Psychodermatology



Psychodermatology


John Koo MD

Ellen De Coninck MD




Psychodermatology and psychocutaneous medicine are unfamiliar terms to many physicians. It is reported that up to 18% of dermatologists routinely prescribe psychotropic drugs. These terms describe a field of medicine that focuses on the interface between psychiatry and dermatology. In a surprisingly large proportion of dermatologic disorders, the understanding of the psychosocial and, sometimes, the occupational context is critical for optimal patient management. Examples range from common skin rashes, such as eczema or psoriasis, to flare-ups during emotional stress, to cases in which there is no real skin disorder, but the patient targets his or her skin to express an underlying psychopathologic condition. Neurotic excoriations, trichotillomania, and delusions of parasitosis are examples. Moreover, because skin disease is visible, patients commonly experience a significant negative impact on their psychological stability resulting from the disfigurement caused by their skin disorder. Patients with disfiguring skin disorders, such as alopecia areata, vitiligo, and psoriasis, frequently report problems with self-esteem, depression, and social anxiety.

The management of psychodermatologic disorders requires special skills. First, to understand what is going on and what the actual diagnosis is, a clinician must not only evaluate the skin manifestation based on the usual dermatologic differential diagnosis, but also evaluate the underlying psychopathology and the relevant social, familial, and occupational issues.

Once the diagnosis is made, optimal management often requires a dual approach to address both the dermatologic and the psychological aspects. Even in cases where the main problem is psychopathologic and the skin manifestations are entirely self-induced, the authors cannot overemphasize the importance of maintaining supportive dermatologic care to avoid secondary complications such as infection and to ensure that the patient does not feel “abandoned” by the nonpsychiatric physician. Such demonstrated support by the nonpsychiatric physician can enhance acceptance of a psychiatric consultation or referral by the patient, should there be a need for one. At the same time, it is important for the clinician to try to understand the nature of the underlying psychopathology so that the appropriate psychiatric management can be initiated. This ranges from providing appropriate psychotropic medication and encouraging the patient to attend stress management courses to making a formal referral to a psychiatrist (depending on the severity of the underlying psychopathology). Psychodermatology cases, just like those in any other field of medical practice, can range from mild to severe. In fact, when a clinician becomes aware of the mind-skin interaction and looks for psychological elements in patients, he or she finds that the large majority of these patients have easily treatable psychopathologies impacting their skin disease, such as situational stress or mild depression. Clinicians who are not fully aware of this field may only be reminded of the skin-mind interaction when they encounter the most difficult and most florid cases, such as delusions of parasitosis. It is the recommendation of the authors that clinicians become familiar with the entire range of psychodermatologic disorders so that their perception of this field is not warped by only being forced to deal with the most difficult and frustrating cases.


Classification

Psychodermatologic disorders can be broadly classified into four categories: psychophysiologic disorders, primary psychiatric disorders, secondary psychiatric disorders, and miscellaneous cases. Psychophysiologic disorder refers to a situation where a real skin disorder, such as eczema or psoriasis, is worsened by emotional stress. Primary psychiatric disorder refers to cases such as trichotillomania where the primary problem is psychological. There is no primary skin disorder and all the manifestations are self-induced. Secondary psychiatric disorder refers to those cases where significant
psychological problems, such as profoundly negative impact on self-esteem and body image, depression, humiliation, frustration, and social phobia, develop as a consequence of having a disfiguring skin disorder. The “miscellaneous” category refers to less well-defined situations where involvement of the central nervous system is suspected, such as cutaneous sensory syndrome. In this condition, a patient with no visible rash presents to a clinician with a purely sensory complaint, such as itching, burning, or stinging, but an extensive medical workup fails to reveal an underlying diagnosis. These patients usually respond better to psychotropic medications than to usual dermatologic therapeutics, such as topical steroids.

It is important to be able to distinguish between these broad categories for several reasons. First, the severity of the underlying psychopathologic condition tends to be different depending on the categories, with psychophysiologic disorders generally involving “milder” psychopathologies (such as situational stress) than the primary psychiatric disorders. Second, the approach to patients is frequently different among these categories. For example, with psychophysiologic cases, it is easy to talk to the patient about his or her situation, whereas in certain cases of primary psychiatric disorder, such as delusions of parasitosis or neurotic excoriation with underlying depression that is being denied by the patient, one must be extremely diplomatic, because these patients may not be ready to be confronted with the psychogenic aspect of their condition.


Psychophysiologic Disorders

Psychophysiologic disorders are skin disorders that are known to be frequently precipitated or exacerbated by emotional stress. However, with each of these conditions, there are “stress responders” and “non-stress responders,” depending on whether a patient’s skin disease is or is not frequently and predictably exacerbated by stress.

The proportion of stress responders depends on the particular dermatologic diagnosis involved. In minor, treatmentresponsive cases of eczema, psoriasis, or acne, the issue of stress may not be that important. However, when a clinician is faced with a more recalcitrant case, it is important to remember to ask the patient whether psychological, social, or occupational stress might be contributing to the activity of the skin disorder. Because of the propensity of so many chronic dermatoses to be exacerbated by emotional stress, and because emotional stress can initiate a vicious cycle referred to as the itch-scratch cycle, recalcitrant patients with chronic dermatoses may be difficult to “turn around” without addressing stress as an exacerbating factor.

With regard to psychological issues, patients often feel embarrassed discussing them, especially if they feel hurried. Once the clinician inquires, patients are frequently glad to share whatever psychosocial or occupational stress might be exacerbating or perpetuating the dermatitis. If the situation is relatively mild, simple encouragement by an authority figure (the physician) to join a stress management class, study relaxation techniques, or even use music or exercise as a stress reducer might suffice. If there is a specific psychosocial or occupational issue that needs to be vented, referral to a therapist or counselor is appropriate.

If the stress or tension is of significant intensity to warrant considering the use of an antianxiety agent, there are three general types of agents available to meet these clinical needs. The first type, the benzodiazepines, can be used on an as-needed basis and can provide relatively quick relief from anxiety, “stress,” and tension. The authors generally recommend relatively “newer” benzodiazepines, such as alprazolam (Xanax), available generically. The much older ones, such as diazepam (Valium) or chlordiazepoxide (Librium), are more often associated with possible cumulative side effects owing to their longer or unpredictable half-lives. Benzodiazepines should be reserved for short-term situations whenever possible because continued usage for more than several weeks can be associated with tolerance, dependence, and withdrawal.

On the other hand, if the “stress” proves to be a chronic predicament, a nonsedating and nonaddictive antianxiety agent such as buspirone (BuSpar) is safer for long-term use. Because of its slower onset of action, which may take up to 2 weeks or more, buspirone cannot be used on an as-needed basis. A common starting dose is 15 mg/d in divided doses, followed by 15 mg twice a day for 1 week, and up to 60 mgQD if required. The therapeutic range for most patients is between 15 and 30 mg/qd. It is not uncommon for a benzodiazepine to be started in conjunction with buspirone and then tapered after 2 or 4 weeks after the therapeutic effect of buspirone is achieved.

Antidepressants are the third type of agents used in the treatment of anxiety. The antidepressant agents paroxetine (Paxil) and venlafaxine (Effexor) are examples of selective serotonin reuptake inhibitors (SSRIs) that are useful not only in the treatment of depression but also in the treatment of chronic anxiety. It was found in an open-label study of paroxetine, imipramine, and a benzodiazepine that by the fourth week of treatment, paroxetine and imipramine were superior to the benzodiazepine for the relief of anxiety symptoms. Furthermore, the effectiveness of a venlafaxine extendedrelease preparation (Effexor XR) was demonstrated in a series of double-blind, randomized, placebo-controlled trials in the treatment of patients with generalized anxiety disorder.

If the intensity and the complexity of the anxiety disorder warrant a psychiatric referral, such a referral should be discussed with the patient in a most supportive and diplomatic way so as to maximize the chance of the patient accepting the referral as an adjunct to continuing dermatologic therapy.


Primary Psychiatric Disorders

Primary psychiatric disorders are less commonly encountered than those in which stress exacerbates a common dermatosis. However, they tend to be more “florid” with a striking presentation.


Delusions of Parasitosis

Delusions of parasitosis belong to a group of disorders called monosymptomatic hypochondriachal psychosis (MHP), where seemingly “normal” patients present with an encapsulated,
somatic delusional ideation of a hypochondriachal nature. Because of the truly encapsulated nature of the delusional disorder, these cases are usually quite different from schizophrenia, which involves multiple functional defects, including auditory hallucinations, lack of social skills, and flat affect in addition to delusional ideation.

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May 28, 2016 | Posted by in Dermatology | Comments Off on Psychodermatology
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