Dermatitis artefacta. This condition involves self-inflicted skin lesions that the patient typically denies. The lesions are usually bilateral and within easy reach of the dominant hand. The lesions may have bizarre shapes with sharp geometrical or angular boundaries. They may appear as burns, purpuric lesions, blisters, ulcers, erythema, and edema. Patients may induce lesions by rubbing, scratching, picking, cutting, sucking, and biting, or by applying dyes, heat, or caustics.
Eating disorders. Patients with anorexia nervosa or bulimia nervosa may exhibit various skin signs and symptoms that provide clues to physicians in making a diagnosis in these complex cases (Table 2). Dermatological signs and symptoms are primarily the results of starvation; malnutrition; self-induced vomiting; and the use of laxatives, emetics, or diuretics.
Various psychotropics can cause dermatological adverse effects (Table 3). SSRIs, tricyclic antidepressants (TCAs), mood stabilizers, and antipsychotic medications have been implicated in several cutaneous adverse effects that mimic typical skin disease. A sound knowledge of psychiatric medications and their cutaneous adverse effects is important in the management of psychiatric conditions. In addition, patients should be advised about the adverse-effect profiles of all treatment drugs.
Cutaneous adverse effects of antidepressants include toxic epidermal necrolysis, Stevens-Johnson syndrome, leukocytoclastic vasculitis, and erythema on sun exposed areas. Lithium(Drug information on lithium), which is commonly used in the treatment of bipolar disorder, may cause several dermatological adverse effects.5 Antidepressants have been used as off-label medications in various psychodermatological disorders. Corticosteroids used in dermatological disorders may cause psychiatric symptoms, such as cognitive impairment, mood disorders, depression, delirium, and psychosis.
Psychiatric disturbances as a result of dermatological medications are still not fully understood. Isotretinoin(Drug information on isotretinoin), which is used in severe recalcitrant acne, has been implicated in depression, suicidal ideation, and mood swings. There are conflicting reports about the relationship between isotretinoin and depression and suicide. The exact causal role has not been established, and caution is recommended when treating patients with isotretinoin.
Treatment approaches
The mainstays of treatment for psychodermatological disorders are an empathetic approach toward the patient; a good physician-patient relationship; and a team approach with psychiatrists, dermatologists, therapists, and social services. The treatment goal is to improve functioning; reduce physical distress; improve sleep disturbances; and manage psychiatric symptoms, such as anxiety, depression, social withdrawal/isolation, and low self-esteem.
Both pharmacological and nonpharmacological treatment are used to manage cutaneous disorders. The medications include antidepressants, antianxiety medications, antipsychotics, and topical skin preparations. The choice of a psychopharmacological agent depends on the nature of the underlying psychopathology (anxiety, depression, psychosis, compulsion). SSRIs and TCAs exert their effects through antihistaminic, anticholinergic, and serotonin blocking properties.
Antipsychotics may be used to augment medications or as monotherapy, particularly in patients with delusions of parasitosis and, more recently, in trichotillomania.6 Other psychiatric drugs used in the psychodermatological setting include gabapentin(Drug information on gabapentin) (postherpetic neuralgia), pimozide (delusions of parasitosis), topiramate(Drug information on topiramate) and lamotrigene (skin picking), and naltrexone(Drug information on naltrexone) (pruritus). Recently N-acetylcysteine and aripiprazole(Drug information on aripiprazole) have been used successfully in treating trichotillomania.6,7 These drugs have been used as evidence-based medications and in research trials, although not all are FDA-approved as psychodermatological treatments.
Several nonpharmacological treatments have also been used in patients with psychocutaneous disorders.8 Supportive psychotherapy, CBT, hypnosis, relaxation training, biofeedback, stress management, and guided imagery have all been employed successfully.
Conclusion
Skin diseases are not just a cosmetic issue; they are associated with a variety of psychological reactions that affect patients’ level of functioning and can produce agony for the family. An increased awareness about psychocutaneous disorders and a team approach to treatment lead to improved patient outcomes. Separate psychodermatology clinics, training opportunities for physicians and residents in psychiatry and dermatology residency programs, and family education are some of the important methods to improve better understanding and management of psychocutaneous disorders.
