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Psychodermatology: The Mind and Skin Connection

American Family Physician, Dec 1, 2001 by John Koo, Andrew Lebwohl

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When the patient's stress or tension is intense enough to warrant consideration of an anti-anxiety medication, two general types are available. Benzodiazepines, which can be used on an as-needed basis, provide relatively quick relief from anxiety, stress and tension.(6) For treatment of chronic anxiety, selective serotonin reuptake inhibitors (SSRIs) are safe and effective.

Other options for the treatment of chronic stress include nonsedating and nonaddictive anti-anxiety agents such as buspirone (Buspar). If a patient's anxiety disorder warrants psychiatric referral, the referral should be discussed with the patient in a supportive and diplomatic way so that the patient is able to accept the referral as an adjunct to continuing dermatologic therapy.

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Primary Psychiatric Disorders

Primary psychiatric disorders are encountered less often than psychophysiologic disorders.

DELUSIONS OF PARASITOSIS

Delusions of parasitosis belongs to a group of disorders called "monosymptomatic hypochondriacal psychosis." Patients with the latter disorder present with isolated delusions regarding a skin complaint.(6) Because the nature of the delusional disorder is truly isolated, these disorders are quite different from schizophrenia, which involves multiple functional deficits, including auditory hallucinations, lack of social skills and flat affect, in addition to delusional ideation.(7)

The most common form of monosymptomatic hypochondriacal psychosis encountered among patients with skin problems is called delusions of parasitosis.(8) Patients with delusions of parasitosis firmly believe that their bodies are infested by some type of organism. Frequently, they have elaborate ideas about how these "organisms" mate, reproduce, move around in the skin and, sometimes, exit the skin. These patients often present with the "matchbox" sign, in which small bits of excoriated skin, debris or unrelated insects or insect parts are brought in matchboxes or other containers as "proof" of infestation (Figure 2).

The psychiatric differential diagnosis includes schizophrenia, psychotic depression, psychosis in patients with florid mania or drug-induced psychosis, and formication without delusion, in which the patient experiences crawling, biting and stinging sensations without believing that they are caused by organisms.(6) Other organic causes such as withdrawal from cocaine, amphetamines or alcohol, vitamin B12 deficiency, multiple sclerosis, cerebrovascular disease or syphilis should also be considered. If any of these underlying causes are diagnosed, a separate diagnosis of delusions of parasitosis should not be made.(9)

The treatment of choice for delusions of parasitosis is an antipsychotic medication called pimozide (Orap). Pimozide is similar to haloperidol (Haldol) in chemical structure and potency, and has been shown to be uniquely effective in the treatment of this condition, especially in decreasing formication.(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 therapy is generally started at the lowest possible dosage of one half of a 2-mg tablet (i.e., 1 mg) daily and increased by 1 mg per week.(11) By the time the usual daily dosage of 4 to 6 mg (i.e., 2 to 3 tablets) is reached, most patients have experienced a decrease in crawling and biting sensations, as well as in the sensations of "organisms" moving in their skin. Optimal therapeutic effect may not occur for 6 to 8 weeks. During the treatment course, patients become less agitated.

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Psychodermatology: The Mind and Skin Connection

American Family Physician, Dec 1, 2001 by John Koo, Andrew Lebwohl

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