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Home , Delusional parasitosis, Pimozide, Psychodermatology

Psychodermatology: The Mind and Skin Connection JOHN KOO, M.D., University of California, San Francisco, Medical Center, San Francisco, California ANDREW LEBWOHL, University of California, San Francisco, School of Medicine, San Francisco, California

A psychodermatologic disorder is a condition that involves an interaction between the mind and the skin. Psychodermatologic disorders fall into three categories: psychophysiologic dis- orders, primary psychiatric disorders and secondary psychiatric disorders. Psychophysiologic disorders (e.g., and eczema) are associated with skin problems that are not directly connected to the mind but that react to emotional states, such as stress. Primary psychiatric disorders involve psychiatric conditions that result in self-induced cutaneous manifestations, such as trichotillomania and of parasitosis. Secondary psychiatric disorders are asso- ciated with disfiguring skin disorders. The disfigurement results in psychologic problems, such as decreased self-esteem, or social phobia. Most psychodermatologic disorders can be treated with anxiety-decreasing techniques or, in extreme cases, psychotropic . (Am Fam Physician 2001;64:1873-8. Copyright© 2001 American Academy of Family Physicians.)

sychodermatology, or psychocuta- neous medicine, focuses on the Classification boundary between and Psychodermatologic disorders can be . Understanding the broadly classified into three categories: psy- psychosocial and occupational chophysiologic disorders, primary psychiatric Pcontext of skin diseases is critical to the optimal disorders and secondary psychiatric disor- management of psychodermatologic disorders. ders.1 The term “psychophysiologic disorder” The management of psychodermatologic refers to a skin disorder, such as eczema or disorders requires evaluation of the skin man- psoriasis, that is worsened by emotional stress ifestation and the social, familial and occupa- (Figure 1). “Primary psychiatric disorder” tional issues underlying the problem. Once refers to a skin disorder such as trichotilloma- the disorder has been diagnosed, management nia, in which the primary problem is psycho- requires a dual approach, addressing both der- logic; the skin manifestations are self-induced. matologic and psychologic aspects. Even with “Secondary psychiatric disorders” affect self-induced skin problems, supportive der- patients with significant psychologic prob- matologic care is needed to avoid secondary lems that have a profoundly negative impact complications, such as infection, and to on their self-esteem and body image. Depres- ensure that the patient feels supported. sion, humiliation, frustration and social Patients with psychodermatologic disorders frequently resist referral to pro- fessionals. Acceptance of psychiatric treat- ment or consultation may be enhanced through support from the family physician. Management options include psychotropic , stress management courses and referral to a psychiatrist. Family physicians are well positioned to help patients with psycho- dermatologic disorders; these patients may be concerned about the stigma associated with FIGURE 1. Psoriasis, like atopic or psychiatrists, and family physicians are famil- other forms of eczema, is exacerbated by emo- iar with the use of psychotropic medications. tional stress in at least one half of patients.

DECEMBER 1, 2001 / VOLUME 64, NUMBER 11 www.aafp.org/afp AMERICAN FAMILY PHYSICIAN 1873 TABLE 1 Diagnoses Associated with Psychodermatologic Disorders

Major categories Examples

Psychophysiologic disorders Alopecia areata Atopic dermatitis therefore, treatment of recalcitrant patients Psoriasis with chronic dermatoses may be difficult Psychogenic purpura without addressing stress as an exacerbating Rosacea factor.5 Patients often are embarrassed about Seborrheic dermatitis discussing psychologic issues, especially if they Urticaria () feel hurried. Stress management classes, relax- Primary psychiatric Bromosiderophobia ation techniques, music or exercise may bene- disorders Delusions of parasitosis Dysmorphophobia fit these patients. If a specific psychosocial or Factitial dermatitis occupational issue exists, therapy or counsel- Neurotic excoriations ing can help. Trichotillomania When the patient’s stress or tension is Secondary psychiatric Alopecia areata intense enough to warrant consideration of an disorders Cystic acne anti-anxiety medication, two general types are Hemangiomas available. Benzodiazepines, which can be used Ichthyosis on an as-needed basis, provide relatively quick Kaposi’s sarcoma relief from anxiety, stress and tension.6 For Psoriasis treatment of chronic anxiety, selective sero- Vitiligo tonin reuptake inhibitors (SSRIs) are safe and effective. Other options for the treatment of chronic phobia may develop as a consequence of a dis- stress include nonsedating and nonaddictive figuring skin disorder.2 Table 1 lists common anti-anxiety agents such as (Buspar). diagnoses associated with the different cate- If a patient’s warrants psychi- gories of psychodermatologic disorders. atric referral, the referral should be discussed with the patient in a supportive and diplo- Psychophysiologic Disorders matic way so that the patient is able to accept Psychophysiologic disorders are conditions the referral as an adjunct to continuing der- that are frequently precipitated or exacer- matologic therapy. bated by emotional stress. Each of these con- ditions has “stress responders” and “non-stress Primary Psychiatric Disorders responders,” depending on whether a Primary psychiatric disorders are encoun- patient’s skin disease is or is not frequently tered less often than psychophysiologic and predictably exacerbated by stress. The disorders. proportion of stress responders depends on the dermatologic diagnosis involved, as illus- DELUSIONS OF PARASITOSIS trated in Table 2.3 Delusions of parasitosis belongs to a group In patients with treatment-responsive skin of disorders called “monosymptomatic hypo- conditions such as eczema, psoriasis and acne, chondriacal .”Patients with the latter the issue of stress may not be important.4 disorder present with isolated delusions However, when physicians are faced with dis- regarding a skin complaint.6 Because the ease recalcitrant to treatment, patients should nature of the is truly iso- be asked whether psychologic, social or occu- lated, these disorders are quite different from pational stress might be contributing to the , which involves multiple func- skin disorder. tional deficits, including auditory hallucina- Emotional stress may exacerbate many tions, lack of social skills and flat affect, in chronic dermatoses and can initiate a vicious addition to delusional ideation.7 cycle referred to as the “-scratch cycle”; The most common form of monosympto-

1874 AMERICAN FAMILY PHYSICIAN www.aafp.org/afp VOLUME 64, NUMBER 11 / DECEMBER1, 2001 TABLE 2 Stress Responders Associated with Dermatologic Diagnoses

The rightsholder did not grant rights to reproduce FIGURE 2. Delusions of parasitosis—the “match- box sign.” Patients with delusions of parasitosis this item in electronic often try to bring specimens to the physician as media. For the missing proof that they have an infestation. item, see the original print version of this publication. called (Orap). Pimozide is similar to (Haldol) in chemical structure and potency, and has been shown to be uniquely effective in the treatment of this con- dition, especially in decreasing .10 This medication has been labeled by the U.S. Food and Drug Administration (FDA) for the treatment of Tourette’s syndrome; its use in the treatment of delusions of parasitosis is off- label. The dosage of pimozide for treatment of delusions of parasitosis is much lower than that used for chronic schizophrenia. Pimozide matic hypochondriacal psychosis encountered therapy is generally started at the lowest possi- among patients with skin problems is called ble dosage of one half of a 2-mg tablet (i.e., delusions of parasitosis.8 Patients with delu- 1 mg) daily and increased by 1 mg per week.11 sions of parasitosis firmly believe that their By the time the usual daily dosage of 4 to 6 mg bodies are infested by some type of organism. (i.e., 2 to 3 tablets) is reached, most patients Frequently, they have elaborate ideas about have experienced a decrease in crawling and how these “organisms” mate, reproduce, move biting sensations, as well as in the sensations of around in the skin and, sometimes, exit the “organisms” moving in their skin. Optimal skin. These patients often present with the therapeutic effect may not occur for 6 to “matchbox” sign, in which small bits of excori- 8 weeks. During the treatment course, patients ated skin, debris or unrelated insects or insect become less agitated. parts are brought in matchboxes or other con- In younger patients, pimozide can be con- tainers as “proof” of infestation (Figure 2). tinued at the lowest effective dosage for several The psychiatric differential diagnosis months and gradually tapered off without includes schizophrenia, psychotic depression, necessarily inviting the recurrence of symp- psychosis in patients with florid mania or toms. If the condition recurs, another course drug-induced psychosis, and formication of therapy with pimozide can be instituted.11 without , in which the patient experi- In elderly patients, long-term maintenance ences crawling, biting and stinging sensations with low dosages of pimozide (1 to 2 mg per without believing that they are caused by day) is sometimes required. Tardive dyskine- organisms.6 Other organic causes such as with- sias can occur, but with low-dose (6 mg per drawal from , or alco- day or less) intermittent usage, the risk is less- hol, , multiple sclerosis, ened. In patients with cardiac arrhythmias, cerebrovascular disease or should also advanced age or dosages of more than 10 mg be considered. If any of these underlying per day, serial electrocardiography is required. causes are diagnosed, a separate diagnosis of As with other agents, extra- delusions of parasitosis should not be made.9 pyramidal side effects (i.e., pseudo-parkin- The treatment of choice for delusions of sonian effects) may develop with the use of parasitosis is an antipsychotic medication pimozide.12 Stiffness and restlessness respond

DECEMBER 1, 2001 / VOLUME 64, NUMBER 11 www.aafp.org/afp AMERICAN FAMILY PHYSICIAN 1875 Patients with delusions of parasitosis frequently bring small bits of excoriated skin, debris or insect parts to their physi- cian as proof of infestation.

to benztropine (Cogentin), in a dosage of 2 mg up to four times per day, as needed. (Benadryl), in a dosage of 25 mg up to three times per day as tolerated and needed, may be substituted. The challenge in managing patients with FIGURE 3. Neurotic excoriation. This man delusions of parasitosis is in introducing the became severely depressed when a stroke par- use of an antipsychotic medication without alyzed his right arm. He then used his func- offending the patient. This step requires a del- tional arm to induce skin lesions. icate balance between the patient’s right to informed consent and the goal of pursuing which the patient uses something more elabo- the most appropriate therapy. The authors rate than the fingernails, such as burning cig- recommend a sensitive, empathic and diplo- arettes, chemicals or sharp instruments, to matic approach. The medication should be damage his or her own skin.13 presented as a “therapeutic trial,”and any con- The most common underlying psycho- tentious argument regarding the pathogenesis pathologies are major depressive episodes, of the disorder or the mechanism of action of anxiety and obsessive-compulsive disorders. pimozide should be purposely avoided. Rarely, patients excoriate their skin in Encouragement suggesting that pimozide response to delusional ideation; in such cases, may “help one focus less on the skin and more the appropriate diagnosis would be psychosis. on enjoying life” may help. Because the FDA- Patients with neurotic excoriations usually labeled use of pimozide in the United States is have depression or anxiety, whereas those with for treatment of Tourette’s syndrome and not factitial dermatitis often have other psychi- psychosis, there is less stigma attached to this atric illnesses. Borderline personality disorder medication than other antipsychotic agents. is just one of the more serious diagnoses asso- ciated with factitial dermatitis. NEUROTIC EXCORIATIONS, FACTITIAL If the patient has underlying depression DERMATITIS AND SKIN LESIONS IN RESPONSE that results in neurotic excoriations, one anti- TO A DELUSIONAL BELIEF depressant frequently used by dermatologists The terms “neurotic excoriations” and “psy- is (Sinequan). Doxepin is a chologic excoriations” are used when patients with one of the most powerful self-inflict excoriations (scratch marks) with anti-itch and antihistaminic effects, as well as their fingernails. Factitial dermatitis (dermati- sedative/tranquilizing effects. Because many tis artefacta) generally refers to a condition in people with depression who excoriate their skin are agitated (i.e., have “agitated depres- sion”), the sedative and tranquilizing effects of doxepin frequently prove to be therapeu- The Authors .14 Moreover, the profound antipruritic JOHN KOO, M.D., is director of the Psoriasis and Skin Treatment Center and Pho- effect of this drug is an added benefit. totherapy Unit and associate clinical professor and vice chairman for the department Although these patients create their own skin of dermatology at the University of California, San Francisco, Medical Center. He lesions as they continue to pick at their skin, earned his medical degree from Harvard Medical School, Boston, and served a resi- dency in psychiatry at the University of California, Los Angeles, Neuropsychiatric Insti- not allowing it to heal, the “itch-scratch cycle” tute, and a residency in dermatology at UCSF. may create intensely itchy patches that can ANDREW LEBWOHL is a research assistant at the University of California, San Fran- benefit from the antipruritic effect of doxepin cisco, School of Medicine. (Figures 3, 4 and 5). Address correspondence to John Koo, M.D., Psoriasis Treatment Center, 515 Spruce The use of doxepin requires the usual pre- St., San Francisco, CA 94118. Reprints are not available from the authors. cautions taken with older tricyclic antide-

1876 AMERICAN FAMILY PHYSICIAN www.aafp.org/afp VOLUME 64, NUMBER 11 / DECEMBER1, 2001 FIGURE 4. Neurotic excoriation. Self-induced FIGURE 5. Neurotic excoriation. The patient skin lesions often have a bizarre appearance shown in Figure 3 after successful treatment without evidence of primary skin disorder. with an antidepressant. When the underlying psychopathology resolved, the patient stopped excoriating his skin. pressants. This includes carefully limiting the amount of medication that may be dispensed at one time to minimize the risk of suicide. A skin can be diagnostic. The hair root under- detailed description is beyond the space avail- goes a unique change called trichomalacia, able in this article; however, it should be men- which only occurs in patients with trichotillo- tioned that if the patient is truly depressed, mania.18 Thus, if the patient continues to deny adequate dosages of are pulling his or her own hair, a skin biopsy can required to prevent undertreatment of the be helpful in determining the diagnosis. patient. Elderly patients may respond to lower As with other conditions, the treatment of dosages. SSRIs may also be used.15 trichotillomania is based on the nature of the underlying psychopathology. Because the TRICHOTILLOMANIA most commonly encountered underlying psy- Trichotillomania, according to the dermato- chopathogy is obsessive-compulsive tendency, logic use of the word, is a condition in which a medications such as (Prozac), person pulls out his or her own hair. The psy- (Paxil), (Zoloft), fluvox- chiatric definition of trichotillomania requires amine (Luvox) and (Anafranil), the presence of “impulsivity.”16 However, using in dosages appropriate for the treatment of the less specific dermatologic definition, the obsessive-compulsive disorder, can be helpful physician once again must ascertain the nature in the pharmacologic management of tri- of the underlying psychopathology to select chotillomania.19 It should be noted that the the most appropriate treatment. anti–obsessive-compulsive dosage for any of The most common underlying psycho- these medications tends to be higher than the pathology is obsessive-compulsive behavior, antidepressant dosage. The nonpharmaco- whether or not it formally meets the criteria of logic approach includes , which the Diagnostic and Statistical Manual of Men- may be useful if the patient has a definable tal Disorders, 4th ed., for obsessive-compulsive issue that can be discussed. Behavior therapy disorder.17 The other possible underlying psy- is another treatment modality. chiatric diagnoses include simple habit disor- der, reaction to situational stress, mental retar- Secondary Psychiatric Disorders dation, depression and anxiety, as well as Although skin conditions are usually not life- extremely rare cases of delusion in which the threatening, because of their visibility they can patient pulls out his or her hair based on a be “life-ruining.” Persons with disfigurement delusional belief that something in the roots frequently feel psychologically and socially needs to be “dug out” so the hair can grow normally. This latter, rare condition is called “trichophobia.” The differential diagnosis of Patients with neurotic excoriations or factitial dermatitis trichotillomania includes pseudopelade, should receive a limited supply of tricyclic antidepressants alopecia areata, syphilis and tinea capitis. Trichotillomania is one of the rare condi- because of the risk of overdose. tions in which pathologic examination of the

DECEMBER 1, 2001 / VOLUME 64, NUMBER 11 www.aafp.org/afp AMERICAN FAMILY PHYSICIAN 1877 REFERENCES FIGURE 6. Psychologic impact of disfigure- 1. Koo JY. Psychodermatology: a practical manual for ment. This student with treatment-resistant clinicians. Cur Prob Dermatol 1995;6:204-32. cystic acne became severely depressed and 2. Koo JY. Psychotropic agents in dermatology. Der- matol Clin 1993;11:215-24. refused to go to school; he had been a top 3. Griesemer RD. Emotionally triggered disease in a der- student before the onset of acne. matology practice. Psychiatr Ann 1978;8:49-56. 4. Gaston L, Lassonde M, Bernier-Buzzanga J, Hod- gins S, Crombez JC. Psoriasis and stress: a prospec- devastated as a result (Figure 6). Moreover, per- tive study. J Am Acad Dermatol 1987;17:82-6. 5. Iyer S, Washenik K, Shupack J. Can psychological sons with skin disorders have trouble getting stress affect psoriasis? Possible mechanisms. J Clin jobs in which appearance is important.20 It is Dermatol 1988;1(5):21-8. 6. Koblenzer CS. Psychocutaneous disease. Orlando: also well documented that persons with visible Grune & Stratton, 1987:77-8,117. disfigurement face discrimination, especially if 7. American Psychiatric Association. Diagnostic and the condition is perceived to be contagious.21 statistical manual of mental disorders. 4th ed. Washington, D.C.: American Psychiatric Associa- Even though many patients adjust to their tion, 1994:147. skin disease, if the physician notes that the 8. Munro A. Monosymptomatic hypochondriacal psy- patient is experiencing significant distress it is chosis. Br J Psychiatry 1988;2(suppl):37-40. 9. Koo J. Skin disorders. In: Kaplan HI, Saduck BJ, eds. important to explore this issue and decide Comprehensive textbook of psychiatry. 6th ed. Bal- whether referral to a mental health profes- timore: Williams & Wilkins, 1995. 10. Srinivasan TN, Suresh TR, Jayaram V, Fernandez MP. sional or dermatologic support group might Nature and treatment of : a help. If the depression, social phobia or sec- different experience in India. Int J Dermatol ondary psychopathology is of significant 1994;33:851-5. 11. Damiani JT, Flowers FP, Pierce DK. Pimozide in delusions intensity, referral to a psychiatrist may be war- of parasitosis. J Am Acad Dermatol 1990;22:312. ranted. Table 3 lists contact information for 12. De Leon OA, Furmaga KM, Canterbury AL, Bailey LG. in the treatment of delusions of some dermatologic support groups. infestation. Int J Psychiatry Med 1997;27:403-9. 13. Koblenzer CS. Dermatitis artefacta: clinical features The authors indicate that they do not have any con- and approaches to treatment. Am J Clin Dermatol flicts of interest. Sources of funding: none reported. 2000;1:47-55. 14. Harris BA, Sherertz EF, Flowers FP. Improvement of chronic neurotic excoriations with oral doxepin therapy. Int J Dermatol 1987;26:541-3. TABLE 3 15. Phillips KA, Taub SL. Skin picking as a symptom of Contact Information for Dermatologic Support Groups body dysmorphic disorder. Psychopharmacol Bull 1995;31:279-88. 16. Stein DJ, Mullen L, Islam MN, Cohen L, DeCaria National Psoriasis Foundation National Eczema Association for CM, Hollander E. Compulsive and impulsive symp- 6600 SW 92nd Ave., Suite 300 Science and Education tomatology in trichotillomania. Psychopathology 1995;28:208-13. Portland, OR 97223 1220 SW Morrison, Suite 433 17. McElroy SL, Phillips KA, Keck PE. Obsessive com- Ph: 503-244-7404 or 800-723-9166 Portland, OR 97205 pulsive spectrum disorder. J Clin Psychiatry 1994; Web: http://www.psoriasis.org Ph: 503-228-4430 55 (suppl):33-53. or 800-818-7546 18. Lachapelle JM, Pierard GE. Traumatic alopecia in National Alopecia Areata Foundation Web: http://www.eczema-assn.org trichotillomania: a pathogenic interpretation of his- 710 “C” St., Suite 11 tologic lesions in the pilosebaceous unit. J Cutan San Rafael, CA 94901 Obsessive-Compulsive Foundation Pathol 1977;4:51-67. Ph: 415-456-4644 337 Notch Hill Rd. 19. Keuthen NJ, O’Sullivan RL, Goodchild P, Rodriguez Web: http://www.alopeciaareata.com North Branford, CT 06471 D, Jenike MA, Baer L. Retrospective review of treat- Ph: 203-315-2190 ment outcome for 63 patients with trichotilloma- National Vitiligo Foundation Web: http://www.ocfoundation.org nia. Am J Psychiatry 1998;155:560-1. P.O. Box 6337 20. Ginsburg IH, Link BG. Psychosocial consequences 611 South Fleishel Ave. of rejection and stigma feelings in psoriasis Tyler, TX 75701 patients. Int J Dermatol 1993;32:587-91. Ph: 903-531-0074 21. Love B, Byrne C, Roberts J, Browne G, Brown B. Adult psychosocial adjustment following childhood Web: http://www.vitiligofoundation.org injury: the effect of disfigurement. J Burn Care Rehabil 1987;8:280-5.

1878 AMERICAN FAMILY PHYSICIAN www.aafp.org/afp VOLUME 64, NUMBER 11 / DECEMBER1, 2001