2. INTRODUCTION
• Psychodermatology : complex interaction between the brain, the cutaneous
nerves, the cutaneous immune system and skin
• Approximately 30–40% : underlying psychiatric /psychological problem that
either causes or exacerbates a skin complaint.
• Affected by stress and psychological events.
3. PATHOGENESIS
• Brain, nerve, and skin are embryologically derived from the neural plate in the
ectoderm.
• The neuro-immuno-cutaneous-endocrine model was proposed by O’Sullivan et al.
to explain the mind and body relationship.
4.
5. SKIN-PSYCHE INTERACTION
• Primary cutaneous disorder influenced by psychological factors :Psoriasis
• Primary psychiatric disease presenting to dermatologist : Delusional infestation,
Body dysmorphic disorder
• Psychiatric illness developing as a result of skin disease : Depression, Anxiety or
both
• Co-morbidity of skin disease with another psychiatric disoder: Alcholism
7. 1. PSYCHO-PHYSIOLOGIC DISORDERS
• Course of a given skin disease is affected by the psychological state of a patient
• Precipitated or exacerbated by emotional stress and/or anxiety
• Percentage of patients presenting with exacerbation with stress-
DISEASE % OF PATIENTS
Psoriasis 54-60
Acne 50
Alopecia areata 60
Rosacea 58
Urticaria 16
Vitiligo vulgaris 47
8. • Other skin disorders exacerbated by stress are atopic dermatitis, hyperhidrosis,
and chronic telogen effluvium
• Nonpharmacological as well as pharmacologic therapy such as with
benzodiazepines (BZD) and selective serotonin reuptake inhibitors (SSRIs) are
helpful.
• In non-responders, a psychiatric referral is required
9. 2. PRIMARY PSYCHIATRIC DISORDERS WITH DERMATOLOGIC
SYMPTOMS
• Primary pathology is psychological, and skin complaints are self-induced and
secondary.
• Disorder of dermatological beliefs Delusion of parasitosis
• Disorder of body awareness Body dysmorphic disorder
• Eating disorders Anorexia nervosa, bulimia nervosa, Eating disorders not otherwise
specified (EDNOS)
• Impulse control disorder Trichotillomania, neurotic excoriations, acne excoriee, neurodermatitis,
onychotillomania, prurigo nodularis
• Factitious skin diseases Dermatitis artefacta, dermatitis simulata, dermatitis passivata
• Psychogenic pruritus
• Cutaneous phobias Mole phobia, venereophobia, wart phobia, and steroid phobia
10. DELUSION OF PARASITOSIS
• Patient develops an impervious belief that their bodies are infested with parasites.
• Patients present with-
• Visual and tactile hallucinations
• Excoriations are usual, sometimes, extensively produced in an attempt to
extricate the organism.
• They often present an evidence of parasite infection in the form of clothing
lint, skin crust, or debris, which were misinterpreted as parasite parts, larva,
ova, or the entire organism.
11.
12. • MORGELLON’S DISEASE –
• a variant where there is itching,
stinging or biting sensation
• Sores that do not heal
• fixed belief that fibers are embedded
in the skin and body
• with associated joint and muscle pain
and fatigue.
• Cognitive dysfunction
13. BODY DYSMORPHIC DISORDER
• Patient is preoccupied and distressed with an imagined defect in appearance or
an excessive concern over a trivial defect.
• “Rich in symptoms but poor in signs” – no perceptible deformity to physician.
• Women complain of – face, breast, hair, nose, stomach, weight
• Males- hair, nose, ear, genitals, body-built
• Doctor-shoppers – repeatedly undergo procedures to find solution for their flaws
and mostly dissatisfied with results and consultation.
• Underlying co-morbid psychiatric disorder present.
• suicidal tendency is common.
14. ANOREXIA NERVOSA
• Female predominant (9:1)
• Associated depression, anxiety, alcohol and substance abuse
• Patient –
• Extremely restricts calorie intake
• Indulges in excessive exercise
• Occasional purging
• Cutaneous manifestations-
Frequent signs-
• Xerosis
• Alopecia
• Fragile nail and hair
• Caries teeth
Guiding signs-
• Russel’s sign – callosities over knuckles of dominant hand due
to constant friction with incisors while inducing gag reflex.
• Hypertrichosis
• Swollen salivary glands
• Self induced dermatitis
• Perimylolysis
15. COMPLICATIONS-
• Slow wound healing
• Deficiency disorders – pellagra, acrodermatitis enteropathica, anemia & hairloss
(secondary to iron deficiency)
• Growth retardation
• Amenorrhoea
• Decreased intestinal motility and abdominal distension
• Pancreatitis
• Frequent vomiting can lead to – gastroesophageal reflux, esophagitis and frequent
sore throats.
• Osteopenic fractures
16. TRICHOTILLOMANIA
• morbid craving/impulsivity to pull out hairs.
• Diagnostic criteria –
• Recurrent pulling out of one’s own hair resulting in hairloss
• Increasing sense of tension before pulling out the hair
• Pleasure, gratification or relief when pulling out hair
• The disturbance is not better accounted for by another mental disorder
• The disturbance provokes clinically marked distress and/or impairment
in occupational or social life
17. • C/F-
• Repeated hair pull causes traumatic alopecia.
• Hair plucking – from scalp (MC), eyebrows, eyelashes (rarely)
• Plucked hairs – stroked / licked /chewed /swallowed
• Hair loss – can be minimal to extensive
• Hairs – short, broken, distorted, irregular in length
regrowing stubby hair.
• Clinically – 3 zones are present in the scalp
• Zone 1 – uninvolved hair
• Zone 2 – missing hair due to recent pulling
• Zone 3 – regrowing short hair of various lengths
19. • COMPLICATIONS –
• Scarring hair loss
• Folliculitis
• keloid formation
• Trichobezoar
• The Rapunzel syndrome
• TREATMENT –
• 1st line –
• of the habit – Habit reversal, other CBT
• Of the hair loss – hair weaves, hair extensions, t/t for iron deficiency
• 2nd line – mood stabilizers ( like Gabapentin & Pregabalin)
• 3rd line – antipsychotics, topiramate, phototherapy
20. NEUROTIC EXCORIATIONS
• characterized by irresistible urge to scratch the skin accompanied by visible tissue
damage and functional impairment.
• psychosocial stress precedes exacerbation in around 30–90% cases.
• involve picking, pulling, poking, prodding, squeezing, or tearing of the skin.
• Can be episodic / irregular / constant.
• lesions are polymorphic.
• Newer lesions - angulated excoriated crusted erosions
• Older lesions - depigmented scarred center &
hyperpigmented periphery
• Prurigo nodularis - extreme variant of this entity
• Distribution of lesions – over most accessible sites (self- inflicted)
• Differentiated from dermatitis artefacta by its conscious and compulsive nature.
22. ACNE EXCORIEE
• variant of neurotic excoriation where patients either have only facial or predominant
facial involvement.
• common in females
• Associated with psychiatric co-morbidity..
• Predominantly around the hairline, forehead,
preauricular cheek, and chin areas
• C/F –
• Lesions resemble chronic excoriations
• They are excoriated until ‘emptied’
• Chronic lesions- show white atrophic scarring with peripheral hyperpigmentation
• Acneiform lesions present
24. DERMATITIS ARTEFACTA
• A factitious disorder leading to deliberately and consciously self-inflicted injuries aimed
at satisfying unconscious emotional needs.
• Seen in adolescents and young adults mostly
• F:M = 3:1 – 20:1
• Cardinal features
• Hollow and vague history
• Bizzare morphology of lesions ,
confined to accessible areas.
• Face > dorsum of hands & forearm
• Lesions-
• Polymorphic, bizzare
• Clearly demarcated from surrounding normal skin
• Crude, angulated
• Have tendency for linear configuration
• Can resemble inflammatory reactions on skin.
25. • DERMATITIS SIMULATA-
• Patients use external disguise to simulate apparent skin disease.
• Make up- used to paint on a rash / simulate a birth-mark
• Glue or crystallized sugar – produce a coagulum simulating desquamating rash
• Topical printing dyes – to produce discoloured sweat
• These discolourations can be removed by aqueous / alcohol swabs.
• DERMATITIS PASSIVATA-
• Lesions are result of self-neglect.
• Cessation of normal skin cleansing will cause accumulation
of keratinous crusts and dirty debris.
• Usually found in – elderly- upper central chest, back, groin
• young – scalp, face or arms
26. PSYCHOGENIC PRURITUS
• Patient has intractable or persistent itch, not ascribed to any physical or
dermatological illness.
• May be generalized (pruritus sine materia) or localized as genital or anal itch.
• SUBTYPES- compulsive / impulsive / mixed
• Detailed cutaneous and systemic examination to rule out
• cutaneous ( atopic dermatitis, psoriasis, lichen planus, dermatitis
herpetiformis, etc) and
• systemic (hyperbilirubinemia, chronic renal failure, diabetes mellitus, etc )
causes of pruritus before diagnosing psychogenic pruritus.
27. • Diagnostic criteria- 3 compulsory criteria:
• Localized or generalized pruritus
• Chronic pruritus (>6 weeks)
• Absence of a somatic cause
• MC sites- legs, arms, back and genitals
• Pruritic episode-
• Unpredictable with abrupt onset and termination
• Predominantly during relaxation
• Quality of itch may be unusual – crawling /stinging/ burning
28. 3. SECONDARY PSYCHIATRIC DISORDERS-
• Includes dermatological diseases with secondary psychiatric symptoms which include
depression, anxiety, dysthymia, obsession and adjustment disorders.
• Psoriasis –
• leads to significant psychosocial disability in patients.
• Patient suffer from poor body image, live in a constant fear of relapse & avoid social interactions.
• Vitiligo -
• Moderate to severe restriction while participating in domestic and social life
• Low self-esteem, anxiety and embarrassment when meeting strangers.
• Alopecia areata-
• Have a major impact on psychosocial wellbeing of patients.
• a/w high psychiatric co-morbidities mainly adjustment disorder & depressive disorder.
• Atopic dermatitis-
• High levels of anxiety and depressive symptoms
• Pruritus severity is directly related to presence of depressive symptoms.
29. CUTANEOUS DYSETHESIA
• Pain is the predominant symptom
• Not explained by a somatic cause/ psychiatric disorder
• It includes-
• Orodynia & glossodynia –
upto 50% cases have deviating personality types
• Trichodynia –
>70% cases have a/w anxiety, depression, compulsive disorders
• Vulvodynia and phallodynia-
genital pain is usually persistent
Pulling in nature
10% cases of vulvodynia have h/o sexual abuse
30. PSYCHOGENIC PURPURA SYNDROME
• Also known as Gardner Diamond Syndrome
• Patients present with bizzare, recurrent, tender purpuric and ecchymotic patches
on extremities, either spontaneously or after following minor trauma, physical or
mental stress.
• More commonly in emotionally unstable middle aged females.
• Causes-
• Abnormalities in neuro-immuno-cutaneous- endocrine network
• Hypersensitivity reaction to extravasated RBCs
• Autoimmunity
• Increased fibrinolysins in the blood
• a/w – neurological and ocular problems, headache, nausea, vomiting and other
hemorrhagic manifestations and psychological co-morbidities.
• Diagnosis – by Auto erythrocyte sensitization test
31. MANAGEMENT OF PSYCHOCUTANEOUS
DISORDERS
• Treatment of dermatological + psychopathological condition
• 1. Psycho-physiologic disorders - non-pharmacological therapies that counteract
stress, supplemented by anxiolytics, or antidepressants when indicated.
• 2. Primary psychiatric disorders –
• psychotropic therapy is the mainline of treatment and somatic modalities are
supportive.
• necessary to start both somatic (i.e., dermatologic) and psychotropic treatment
simultaneously in these patients
• 3. Secondary psychiatric disorders - approach is treating the dermatoses by using
a potent therapeutic option because of the great emotional distress suffered by the
patient
32. Non-pharmacological interventions
1. Behaviour therapy-
a) Systemic desensitization – to overcome phobias and anxiety disorders
b) Modeling
c) Relaxation / BIOFEEDBACK-
• helps in reducing anxiety
• Includes- breathing practice, hypnosis, massage therapy, meditation, music therapy
• useful in skin disorders that have an autonomic nervous system component, such as
biofeedback of galvanic skin resistance (GSR) for hyperhidrosis and biofeedback
of skin temperature for Raynaud’s syndrome
33. d) Habit reversal-
• Has 3 main components –
• Habit awareness training
• Relaxation training
• Replacement behaviour training
• Used to address repetitive behaviour disorders – acne excoriee,
trichotillomania
2. Group therapy-
• Psycho-education
• Social and assertiveness skills training
• Role play
34. 3. Cognitive behaviour therapy(CBT)-
• Problem solving
• Cognitive restructuring
• Modeling and guided imagery
4. Psychodynamic therapy-
• Past regression- patient by means of hypnosis is made to recall childhood
suppressed memories of traumatic events, thus acting as mental release
phenomenon.
• Hypnotherapy – guiding a patient to a trance state for a specific purpose i.e.
relaxation or habit modification.
36. Pharmacotherapy
• The choice of a psychotropic medication is based primarily on the nature of the
underlying psychopathology, broadly categorized under four diagnoses:
• (a)Anxiety, (b) depression, (c) psychosis, and (d) OCD.
• ANXIETY-
• Therapeutic modalities for anxiety include BDZ, non-BDZ, and CBT.
• BDZ - indicated only for short-term treatment (2–4 weeks) for severe and disabling
symptoms and should be avoided in milder forms.
• Non-BDZ used are-
• selective SSRIs – Citalopram, escitalopram, paroxetine
• SNRIs - Venlafaxine, duloxetine
• Antihistamines - Hydroxyzine
• Beta-blockers - Propranolol
• Antiepileptic - Pregabalin
• Antidepressants
37. DEPRESSION
• Depression can be a PPsD or secondary to dermatological condition.
• Treatment depends on the severity of symptom
• Mild - watchful waiting or CBT
• Moderate - SSRI and CBT
• Severe with suicidal ideation - admission, antidepressants with
electroconvulsive therapy (ECT)
• Antidepressants –
• clinical response is gradual
• usually begins 2–3 weeks after the therapeutic dosage is reached,
• for complete therapeutic effectiveness minimum of 6 weeks of full-dose
treatment is required.
38. PSYCHOSIS
• Antipsychotics are used in the therapy of psychocutaneous disorders such as
delusions of parasitosis, dermatitis artefacta, and monosymptomatic
hypochondriasis.
• Risperidone, olanzapine, quetiapine, aripiprazole, zisperidone
• Second-generation antipsychotics are considered the treatment of choice for patients
with psychosis, because of a better side effect profile and compliance.
• Main side-effects are sedation and weight gain (aripiprazole and ziprasidone are
least likely to cause these effects)
• Risperidone and olanzapine are useful in patients who are rapidly deteriorating
or have a severe negative effect on the quality of life.
39. OBSESSIVE- COMPULSIVE DISORDERS
• Disorders like BDD and impulse control disorder (acne excoree, trichotillomania,
onychotillomania, neurodermatitis) are treated on the lines of OCD.
• SSRIs—fluoxetine, paroxetine, and sertraline- first-line therapy for the
management of OCD.
• Patients - require higher doses and more time to respond than those with
depression.
• Initial response may require up to 4–8 weeks, and maximal response may take 20
weeks.
• Therapy should be continued for at least 6 months to 1 year once a therapeutic
response is achieved.
• Medications require slow tapering during discontinuation and restarted if
symptoms reappear.
• Behavioral modification is the cornerstone in the management of OCD, therefore,
the most effective treatment is a combination of medication and CBT
