Introduction:
The line where the mind and body meet, the role of psychology in dermatological conditions, and the impact of skin conditions on the mental state of a person; this interplay is called psychodermatology. Psychocutaneous medicine focuses on the boundary between two specialties in medicine, psychiatry, and dermatology. Understanding the connection between the two is the key to managing such disorders.
The management involves evaluating the underlying issues such as skin manifestations, socio-cultural factors, and occupational issues. This specialty focuses on non-visible diseases, which are responsible for externally visible dermatological diseases. This is an interdisciplinary approach between neuroendocrine and immune systems and can be described as NICS (Neuro-immuno-cutaneous system).
One-third of skin disorders may need adjuvant psychological management along with direct dermatological management.
How Are Psychodermal Conditions Classified?
Psychocutaneous disorders can be categorized into:
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Psychophysiologic disorders.
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Primary psychiatric disorders.
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Secondary psychiatric disorders.
1. Psychophysiological Disorders:
These are conditions that are aggravated by emotional stress. This is associated with stress responders and non-stress responders. Emotional stress may exacerbate long-standing dermal problems, becoming a vicious cycle: the itch-scratch cycle. And because of this, treatment is not possible without managing the aggravating factor. But the limitation associated with managing it is that patients may not be ready to discuss psychological issues.
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Psoriasis: Psoriasis an autoimmune disorder that may flare up during stress. It may be associated with the anticipation of rejection, guilt, and shame, feelings of being flawed.
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Urticaria: Increased emotional tension, and stress, may exacerbate pre-existing urticaria.
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Atopic Dermatitis: It has been seen that the disease may be triggered by stressful events. Symptoms may become severe when there is familial stress and low self-esteem.
2. Primary Psychiatric Disorders:
This is not as common as psychophysiological disorders. These diseases are distinguished from psychiatric diseases as they are associated with isolated symptoms, hence called ‘monosymptomatic hypochondriacal psychosis. In cases of conditions such as schizophrenia, it is accompanied by auditory hallucinations, multiple functional deficits, and a lack of social skills, in addition to delusions.
Here the primary problem is psychiatric, and the skin conditions are mainly self-inflicted
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Trichotillomania: A compulsive condition or desire to pull out one’s hair.
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Factitial Dermatitis is a psychiatric disorder that causes patients to inflict wounds on themselves.
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Delusions of Parasitosis: The patient has a false belief that they have a parasite or an organism infection.
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Dysmorphophobia: Fear of one’s body or any part of it.
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Neurotic Excoriations: Also called skin picking, is the urge to pick on healthy skin and inflict wounds.
A. Delusions of Parasitosis:
It is a major disorder in the category of ‘monosymptomatic hypochondriacal psychosis. These patients believe their body is infested with some parasite. They present with isolated delusions with regard to a skin complaint. These patients have elaborate descriptions of how these parasites enter, exit, and reproduce inside their bodies. They may even present insects or parts of insects as proof. This phenomenon is called the “matchbox sign.”
It could be misunderstood or confused with psychotic depression, schizophrenia, drug-induced psychosis, florid mania, or formication without delusion- in this, the patient experiences crawling, stinging, or biting sensations but does not believe they are caused by organisms.
It may also be associated with cocaine or alcohol withdrawal, vitamin B12 deficiency, syphilis, cerebrovascular disease, or multiple sclerosis. These diseases must be ruled out before a diagnosis of delusions of parasitosis is confirmed.
B. Factitious Dermatitis:
It is a condition in which the patient inflicts wounds on themselves. The cause of the wound given by the patient may not be consistent with the skin lesions. The skin lesions are found in areas that the patient can reach.
C. Trichotillomania:
It is the condition where the patient pulls out their hair. It may be associated with obsessive-compulsive behavior, underlying stress, depression, and anxiety.
3. Secondary Psychiatric Disorders:
In many incidences, the skin condition is not fatal, but they are associated with a severe lack of self-esteem and confidence. The disfigurement may make the patient feel psychologically drained and socially awkward. The skin condition may hinder their job prospects and hamper their social interaction.
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Alopecia Areata: It is a type of hair loss. This may lead to depression and generalized anxiety in the patients.
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Vitiligo: It is a type of leukoderma characterized by depigmentation. Patients may be frightened and embarrassed about their appearance.
Physiological problems have a significant impact on body image and self-esteem. This may lead to social anxiety, depression, humiliation, and so on.
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Cystic Acne: A type of inflammation that is characterized by pus-filled pimples.
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Ichthyosis: Skin condition where the epidermis is thick and scaly.
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Hemangiomas: A vascular condition where the blood vessels proliferate to form a benign mass.
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Psoriasis: A skin condition characterized by itchy, scaly, red patches.
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Vitiligo: A skin condition where melanin pigment is lost, causing white patches.
What Causes the Interaction?
It is believed that in the embryonic developmental stage, these two seemingly unrelated entities were connected through ectoderm. Therefore, the skin responds to both external and internal stimuli. It can sense environmental cues as well as transmit internal conditions to the outside world. This is believed to be the basis for the correlation between the skin and the mind.
These skin conditions may be triggered by a lack of positive nurturing in childhood which can lead to decreased self-esteem and behavioral problems in adulthood. These may lead to primary psychiatric disorders. While in secondary psychiatric disorders, dermatologic disorders affect the quality of life and confidence of the patient.
Other risk factors include:
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Demographic characteristics.
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Personality traits.
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Life situation.
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Neurotic symptoms.
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It has also been seen that female dermatology patients and widows or widowers exhibit a higher prevalence of psychiatric symptoms.
What Is the Treatment?
Identifying the disorder is the first step in managing the disease. The patient should be reassured and should feel confident in the doctor. The problem itself is multidisciplinary in nature; the management also includes multiple levels, such as psychotropic medication, psychiatrist consultation, and stress management. The main limitation includes social stigma and reluctance from patients and families.
Psychophysiological:
Management includes reducing stress, thereby reducing the exacerbation of the disorder.
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Relaxation techniques.
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Stress management courses.
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Counseling.
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Music.
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Exercise may be helpful.
In severely stressful patients, anti-anxiety medication may be necessary.
Benzodiazepines may be used to provide quick relief from anxiety, tension, and stress.
For long-standing anxiety, selective serotonin reuptake inhibitors (SSRIs) are effective.
Buspirone is a non-sedating and non-addictive option.
In severe cases where psychiatric consultation is warranted, patients must be diplomatically approached, and psychiatric treatment may be an adjuvant to dermatological management.
Primary Psychiatric Disorders:
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Since the underlying cause is psychiatric, the first line of treatment should also be antipsychotic.
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Pimozide (Orap) is the treatment of choice for delusions of parasitosis. It helps in decreasing formication (the sensation of insects crawling on the skin). It is used at a lower dosage than when used for schizophrenia. It may take up to six to eight weeks for the therapeutic effect to be evident. As the treatment progresses, the patient becomes less agitated. In younger patients, Pimozide should be continued at the lowest effective dosage and gradually tapered off. It must be restarted if the condition recurs. In older patients, however, the medicine should be continued on a long-term basis.
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The challenge in treating patients with primary psychiatric disorders is offering the treatment without offending the patients. Proper counseling and a sympathetic approach are crucial for the success of the treatment. In some cases, the patient may even have to be told that the medicine is part of a therapeutic trial.
Conclusion:
Since proper distinctions between psychological and dermatological aspects of the disease are difficult to be defined, proper diagnosis is often a challenge. Once it has been diagnosed, both aspects have to be addressed. The patient should be dealt with empathy and diplomacy. Secondary infections must be prevented. The support of the physician and the family of the patient significantly improves the acceptance and success of the treatment. Psychodermal disorders are many times a challenge for the dermatologist, but the reasonable effort can dramatically improve the quality of life of the patient.
