Mohammad Jafferany Psychodermatology: A Guide to Understanding Common Psychocutaneous Disorders Mohammad Jafferany, M.D. sychodermatology addresses the interaction be- tween mind and skin. Psychiatry is more focused on Objective: This review focuses on classifi- P cation and description of and current treatment the “internal” nonvisible disease, and dermatology is fo- recommendations for psychocutaneous disorders. cused on the “external” visible disease. Connecting the 2 Medication side effects of both psychotropic disciplines is a complex interplay between neuroendocrine and dermatologic drugs are also considered. and immune systems that has been described as the NICS, Data Sources: A search of the literature from or the neuro-immuno-cutaneous system. The interaction 1951 to 2004 was performed using the MEDLINE search engine. English-language articles were between nervous system, skin, and immunity has been ex- identified using the following search terms: skin plained by release of mediators from NICS.1 In the course and psyche, psychiatry and dermatology, mind of several inflammatory skin diseases and psychiatric con- and skin, psychocutaneous, and stress and skin. ditions, the NICS is destabilized. In more than one third of Data Synthesis: The psychotropic agents most dermatology patients, effective management of the skin frequently used in patients with psychocutaneous disorders are those that target anxiety, depression, condition involves consideration of associated psycho- and psychosis. Psychiatric side effects of derma- logic factors.2 Dermatologists have stressed the need for tologic drugs can be significant but can occur psychiatric consultation in general, and psychological fac- less frequently than the cutaneous side effects of tors may be of particular concern in chronic intractable psychiatric medications. In a majority of patients dermatologic conditions, such as eczema, prurigo, and presenting to dermatologists, effective manage- 3–5 ment of skin conditions requires consideration of psoriasis. associated psychosocial factors. For some derma- Lack of positive nurturing during childhood may tologic conditions, there are specific demographic lead in adulthood to disorders of self-image, distortion of and personality features that commonly associate body image, and behavioral problems.6 The emotional with disease onset or exacerbation. problems due to skin disease include shame, poor self- Conclusions: More than just a cosmetic disfigurement, dermatologic disorders are asso- image, and low self-esteem. The psychosocial impact ciated with a variety of psychopathologic prob- depends upon a number of factors, including the natural lems that can affect the patient, his or her family, history of the disease in question; the patient’s demo- and society together. Increased understanding graphic characteristics, personality traits, and life situa- of biopsychosocial approaches and liaison tion; and the meaning of the disease in the patient’s family among primary care physicians, psychiatrists, 7 and dermatologists could be very useful and and culture. Hostile personality characteristics, dysthy- highly beneficial. mic states, and neurotic symptoms have been frequently (Prim Care Companion J Clin Psychiatry 2007;9:203–213) observed in common skin conditions like psoriasis, urtica- ria, and alopecia.8 It has been reported that female dermatology patients and widows/widowers exhibit a higher prevalence of asso- Received Sept. 9, 2006; accepted Oct. 10, 2006. From the Division 9 of Child and Adolescent Psychiatry, University of Washington School ciated psychiatric comorbidity. It has been reported that of Medicine, Children’s Hospital and Regional Medical Center, Seattle. psychologic stress perturbs epidermal permeability barrier The author greatly acknowledges Bryan H. King, M.D., Head, homeostasis, and it may act as precipitant for some inflam- Division of Child and Adolescent Psychiatry, and Vice Chair, Department 10 of Psychiatry and Behavioral Sciences, University of Washington School matory disorders like atopic dermatitis and psoriasis. of Medicine, Seattle, Wash., for his valuable suggestions and for Patients with psychocutaneous disorders frequently resist reviewing and editing the final manuscript. Dr. King is an unpaid consultant for Forest, Abbott, Neuropharm, and Seaside Therapeutics. psychiatric referral, and the liaison among primary care Dr. Jafferany reports no financial or other relationship related to physicians, psychiatrists, and dermatologists can prove the subject of this article. very useful in the management of these conditions. Corresponding author and reprints: Mohammad Jafferany, M.D., Division of Child and Adolescent Psychiatry, University of Washington Although there is no single universally accepted clas- School of Medicine, Children’s Hospital and Regional Medical sification system of psychocutaneous disorders and many Center, 4800 Sand Point Way NE., M/S W3636, Seattle, WA 98105 (e-mail: [email protected]). of the conditions are overlapped into different categories, the most widely accepted system is that devised by Koo 204203 Prim Care Companion J Clin Psychiatry 2007;9(3) Psychodermatology: Guide for Psychocutaneous Disorders Table 1. Classification of Psychodermatologic Disorders management, relaxation techniques, benzodiazepines, and selective serotonin reuptake inhibitors (SSRIs) have been Psychophysiologic disorders Psoriasis found useful in these disorders. Atopic dermatitis Acne excoriee Psoriasis Hyperhidrosis Urticaria Onset or exacerbation of psoriasis can be predated by Herpes simplex virus infection a number of common stressors. Stress has been reported Seborrheic dermatitis in 44% of patients prior to the initial flare of psoriasis, and Aphthosis Rosacea recurrent flares have been attributed to stress in up to Pruritus 80% of individuals.13,14 Early onset psoriasis before age Psychiatric disorders with dermatologic symptoms 40 years may be more easily triggered by stress than late Dermatitis artefacta Delusions of parasitosis onset disease, and patients who self-report high levels of Trichotillomania psychologic stress may have more severe skin and joint Obsessive-compulsive disorder symptoms.15–17 Phobic states Dysmorphophobia The most common psychiatric symptoms attributed to Eating disorders psoriasis include disturbances in body image and impair- Neurotic excoriations ment in social and occupational functioning.18 Quality of Psychogenic pruritus Dermatologic disorders with psychiatric symptoms life may be severely affected by the chronicity and visibil- Alopecia areata ity of psoriasis as well as by the need for lifelong treat- Vitiligo ment. Five dimensions of the stigma associated with pso- Generalized psoriasis Chronic eczema riasis have been identified: (1) anticipation of rejection, Ichthyosiform syndromes (2) feelings of being flawed, (3) sensitivity to the attitudes Rhinophyma of society, (4) guilt and shame, and (5) secretiveness.19 Neurofibroma Albinism Depressive symptoms and suicidal ideation occur more Miscellaneous frequently in severe psoriasis compared with controls.20 Cutaneous sensory syndromes Depression may modulate itch perception, exacerbate pru- Glossodynia Vulvodynia ritus, and lead to difficulties with initiating and maintain- Chronic itching in scalp ing sleep. In a study21 of 217 psoriasis patients with as- Psychogenic purpura syndrome Pseudopsychodermatologic disease sociated depression, 9.7% acknowledged a “wish to be Suicide in dermatology patients dead,” and 5.5% reported active suicidal ideation. Psoriasis also affects sexual functioning. In one study,22 30% to 70% of patients reported a decline in sexual activ- and Lee11: (1) psychophysiologic disorders, (2) psychiatric ity, and these patients more frequently reported joint pains, disorders with dermatologic symptoms, and (3) dermato- psoriasis affecting the groin region, scaling, and pruritus logic disorders with psychiatric symptoms (Table 1). Sev- compared with patients without sexual complaints. These eral other conditions of interest can be grouped under a patients also had higher depression scores, greater ten- heading of miscellaneous, and medication side effects of dency to seek the approval of others, and a marginally both psychotropic and dermatologic drugs should also be greater tendency to drink alcohol.22 considered. Psychophysiologically, neuropeptides such as vasoac- A search of the literature from 1951 to 2004 was tive intestinal peptide and substance P may have a role in performed using the MEDLINE search engine. English- the development of psoriatic lesions.23 Imbalance of vaso- language articles were identified using the following active intestinal peptide and substance P has been reported search terms: skin and psyche, psychiatry and dermatol- in psoriasis, and there may be an associated increase in ogy, mind and skin, psychocutaneous, and stress and skin. stress-induced autonomic response and diminished pitu- itary-adrenal activity.24,25 Biofeedback, meditation, hypno- PSYCHOPHYSIOLOGIC DISORDERS sis-induced relaxation, behavioral techniques, symptom- control imagery training, and antidepressants are important Here psychiatric factors are instrumental in the etiology adjuncts to standard therapies for this disease.18,26–28 and course of skin conditions. The skin disease is not caused by stress but appears to be precipitated or exacer- Atopic Dermatitis bated by stress.11 The proportion of patients reporting emo- Stressful life events preceding