Skin disease often results in psychological problems. As the skin is so visible and because it has such a major role in formal and intimate communication, relationships may be impaired and self-esteem lowered, resulting in distress that may be hard to resolve (Figure 44.1). The prevalence of depression is high in people with widespread skin disease; this is often unrecognised by their carers. Therefore, it is important in all patients to consider their psychological state, especially in chronic widespread inflammatory skin disease (Table 44.1). There are a few skin diseases in which psychological influences or mental illness have a major causative role.

Psychiatric and Skin Co-Morbidity

Depression: high prevalence in severe psoriasis.
Obsessive–compulsive disorder (OCD): may cause excessive scratching in atopic dermatitis. Hand dermatitis occurs with frequent hand washing.
Social phobia: anxious avoidance of social situations where previously their skin condition resulted in problems.
Body dysmorphic disorder: distorted self-image.

Skin Diseases Primarily Caused by Psychological and Psychiatric Problems

Factitious Dermatitis

Rarely, people deliberately damage their skin, sometimes repeatedly over many months or years. They draw attention to the damaged skin and seek treatment, but deny any knowledge of how it was caused: both lesions and history are false. They may cause non-healing ulcers by constantly picking at the skin (Figure 44.2), by injecting toxic matter or by cigarette burns. Lesions may be odd shapes (Figure 44.3). Patients may gain by taking on a sickness role.

Management is very difficult. Clearly, the patient needs psychological help. It is debatable whether it is helpful to confront a patient with the diagnosis. A face-saving strategy is to allow the patient to retreat from the self-harming procedure without having to admit their responsibility for it.