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Industry: Email Alert RSS FeedPsychodermatology: The Mind and Skin Connection
American Family Physician, Dec 1, 2001 by John Koo, Andrew Lebwohl
A psychodermatologic disorder is a condition that involves an interaction between the mind and the skin. Psychodermatologic disorders fall into three categories: psychophysiologic disorders, primary psychiatric disorders and secondary psychiatric disorders. Psychophysiologic disorders (e.g., psoriasis 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 delusions of parasitosis. Secondary psychiatric disorders are associated with disfiguring skin disorders. The disfigurement results in psychologic problems, such as decreased self-esteem, depression or social phobia. Most psychodermatologic disorders can be treated with anxiety-decreasing techniques or, in extreme cases, psychotropic medications. (Am Fam Physician 2001;64:1873-8. Copyright[C] 2001 American Academy of Family Physicians.)
Psychodermatology, or psychocutaneous medicine, focuses on the boundary between psychiatry and dermatology. Understanding the psychosocial and occupational context of skin diseases is critical to the optimal management of psychodermatologic disorders.
The management of psychodermatologic disorders requires evaluation of the skin manifestation and the social, familial and occupational issues underlying the problem. Once the disorder has been diagnosed, management requires a dual approach, addressing both dermatologic and psychologic aspects. Even with self-induced skin problems, supportive dermatologic care is needed to avoid secondary complications, such as infection, and to ensure that the patient feels supported. Patients with psychodermatologic disorders frequently resist referral to mental health professionals. Acceptance of psychiatric treatment or consultation may be enhanced through support from the family physician.
Management options include psychotropic medication, stress management courses and referral to a psychiatrist. Family physicians are well positioned to help patients with psychodermatologic disorders; these patients may be concerned about the stigma associated with psychiatrists, and family physicians are familiar with the use of psychotropic medications.
Classification
Psychodermatologic disorders can be broadly classified into three categories: psychophysiologic disorders, primary psychiatric disorders and secondary psychiatric disorders.(1) The term "psychophysiologic disorder" refers to a skin disorder, such as eczema or psoriasis, that is worsened by emotional stress (Figure 1). "Primary psychiatric disorder" refers to a skin disorder such as trichotillomania, in which the primary problem is psychologic; the skin manifestations are self-induced. "Secondary psychiatric disorders" affect patients with significant psychologic problems that have a profoundly negative impact on their self-esteem and body image. Depression, humiliation, frustration and social phobia may develop as a consequence of a disfiguring skin disorder.(2) Table 1 lists common diagnoses associated with the different categories of psychodermatologic disorders.
TABLE 1
Diagnoses Associated
with Psychodermatologic Disorders
Major categories Examples
Psychophysiologic Acne
disorders Alopecia areata
Atopic dermatitis
Psoriasis
Psychogenic purpura
Rosacea
Seborrheic dermatitis
Urticaria (hives)
Primary psychiatric Bromosiderophobia
disorders Delusions of parasitosis
Dysmorphophobia
Factitial dermatitis
Neurotic excoriations
Trichotillomania
Secondary psychiatric Alopecia areata
disorders Cystic acne
Hemangiomas
Ichthyosis
Kaposi's sarcoma
Psoriasis
Vitiligo
Psychophysiologic Disorders
Psychophysiologic disorders are conditions that are frequently precipitated or exacerbated by emotional stress. Each of these conditions has "stress responders" and "non-stress responders," depending on whether a patient's skin disease is or is not frequently and predictably exacerbated by stress. The proportion of stress responders depends on the dermatologic diagnosis involved, as illustrated in Table 2.(3)
In patients with treatment-responsive skin conditions such as eczema, psoriasis and acne, the issue of stress may not be important.(4) However, when physicians are faced with disease recalcitrant to treatment, patients should be asked whether psychologic, social or occupational stress might be contributing to the skin disorder.
Emotional stress may exacerbate many chronic dermatoses and can initiate a vicious cycle referred to as the "itch-scratch cycle"; therefore, treatment of recalcitrant patients with chronic dermatoses may be difficult without addressing stress as an exacerbating factor.(5) Patients often are embarrassed about discussing psychologic issues, especially if they feel hurried. Stress management classes, relaxation techniques, music or exercise may benefit these patients. If a specific psychosocial or occupational issue exists, therapy or counseling can help.
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