methamphetamine.
counterproductive in that the patient often flees from
However, their reasons for self-mutilation are variable,
treatment. Frequent visits and symptomatic topical
and are not usually consistent with efforts for primary
treatments are initially useful.23 However, the clinician
or secondary gain. Occasionally, a psychologically dis-
must be careful not to collude in the patient’s abnor-
turbed adult will induce skin lesions in their children.20
mal illness behavior. Ultimately, the recognition of the
patient’s role in the production of the lesions must be
EPIDEMIOLOGY. Predominating in females, the broached. The goal is to establish a trusting relation-
age of onset varies significantly from adolescence
ship such that the patient will accept a psychiatric
through adulthood.21 Comorbid depressive and per-
referral. Antidepressants (eBox 104-2.2 in online edi-
sonality disorders may also be seen coexisting with
tion) and low-dose atypical antipsychotics (eBox 104-
this rare syndrome.6
2.1 in online edition) have been reported to be useful
adjunctive therapies.24,25 In the case of inflicted lesions
CLINICAL FINDINGS. Although it has long been in a child protective services or equivalent agencies
observed that patients with dermatitis artefacta may must be alerted immediately to safeguard the welfare
present with lesions in virtually all areas of the body of the child.
that can mimic most dermatoses, some common ele-
ments may hint at this diagnosis. Lesions are often in
areas readily accessible to the patient, and may have
geometric patterns or angulated borders surrounded
by completely healthy skin. Morphology is often
bizarre and does not conform to typical presentations
of known dermatoses (Figs. 104-2 and 104-3). Patients
are often unable to provide a clear history of the initial
appearance or evolution of the process, typically deny
any role in the production of the lesions, and may self-
induce the lesions in a dissociated state.22 Characteris-
tically, the histopathology is unrevealing.

DIFFERENTIAL DIAGNOSIS. As in all cases of

factitious disease, the clinician must rule out possible
disease entities that are consistent with the history and
clinical findings. Unusual presentations of common ill-
nesses and rare conditions must be entertained. How-
ever, exhaustive searches for primary skin pathology
without supporting clinical evidence may compound Figure 104-3  Dermatitis artefacta. Part of the nasal carti-
the problem and actually perpetuate the patient’s fac- lage has been manually destroyed. 1161
18 COURSE AND PROGNOSIS. These are funda- eyelashes, eyebrows, and pubic hair, with a major-
ity of patients pulling hair from more than one site.
mentally determined by the underlying psychopa-
thology. In those patients with severely disturbed Rarely, this is followed by the ingestion of the hair,
personalities, the recurrent self-defeating and destruc- leading to the potentially dangerous complication of
tive behaviors are likely to continue. trichobezoar.30 Awareness of the behavior is partial to
complete in a vast majority of patients, and frequently
occurs while patients are engaged in isolated, seden-
DERMATITIS PARA-ARTEFACTA tary activities. Attempts to resist the behavior and to
SYNDROME disguise its cosmetic sequelae are common. Typical
histopathologic findings that may be helpful in con-
These are a group of factitious diseases, where prob- firming the diagnosis in questionable cases include
lems of impulse control play a significant role; the catagen and telogen hairs, pigment casts, and trauma-
patients are conscious or semiconscious of manipulat- tized hair bulbs without significant inflammation or
ing their skin, but are unable to stop this behavior. scarring.31 Perifollicular hemorrhage near the hair bulb
Trichotillomania is an impulse control disorder,7 char- is diagnostic.
Section 18

acterized by repetitive pulling of hair, resulting in alo-

pecia. Strict criteria also include a build up of tension DIFFERENTIAL DIAGNOSIS. When patients do
before hair pulling or when resisting an urge to do so, not have awareness of pulling their own hair and pres-
pleasure or relief after pulling out the hair, and signifi- ent with alopecia, other etiologies of hair loss must be
cant functional impairment and distress in the patient. ruled out.
::
Neurocutaneous and Psychocutaneous Skin Disease

EPIDEMIOLOGY. Prevalence rates are estimated to TREATMENT. Because of trichotillomania’s similari-

be between 0.5% and 3.5% with a mean age of onset ties to OCD, the use of selective serotonin reuptake
between 10 and 13 years. Despite its current classifica- inhibitors (SSRIs) and clomipramine, as well as com-
tion, there are marked similarities with obsessive-com- binations with atypical antipsychotics have received
pulsive disorder (OCD), which may have important much attention (eBoxes 104-2.1 and 104-2.2 in online
treatment implications.26–28 Comorbid psychiatric dis- edition).28,32–37 However, psychopharmacologic data
orders are depression, anxiety, and OCD. have been conflicting, and the best-designed studies
have not demonstrated superiority of psychotropics
CLINICAL FINDINGS. Trichotillomania presents over nonpharmacologic interventions. Nonpharmaco-
clinically with nonscarring alopecia, most commonly logic treatment of trichotillomania relies heavily upon
with hairs broken at different lengths, normal over- behavioral therapies, especially habit reversal, which
all hair density (Fig. 104-4), and a negative pull test29; entails engaging the patient in a behavior incompatible
occasionally, repeated trauma may result in some scar- with hair pulling when the urge appears. The addition
ring. Body areas involved typically include the scalp, of cognitive-behavioral or insight-oriented psycho-
therapy have good results; hypnotherapy may also be
very useful, particularly in children.38

PROGNOSIS AND CLINICAL COURSE. Tricho-

tillomania is a chronic disorder and data on long-term
success of pharmacologic and psychotherapeutic inter-
ventions are inconclusive. Though children typically
have a benign course, adult-onset trichotillomania is
often associated with other psychiatric conditions and
sustained improvement has yet to be shown convinc-
ingly.

SKIN PICKING (NEUROTIC

EXCORIATIONS)
This is also a condition in which patients induce skin
lesions through repetitive, compulsive excoriation of
their skin. However, unlike patients with dermatitis
artefacta syndrome, these patients admit their role in
the production of the lesions.

EPIDEMIOLOGY. This is the most common psy-

cho-cutaneous disorder, reported in up to 2% of der-
matology clinic patients39 with a predominance in
middle-aged females, and are frequently associated
Figure 104-4  Trichotillomania. Hairs broken off at differ- with compulsivity–impulsivity spectrum and mood
1162 ent lengths. disorders.40,41
 18

Chapter 104
::
Psychocutaneous Skin Disease
Figure 104-5  Dermatitis para-artefacta: skin picking on
the breast of a 16-year-old girl.

CLINICAL FINDINGS. Patients with skin picking Figure 104-6  Prurigo nodularis.
often describe significant itch leading to persistent
scratching, which is frequently antedated by consider-
able psychological stressors. The development of this
disorder has also been noted to be associated with the
TREATMENT. Work-up for pruritus should be insti-
tuted in those patients that present significant itch.
marked limitation in activity seen in illness or senes-
In the absence of organic cause, these patients may
cence.42 The repeated excoriation can lead to the devel-
improve with phototherapy. Additional treatment
opment of an “itch–scratch cycle,” perpetuating the
should be directed at underlying psychopathology
behavior. Patients present with multiple excoriations
when identifiable. Antidepressants, helpful in both
in various stages of evolution and healing, with postin-
depressive and anxiety disorders including OCD,44 are
flammatory hyperpigmentation and frequent scarring
very useful. Subsequent addition of low-dose atypical
(Fig. 104-5). The distribution of the lesions reflects their
antipsychotics has been found effective. Supportive
self-inflicted nature with most being on the extensor
psychotherapeutic approaches and behavioral inter-
surfaces of the extremities, upper back, and face, spar-
ventions as those used to treat self-injurious behaviors
ing unreachable areas such as the central mid-upper
in Tourette’s syndrome may be helpful.45
back. Frequently, patients develop excoriations over-
lying preexisting dermatosis, such as folliculitis and
acne; excessive manipulation of the latter leads to the
COURSE AND PROGNOSIS. This can be a chronic
condition whose prognosis depends on the underlying
condition known as “acne excorieé”. These patients
psychiatric illness.46 With appropriate therapy, patients
often spend many hours each day in front of the mirror
with affective and anxiety disorders may have excel-
injuring the skin with instruments such as tweezers.
lent outcomes, with a symptom-free, normally func-
The trauma often results in temporary relief of anxi-
tioning state.
ety. Prurigo nodularis can be considered an extreme
variant of this entity, characterized by severely pruritic
nodules varying from a few millimeters to 1–2 cm in MALINGERING
diameter, preferentially located on the extremities (Fig.
104-6) (see also Chapter 15). Malingerers intentionally induce skin lesions in order
to obtain secondary gains, often workman’s compen-
DIFFERENTIAL DIAGNOSIS. The clinician must sation or disability. Since there is no patient motivation
evaluate the patient for causes of pruritus (see Chapter for therapy, treatment is not possible.6,47
103) and rule out possible internal diseases including
neoplasms, in particular, lymphomas. The differential
for the underlying psychiatric disorder,43 if present, SOMATOFORM DISORDERS
must include depressive and anxiety disorders and,
more rarely, excoriations secondary to delusions of This is a group of heterogeneous disorders where the
parasitosis. patients complain of a variety of symptoms that cannot 1163
18 be objectively verified by the physician, but they share
similar psychiatric underlying problematics.
their illness. Evidence suggests that if patients receive
such treatment they do not improve, are usually disap-
pointed with the results, and may even experience an
exacerbation of their symptoms. It is strongly recom-
BODY DYSMORPHIC DISORDER mended that cosmetic lines of treatment be avoided.
BDD is a severe and complex disorder that often
BDD is a chronic condition characterized by an exces- requires multimodal treatment using cognitive behav-
sive preoccupation or concern with a presumed defect ioral therapy (including exposure response preven-
in physical appearance despite normal or minimally tion) and medication.60,61
objective anomalous findings.48 Also known as dys- Pharmacologic trials show a good response to SSRIs
morphophobia,49,50 this is a psychological experience that (see eBox 104-2.2 in online edition), improving insight
also results in functional impairment, poor quality of while decreasing distress, compulsions, and frequency
life, and low treatment response. and intensity of obsessions about perceived defects.
The nosological classification of BDD revolves Interestingly, SSRIs appear equally effective for delu-
around the intensity with which patients hold on to sional as well as nondelusional patients. Efficacy usu-
Section 18

their abnormal beliefs. Those with unshakeable con- ally requires 12–16 weeks of relatively high dosages.
victions are currently diagnosed as having a delusional Issues of compliance require close monitoring, since
disorder.7 However, there appears to be a continuum they are a frequent cause of treatment failure. A sig-
of intensity and insight from preoccupations, through nificant proportion of patients who fail one adequate
overvalued ideas to clear delusions.51 Those patients SSRI trial respond favorably to a second SSRI, suggest-
::

that retain a certain degree of insight evidence char- ing that serial trials of similarly acting agents should
Neurocutaneous and Psychocutaneous Skin Disease

acteristics more similar to the obsessive–compulsive be administered in initially refractory cases. Lack of
spectrum of disorders,51,52 a finding that has significant clear success has been noted with other agents such as
potential treatment implications. BDD patients have antipsychotics, tricyclic antidepressants (TSA) (other
obsessive thoughts about their “flaws” and engage than clomipramine), benzodiazepines, and anticon-
in compulsive behaviors related to how they perceive vulsants.62–67 Similar to patients with OCD, cognitive-
their appearance, similar to behavior seen in obsessive– behavioral therapy is strongly recommended.
compulsive disorder.53
PROGNOSIS AND CLINICAL COURSE. BDD is
EPIDEMIOLOGY. The prevalence of BDD, is esti- a chronic illness without clear evidence for spontane-
mated to be from 0.7% to 2.4% in the general popu- ous remission without treatment. Pharmacotherapy
lation to 12% in dermatology clinic patients, often with appropriate medications may lead to improve-
in association with mood disorders such as major ment in a considerable number of patients. However,
depressive disorder (MDD) (37%), social phobia (33%) effective doses of SSRIs are usually beyond those
and OCD (26%).54,55 Improvement of MDD and BDD approved by the FDA; the data also indicate high recur-
seems to be closely related, with the improvement of rence rates with discontinuation of treatment.64 Thus
each disorder significantly predicting the remission of patients may require long-term treatment, including
the other. Improvement of OCD significantly predicts adjunctive insight oriented psychotherapy.57,60
remission of BDD, but not vice versa. Approximately
80% of patients report a history of suicidal ideation
and 24%–28% have attempted suicide.56–58 SOMATIZATION DISORDER
CLINICAL FINDINGS. Patients present with These patients present to the physician with multiple
intensely articulated distress about various body parts. significant physical complaints and the belief that their
Most patients also develop ideas of reference in which symptoms are due mostly to exposure to environmen-
they think or are convinced that others notice and com- tal causes. This disorder includes Gulf War syndrome,
ment upon the presumed defect. Time-consuming, multiple chemical sensitivity syndrome, amalgam
compulsive behaviors often accompany the worrisome related syndrome, chemical or detergent allergies,
thoughts, including repeated examination in mirrors, “sick building syndrome,” food intolerances, and “can-
covering up defects, and asking others for reassurance. dida hypersensitivity syndrome,” among many others.
Consultations with other physicians and past opera- There is no medical proof of a direct causal relation-
tions on the perceived defect are common. Marked ship between exposure and the extent of complaints.
restriction in social and occupational functioning is The widespread dissemination of information through
seen in up to 98% of individuals, and 30% of patients the Internet as well as the insistence of self-proclaimed
have been described as housebound.59 Thoughts and experts reinforces the patients’ misinterpreted beliefs.
attempts of suicide are frequent. Thus, current or past
suicidal ideation should be routinely assessed by the
practitioner. Particular monitoring may be needed with HYPOCHONDRIACAL DISORDERS
younger patients as antidepressant action may increase
impulsivity and likelihood of suicidal attempts.58 Typically these patients express the conviction or
fear of suffering from a serious illness (such as AIDS,
TREATMENT. Many patients with BDD will seek venereal diseases or cancer) despite the lack of medi-
1164 dermatologic or surgical treatment over the course of cal evidence.
 CUTANEOUS DYSESTHESIAS
conditions such as trichotillomania or skin picking (see
above).
18
(ATYPICAL CHRONIC PAIN/BURN
SYNDROME)
PSYCHOTROPIC MEDICATIONS
Occasionally, patients will present to dermatologists USED IN DERMATOLOGY
with complaints of burning, pain, or dysesthesias in
the skin or mucus membranes for which no identifi-
Dermatologists who elect to treat psychocutaneous
able pathology can be found. This can be a frustrating
disorders routinely use a number of different classes
situation for patient and clinician alike. A psychiat-
of psychotropic medications. Knowledge of the drugs
ric approach to these patients may offer a means of
and their actions, indications, side effects, therapeu-
understanding the complex factors underlying this
tic doses, and potential drug interactions is critical.71
syndrome, such as comorbid affective disorders, per-
These drugs are classified according to their clinical
sonality vulnerabilities, behavioral problems, and life
utility (e.g., antidepressants or antipsychotics) and
circumstances that may perpetuate the pain cycle and

Chapter 104
further identified by their chemical structure and/
maintain the patient in an illness role.
or mechanism of action. All of the drugs discussed in
There is a significantly increased rate of depression in
this section exert their clinical effects through modula-
patients with chronic pain syndromes and a clear rela-
tion of neurotransmitter function in the CNS by alter-
tionship between lifetime depression and the develop-
ing presynaptic reuptake of the transmitters, blocking
ment of medically unexplained symptoms, including
their pre- and/or postsynaptic receptor binding, stim-

::
pain.68 Depression not only worsens the experience
ulating those receptors, or some combination thereof.
of pain by psychologically magnifying negative per-

Psychocutaneous Skin Disease

The most appropriately used in each of the following
ceptions, but may also interfere with the function of
three major classes are discussed: antipsychotics, anti-
descending monoaminergic neurons that dampen
depressants, and anxiolytics.
nociceptive transmission.69,70 Other complicating fac-
For a detailed discussion of these drugs, their side
tors include anxiety, which is also commonly seen in
effects, and precautions, see online edition of the book.
patients with chronic pain.68 Personality disorders
influence all aspects of patients’ lives and may make
the burden of a chronic condition more challenging. At NONPHARMACOLOGIC
times, family or social environments may unwittingly
play a role in undermining the chronic pain patient’s TREATMENTS FOR
rehabilitation by rewarding illness behaviors with
well-meaning, yet oversolicitous, attention. Pain states
PSYCHOCUTANEOUS DISORDERS
can further be complicated if the patient develops an
The dermatologist should request a consultation with
inappropriate pattern of using prescribed analgesics.
a psychiatrist or a liaison clinic during the treatment
For all of these reasons, the best course of action for
of patients with psychocutaneous disorders as soon as
patients presenting with poorly explained chronic
it is amenable to the patient. Although dermatologists
pain is to refer them to a multidisciplinary pain cen-
are becoming more comfortable with the use of certain
ter for thorough evaluation and treatment. The pres-
psychotropic medications, they generally do not have
ence of burn syndrome may occasionally respond to
the time or the training to use effectively nonpharma-
the administration of gabapentin (see eBox 104-2.2
cologic modalities. Therefore, it is sufficient that the
in online edition). Milnacipran, an SNRI approved
practicing dermatologist be aware that a variety of
for fibromyalgia (eBox 104-2.2 in online edition), also
adjunctive, stress-reducing approaches are available,
may be effective for chronic pain/burn/dysesthesia
including hypnosis, biofeedback, progressive muscle
syndrome. Extreme forms of chronic dysesthesia can
relaxation, and psychotherapy (Box 104-3). Although
resolve with the administration of antipsychotic medi-
no modality has been demonstrated to be superior to
cation, suggesting that it represents a form of delusion.
another, certain types of therapies may be more effec-
tive for a given condition. Diagnosis should drive
PSYCHOGENIC PRURITUS choice of therapy.

Psychogenic pruritus and itch in general are discussed

in Chapter 103. Box 104-3  Nonpharmacological
Treatments
OBSESSIVE-COMPULSIVE Cognitive-behavioral therapy
Insight-oriented psychotherapy
DISORDERS (OCD) Hypnosis
Mindfulness-based cognitive therapy
These include dermatological findings that are the Biofeedback
result of disorders such as compulsive washing (xero-
Family therapy
sis, eczema) or rubbing (lichen simplex chronicus).
OCD is also related to BDD as well as some factitious 1165
18 KEY REFERENCES
6. Harth W et al: Clinical Management in Psychodermatology,
1st edition. New York, Springer, 2008
14. Sandoz A et al: A clinical paradigm of delusions of parasit-
Full reference list available at [Link] osis. J Am Acad Dermatol 59(4):698-704, 2008
59. Phillips KA: Understanding Body Dysmorphic Disorder.
DVD contains references and additional content New York, Oxford University Press, 2009
72. Koo JYM, Lee CS: Psychocutaneous Medicine. New York,
3. Gupta MA: Psychocutaneous disease. Dermatol Clin 4:591- Marcel Dekker, 2003
745, 2005
5. Koblenzer C: Psychosomatic Concepts in Dermatology. Or-
lando, FL, Grune & Stratton, 1987

Chapter 105 :: C utaneous Manifestations

Section 18

of Drug Abuse
:: Haley Naik & Richard Allen Johnson
::
Neurocutaneous and Psychocutaneous Skin Disease

MUCOCUTANEOUS MANIFESTATIONS DEFINITIONS

OF DRUG ABUSE AT A GLANCE
Illicit drug use is a maladaptive pattern involving self-
The morphology and arrangement of skin administration of prescribed or recreational drugs.
Chipping is a lay term used to describe a pattern of drug
lesions can identify persons with former and
use in which the user is not physically dependent, but
current drug dependency.
rather sustains “controlled use” of a drug. A certain
Skin lesions associated with drug use can percentage of users will progress to drug dependence, a
physical and/or psychological need for the effects of a
be related directly to the drug itself, mode
chemical in order to avoid withdrawal symptoms asso-
of drug delivery, and/or adulterants or
ciated with abstinence (Box 105-1). Drug dependence
infectious agents mixed with the drug.
often leads to drug abuse, an intense desire to recurrently
Drug addiction-related bacterial infections obtain increasing amounts of one or more chemical sub-
stances to the exclusion of all other activities, resulting in
predominantly involve the skin and soft
tissue. Culture-guided antibiotic therapy
is essential because infection with unusual
organisms, antibiotic-resistant strains, and
polymicrobes is more common. Box 105-1  Criteria for Drug
Dependence
Behavioral effects of drug use can lead to the
transmission of sexually transmitted diseases The presence of three or more of the following, occur-
and blood-borne pathogens including ring any time in the same 12-month period:
Treponema pallidum, hepatitis B virus,
Tolerance
hepatitis C virus, human immunodeficiency
virus, and human T-lymphotropic viruses 1
Withdrawal symptoms
and 2. Sustained intent or unsuccessful efforts to abate
drug use
Administration of drug in higher doses and longer
duration than initially intended
Significant time devoted to obtaining the drug or
recovering from its effects
Relinquishment or reduction of social, occupational
INTRODUCTION or recreational activities because of drug abuse
Continued drug use despite awareness of the pres-
Drug abuse and addiction can be suspected or diag-
nosed on the basis of mucosal and cutaneous findings. ence of a persistent or recurrent physical or psycho-
The administration of drugs may cause cutaneous stig- logical problem caused or exacerbated by the drug
mata and eruptions predominantly through local or Adapted from American Psychiatric Association: Diagnostic and
systemic, toxic or hypersensitivity-induced effects as a Statistical Manual of Mental Disorders IV-TR, 4th edition. Washing-
result of the drug itself, adulterants, infectious agents, ton DC, American Psychiatric Press, 2000.
1166 or the mode of drug delivery.