Folliculitis necrotica is a peculiar dermatosis of the scalp that preferentially affects adult males, with chronic symptoms that wax and wane over time. Traditionally, the condition has been nosologically classified among the primary scarring alopecias. There is circumstantial evidence to also classify it among the psychophysiological disorders.

The disorder is characterized by minute and usually intensely pruritic follicular erythematous papules and pustules of the scalp that may become sore and crusted due to repeated scratching. The lesions may concentrate along the frontal hairline but can appear anywhere on the scalp, varying in number from just a few to numerous lesions covering the scalp (Fig. 5.1). The disease has been classified into acne necrotica miliaris and acne necrotica varioliformis. The former affects the superficial portion of the hair follicle, allowing for hair regrowth after successful treatment. Miliaris refers to a millet, a term for a small seed. The latter represents deeper lesions that progress to scabs that leave smallpox-like (varioliform) scars in their wake. Focal permanent alopecia may occur where the scalp has been scarred.

Histological studies of early lesions demonstrate lymphocytes centered around a hair follicle, with keratinocytes within the external hair root sheath and surrounding epidermis showing extensive cell necrosis.

The etiology is unknown; however, an abnormal inflammatory reaction to components of the hair follicle has been postulated, particularly to commensal or pathogenic microorganisms, such as Propionibacterium acnes, Malassezia spp., Demodex folliculorum, and, in the more severe cases, Staphylococcus aureus.

The condition usually responds well to oral antibiotics, particularly long-term tetracyclines, in combination with a topical corticosteroid cream, and a shampoo treatment alternating an antiseptic shampoo containing povidone-iodine with an antidandruff shampoo containing ketoconazole. Mild cases may be treated with topical antibiotics such 0.5–1.0 g tetracycline in 70 % isopropyl alcohol (at 100.0 g), 1 % clindamycin solution, or 4 % erythromycin gel. Refractory cases usually can be managed with long-term low-dose oral isotretinoin (start with 20 mg daily and taper to the individually required minimal dosage). In particularly tense patients, the addition of oral doxepin hydrochloride 10–50 mg in the evening may be helpful in alleviating the itch–scratch cycle.

The term neurotic excoriations refers to patients with self-inflicted excoriations of the scalp in the absence of an underlying specific dermatologic disease condition. The etiology is varied, and psychiatrically, patients with neurotic excoriations are not a homogenous group, each requiring an individual therapeutic approach.

The condition may occur at any time from childhood to old age, with the most severe and recalcitrant cases reportedly starting in the third to fifth decade.

Because the patients, by definition, can inflict lesions only on those areas of the body that can be reached, and because patients tend to excoriate areas that are easily accessible, the clinical distribution of lesions besides the scalp can give a clue to the diagnosis. The lesions may affect the scalp in an isolated manner or may be associated with excoriations of the face and/or of the upper trunk and extensor aspects of the arms. The excoriations may be initiated by minor irregularities of the skin surface, such as a keratin plug, insect bite, acne papule (acne excoriée), or irritated hair follicle, or may start de novo. There is a decreased threshold for itch with tendency to habitual or neurotic scratching. Picking activity may start inadvertently as the hand comes across on an irregularity of the skin, or it may occur in an organized and ritualistic manner, sometimes using an auxiliary instrument, such as the point of a knife, etc. Tissue damage itself may again trigger itching, and the itch–scratch cycle may take on a life of its own. This activity typically takes place when the patient is unoccupied, and precipitating psychosocial stressors are usually present.

The inflicted lesions are rather nonspecific. Varying in size from a few millimeters to several centimeters in the well-developed case, lesions are seen in all stages of evolution, from small superficial saucerized excoriations, to deep scooped-out skin defects (Fig. 5.2), to thickened hyperpigmented nodules, and finally to hypopigmented atrophic scars. Secondary bacterial infection may lead to regional lymphadenopathy. The histology is that of an excoriation with nonspecific inflammatory changes. Microbiological studies may reveal secondary bacterial infection, usually with S. aureus.

Examples are atopic dermatitis, folliculitis necrotica, chronic cutaneous lupus erythematosus, pemphigus vulgaris, pemphigoid, parasitic infestation, neurologic disorders, and other psychiatric disorders, such as cocaine intoxication, delusions of parasitosis, and factitial dermatitis.

Most importantly, one needs to confirm the diagnosis by ascertaining the presence of psychopathology through both clinical observation and direct patient questioning.

Although behavioral modification, cognitive psychotherapy, psychodynamic psychotherapy, and an eclectic approach have met variable success, many patients who present to the dermatologist are reluctant to agree to the psychiatric nature of their skin disorder and lack insight into the circumstances that trigger the drive to excoriate. Unless the patient is managed in a liaison clinic where dermatologists and psychiatrists can confer, it is the dermatologist who will take the responsibility for treatment.

If the patient is suffering from excessive stress, there are specific and nonspecific approaches. Those individuals who can find specific, real-life solutions to the difficulties they report are the more fortunate ones. Many patients experience stress from work or home relationships for which there is no easy way out. For these patients, a nonspecific solution to the stress can still be beneficial. Among the nonspecific solutions to stress, there are nonpharmacologic and pharmacologic means. The nonpharmacologic means include exercise, biofeedback, yoga, self-hypnosis, progressive relaxation, and other techniques learned in stress-management courses. Some patients do not have time to take stress-management courses, and others have special difficulty benefiting from this type of approach, for example, those who are not psychologically minded. For these patients, cautious use of antianxiety agents may be an alternative. In general, there are two types of anxiolytics: a quick-acting benzodiazepine type that can be sedating and produce dependency, such as alprazolam, and a slow-acting non-benzodiazepine type that is nonsedating and does not produce dependency, such as buspirone. Alprazolam differs from the older benzodiazepines such as diazepam and chlordiazepoxide because its half-life is short and predictable. Another advantage is that it has an antidepressant effect, whereas most other benzodiazepines generally have a depressant effect. Because of the possible risk of addiction with long-term use, the most prudent way of using alprazolam would be to restrict its use to 2–3 weeks. If the patient requires long-term therapy for anxiety, buspirone may be considered. However, it must be kept in mind that the effect of buspirone is usually not experienced by the patient for the first 2–4 weeks of treatment. Also, buspirone cannot be used on an “as-needed” basis. If buspirone does not work for a patient with chronic anxiety disorder, an alternative would be the use of low-dose doxepin. Even though doxepin is a tricyclic antidepressant, in low doses, it has been compared to benzodiazepines in terms of its anxiolytic effects. Sometimes, also a low dose of a low-potency antipsychotic agent such as thioridazine can be used.

Although there are a number of nonpharmacologic treatment options for depression, most dermatologists have neither the time nor the training to execute these treatment modalities. Nonetheless, it is advantageous to be conscious of these options, especially for those patients who agree to a referral to a mental health professional. Individual psychotherapy can be useful if there are definable psychological issues to be discussed, e.g., frustrations at work, a maladaptive style in interpersonal relationships, and the presence of maladaptive views of oneself, such as unrealistic expectations or fear of failure. Other patients have neurobiological predispositions to depression, and their depressive episodes may not be associated with any identifiable psychosocial difficulties. For these patients, the use of specific psychopharmacologic agents may in fact correct the primary cause of their depression. There are a number of antidepressants to choose from for the treatment of depression pharmacologically. Among the tricyclic antidepressants, again doxepin is probably the most suitable for the treatment of depressed patients with neurotic excoriations. If the patient cannot tolerate the sedative side effect of doxepin, desipramine or one of the newer, nontricyclic antidepressants such as fluoxetine, sertraline, and paroxetine are alternatives.

Finally, for the obsessive–compulsive patient with neurotic excoriations, there are, once again, nonpharmacologic and pharmacologic therapeutic options. However, if the dermatologist were to follow a nonpharmacologic approach for patients who reject referral to a mental health professional, it would have to be a technique that is simple enough to perform in a dermatologic setting. One such technique is the invocation of a “1- or 5-minute rule,” a simple behavioral technique to try to interrupt the progression from obsessive thoughts to compulsive behavior. The patient is asked to try to put an interval of 1–5 min between the occurrence of the obsessive thought and the execution of the compulsive behavior. Once the patient is successful in refraining for 1 min, the time is gradually increased to 5, 10, or even 15 min, and, eventually, with such a long interruption between the obsessive thought and the compulsive behavior, one anticipates to break the natural progression from one to the other. In a dermatologic setting, the pharmacologic approach may be most feasible for patients who refuse to be referred elsewhere. Moreover, the recognition that serotonin pathways are involved and that the SSRI group of antidepressant agents reduces compulsive activity has made it more likely that the dermatologist will meet with success. Frequent short visits should be scheduled for supervision of the dermatologic regimen and for emotional support, and either clomipramine (an older antidepressant with extensive documentation about its anti-obsessive–compulsive efficacy in the medical literature) or one of the newer SSRIs (fluoxetine or fluvoxamine maleate) should be prescribed.

Patients with imaginary hair loss or psychogenic pseudoeffluvium are frightened of the possibility of going bald or are convinced they are going bald without any objective findings of hair loss. Basically they suffer from what Cotterill has termed “dermatologic nondisease.” Although dermatologists are used to seeing patients with minor skin and hair problems in significant body areas that cause disproportionate anxiety and cosmetic distress, with dermatologic nondisease, there is no dermatologic pathology.

The most common underlying psychiatric problems present are depressive disorder and body dysmorphic disorder. The clinical spectrum is wide, and the majority of patients are at the neurotic end of the spectrum and merely have overvalued ideas about their hair, whereas a minority of patients are truly deluded and suffer from delusional disorder. These patients lie at the psychotic end of the psychiatric spectrum. Those parts of the body that are important in body image are the focus of the preoccupation and concern.

True telogen effluvium resulting from androgenetic alopecia, telogen effluvium, or involutional alopecia must carefully be excluded.

A careful medical history, including medications, hormones, and crash diets, clinical examination of the hair and scalp (no alopecia, normal scalp), hair calendar (normal counts of hairs shed), trichogram (normal anagen and telogen rates), and laboratory work-up should be performed to exclude real effluvium and if necessary repeated.

In addition to the relentless complaint of hair loss, patients suffering from body dysmorphic disorder adopt obsessional, repetitive ritualistic behavior and may come to spend the majority of the day in front of a mirror, repeatedly checking their hair. Another aspect of this behavior is a constant need for reassurance about the hair, not only from the immediate family but also from the medical profession and from dermatologists in particular. These patients may become the most demanding types of patient to try to manage. The first step in the treatment is to establish a good rapport with the patient.

Patients with overvalued ideas may respond to a sympathetic and unpatronizing dermatologist.

Psychotherapy is aimed at any associated symptomatology of depression, regardless of whether there is a causal relationship between the psychiatric findings and the imagined hair loss, because it is possible that patients who are depressed perceive even normal hair shedding in an exaggerated manner.

Patients with anxiety related to the fear of hair loss may also benefit from anxiolytic therapy with alprazolam or buspirone.

Many different treatments have been advocated to treat patients with body dysmorphic disorder: a wide variety of psychotropic agents (including tricyclic antidepressants and benzodiazepines) and antipsychotic drugs (including pimozide and thioridazine) have been tried in this condition, with poor results. Although there have been no controlled clinical trials of the treatment of patients with body dysmorphic disorder, preliminary data indicate that SSRIs, such as fluoxetine and fluvoxamine maleate, may be effective, though the effective dosage of the SSRI drugs needs to be higher than the dosage conventionally employed to treat depression, and the duration of treatment is long term. Response to this group of drugs takes up to 3 months, and not all patients with body dysmorphic disorder will respond to treatment with SSRIs. In patients who fail to respond to SSRIs given for 3 months, it has been suggested to add either buspirone to the SSRIs or, if the patient has delusional body dysmorphic disorder, to add an antipsychotic agent such as pimozide.

Accordingly, following an initial consultation, it is common for a patient with body dysmorphic disorder to be given dermatologic treatment for alopecia. After repeated consultations with the patient, the dermatologist realizes that he or she is dealing with dermatologic nondisease. The result is often a frustrated dermatologist and a patient who eventually defaults from follow-up. The long and tough consultations, repeated telephone calls, and constant need for reassurance can put a significant strain on the dermatologist involved. Finally, a minority of patients with dysmorphic body disorder are angry, and these patients can direct this anger not only at themselves but also at the attending physician, with reproachful letters (Fig. 5.3), threats, and even physical violence. It is important not to reject these patients and treat them mechanistically, but to adopt an empathetic approach.

The prognosis depends on the underlying psychopathology, its appropriate treatment, and the attending physician’s capability to reassure and guide the patient.

The syndrome was first described on the occasion of a symposium on lifestyle drugs and aesthetic medicine and is named after Oscar Wilde’s famous gothic horror novel “The Picture of Dorian Gray,” in which the protagonist, a beautiful young aesthete, exclaims in front of his portrait:

Why should it keep what I must lose? Every moment that passes takes something from me, and gives something to it. Oh, if it were only the other way! If the picture could change, and I could be always what I am now! For that – for that – I would give everything! Yes, there is nothing in the whole world I would not give! I would give my soul for that!

The syndrome probably represents a variant of body dysmorphic disorder. Body dysmorphic disorder represents a condition in which sufferers are intensely preoccupied with an imagined or grossly exaggerated defect in some aspect of their physical appearance. They are more likely to consult physicians for correction of the “defect” than to seek help from mental health professionals. The particularity of the Dorian Gray syndrome is that patients wish to remain forever young and seek lifestyle drugs and surgery to deter the natural aging process (Table 5.2).

An estimated 3 % of the total population in Western society displays features of the syndrome. Disastrous results of excessive plastic surgery and cosmetic dermatologic procedures are found under www.​oddee.​com/​item_​96587.​aspx. Among the ten worst male celebrity examples are Michael Jackson (1958–2009) and Pete Burns (of “Dead or Alive”). If the defensive “acting out” character of the syndrome is not understood properly and the patient incessantly uses lifestyle products without understanding the underlying psychodynamics, a chronic state of narcissistic emptiness may develop. Depressive episodes and suicidal crisis are often observed if medical and surgical lifestyle treatments as means of defense are not sufficient to preserve the patient’s idea of beauty.

Beauty is an abstract concept and has been an object of interest and discussion both of philosophers since Ancient Greece and of evolutionary scientists. The earliest Western theory on beauty can be found in the records of early Greek philosophers from the pre-Socratic period, such as Pythagoras (570–495 BC). The Pythagorean school believed in a strong association between mathematics and beauty; in particular, they noted that objects proportioned according to the golden ratio seemed more attractive. Plato (428–348 BC) considered beauty to be the idea (form) above all other ideas. Aristotle (384–322 BC) saw a relationship between the beautiful and virtue, arguing that “virtue aims at the beautiful.” The classical Greek noun for beauty was kállos, and the Koine Greek word for beautiful was hōraios, an adjective etymologically coming from the word hōra, meaning “hour.” In Koine Greek, beauty was thus associated with “being of one’s hour.”

Youthfulness in particular marks an extended period of reproductive potential. Looking young may be more important than actually being young, and altering facial features in the direction of youth results in higher ratings of attractiveness.

In the 1990s, body image became one of the hottest topics covered by numerous professional textbooks and hundreds of journal articles. In a landmark publication, “Exacting Beauty,” Thompson et al. pointed out that at least 14 terms are used with reference to body image and that body image is akin to self–esteem. Thompson et al. suggested that body image has come to be accepted as the internal representation of our own outer appearance and plays a significant role in how people feel about both their appearance and themselves. While there is little agreement to the exact definition of body image, there is a consensus that body image is a multidimensional construct: perceptual influences account for an individual’s capacity to determine the physical features of a specific body part; developmental influences take the influence of childhood and adolescent experiences, such as appearance-related teasing, into consideration; and sociocultural influences relate to the interaction of the mass media and cultural ideas of appearance, which frequently portray unrealistic or exaggerated iconic images of beauty.

Sarwer et al. suggested that attitudes toward the body condition have two dimensions: The first consists of valence, defined as the degree of importance of body image to one’s self-esteem, and the second consists of value, which is understood as the degree of satisfaction or dissatisfaction with the body image. The theory of body image can be used to understand physical appearance concerns and the relentless pursuit of an improved body image through respective behaviors.

In contrast to the substantial literature on the psychology of physical appearance and attractiveness, relatively little has been published on the impact of androgenetic alopecia. In the earliest study, published in 1971, sketches of balding men were rated as weak, inactive, and least potent; those of bald men were considered as most unkind, bad, ugly, and hard; while men with a full head of hair were seen as most handsome, virile, and active. Because of the limited validity of a study design with sketches of men, Cash subsequently conducted a controlled study on the first impressions brought forth by photographs of 18 men with visible androgenetic alopecia compared with 18 men with a full head of hair, who were matched on age, facial expression, attire, and other physical features. Adults of both sexes judged balding men as older and less physically and socially attractive that their non-balding peers. When the physical attractiveness differences between balding and non-balding men were statistically removed, all other perceived differences disappeared as well.

Although androgenetic alopecia may initially influence social perceptions, the more important issue is whether hair loss affects the individual’s own psychological well-being and quality of life. Patients’ reactions to their hair loss relate more to self-perceptions of their alopecia than to objective clinical ratings. Extreme distress in some patients may involve body dysmorphic disorder, a condition in which sufferers are intensely preoccupied with an imagined or grossly exaggerated defect in some aspects of their physical appearance.

In delusions of parasitosis or Ekbom’s disease, there is an unshakable conviction that the skin is infested by parasites. In the older literature, this condition is also described as “parasitophobia” or “acarophobia.” However, the terms with “phobia” attached to them are misnomers and should be omitted, because in classic phobia, patients are aware of the fact that their fearful reactions are both excessive and irrational, while in the case of delusions of parasitosis, the patient is truly convinced of the validity of his or her perceptions.

In dermatologic practice, the type of delusional patient most frequently seen is the patient with a delusional ideation that revolves around only one particular hypochondriacal concern. These patients are said to suffer from monosymptomatic hypochondriacal psychosis. These patients are different from other psychotic patients, such as schizophrenics or patients with a major depression, since the latter have many deficits in mental functioning, which is not the case in patients with monosymptomatic hypochondriacal psychosis. Moreover, a delusional disorder appears to run distinct from schizophrenia and mood disorders and does not appear to be a prodrome to either of these conditions. From a nosological point of view, delusions of parasitosis are classified as a delusional disorder of the somatic type/with predominantly somatic delusions.