© Dr. Maged N. Kamel Boulos - MediCAD Multimedia, 1992-98. All rights reserved.
If you happen to have a wart on your nose or forehead, you cannot help imagining that no one in the world has anything else to do but stare at your wart, laugh at it, and condemn you for it, even though you have discovered America. (Fyodor Dostoevsky, The Idiot)
The relation between the skin, the nervous system and the psyche is intimate. The nervous tissue and a considerable part of the skin share a common embryonic origin: the ectoderm.
As an organ of touch, temperature and pain sensation, and as an erogenous zone, the skin has great psychological importance at all ages. It is an organ of emotional expression and a site for the discharge of anxiety. Caressing favours emotional development, learning and growth of newborn mammals.
Skin disorders carry their own unique sets of emotional problems: shame, embarrassment, poor self-image and low self-esteem. Skin disease is visible to others, it carries the taint of contagion (and possibly sexual sinfulness), and it is something which is socially unacceptable because of public ignorance and superstition. Even the colour of a completely normal skin (e.g., negroes) may sometimes cause the person to be socially isolated from others with different skin colour (e.g., white men).
Patients with psoriasis often feel that others stare at them, and experience much social distress. Skin diseases can cause great disability to the patient: for instance, the most trivial psoriasis affecting the fingertips in a blind patient may completely devastate that person's life by making it impossible to read braille and the presence of relatively trivial amounts of psoriasis on an individual's face may induce disparate depression. Sufferers from vitiligo adjust better to their disorder than do those with psoriasis, but also tend to have low self-esteem.
Disfiguring skin lesions (e.g., intractible atopic eczema and port-wine stains) may profoundly influence the emotional development of a child which is also affected by the attitude of the parents and, later, of teachers.
With the approach of puberty, a disfuguring skin disease (e.g., acne vulgaris) becomes an increasing anxiety to many teenagers and may handicap them in developing easy relationships with the opposite sex. The adolescent may become increasingly introspective and solitary, or may become aggressive and uncooperative. Individuals with acne are also less successful at gaining emplyment...
Psychiatry is not an "exact" science. Some anxiety or depression will be felt by many of the patients seen by a dermatologist. This may be unrelated to their skin disease. Dermatologists should not abuse psychological factors to fill gaps in the aetiology of diseases they are still ignorant about their pathogenesis. Take as an example lichen planus: considerable evidence, that was not present before, now exists that the underlying processes involved in its pathogenesis are immunologically mediated, and that a relation with certain HLA antigens exists...
It is well known that systemic glucocorticoid therapy can induce either depression or hypomania. Indeed, particular care must be taken with corticosteroids in patients with a past history of manic-depressive illness.
A variety of skin eruptions -- including urticarial, maculopapular, petechial, and oedematous eruptions can occur early in treatment, generally in the first few weeks. A contact dermatitis can also occur in personnel who handle chlorpromazine. A photosensitivity reaction of the phototoxic type that resembles severe sunburn can occur in patients receiving chlorpromazine. Long-term side effects include a blue-gray metallic discolouration of sun-exposed areas of the skin.
Used in the treatment of manic-depressive illness, lithium can cause acneiform eruptions, pretibial ulcerations and worsening of psoriasis. Concurrent administration of tetracycline to control acneiform eruptions may precipitate lithium toxicity.
A rare condition, where the patient has unshakeable conviction that his/her skin is infested by parasites: this must be differentiated from parasitophobia -- the fear of becoming infested.
D.O.P. in a young adult suggest illicit exposure to drugs such as amphetamine or cocaine, or are part of a delusion shared with another member of the family (folie à deux).
The term monosymptomatic hypochondriacal psychosis may be applied to patients with a single, fixed hypochondriacal delusion which is apparently not secondary to another psychiatric disorder. Most patients with D.O.P. fit into this category. Such patients are often intelligent, and the professions are well represented, including doctors and even psychiatrists, but they are often rather solitary and sometimes thought to be eccentric individuals. Some of these patients may also have an obsessional premorbid personality.
Delusions of perception may follow diseases in the non-dominant hemisphere and so D.O.P. are sometimes seen in patients after a cerebrovascular accident involving that side of the brain. D.O.P have also been described in pellagra, Vitamin B12 deficiency and severe renal disease. It is particularly important to exclude the possibility of a real infection.
Clinically, patients with D.O.P. are often "doctor-shoppers" and complain bitterly about the incompetence of their medical advisers. The presenting symptoms are often ill-defined. Some speak of a sensation in their skin as though an insect is crawling around, and may describe and draw the insects concerned. Excoriations are common and follow attempts by the patient to extract "parasites". Purification rituals rapidly become established and patients will go to great lengths to cleanse the skin and their evironment.
It is important not to collude with the patient and it is better to say "I can't see any of these parasites today," than to tell the patient that he has a mental problem. Sometimes patients can be persuaded to accept medication if told that it has helped previous patients with similar problems. The response to pimozide is often good in these patients and the initial dose, usually 2 mg, slowly increased as necessary to a maximum of 12 mg daily. An ECG (EKG) should be performed before pimozide therapy and the drug should not be given to patients with a prolonged Q-T interval or to patients with a history of cardiac arrhythmia.
This term was introduced to describe patients who are rich in symptoms but poor in signs of organic disease. Dermatological non-disease presents with symptoms in three main areas: the face, the scalp and the genital area. It is the commonest type of dermatological delusional disease seen in practice.
Facial symptoms include cornplaints of excessive redness, blushing, a burning feeling, scarring, large pores, excessive facia1 hair and facial greasiness. Scalp symptoms include a feeling of intense burning and excessive hair loss. Perineal symptoms in males include complaints of an excessively red scrotum, discomfort in the genital area, urethral discharge, herpes and AIDS phobia. Female equivalents are vulvodynia (the burning vulva syndrome) the discomfort of which may be so severe that the patient will neither sit down nor go to bed.
Patients with dysmorphophobia have similar personalities to those with D.O.P. Their symptoms may appear after severe emotional, especially marital, problems and perineal symptoms in men may follow imagined or real sexual exposure.
The commonest associated psychiatric illness is depression, but patients seldom admit to this. The management of these patients is very difficult and includes: superficial psychotherapy, antidepressant drugs when indicated and psychiatric consultation. Pimozide is singularly ineffective in this group of individuals. Bizarre cutaneous delusions are sometimes a presenting manifestation of overt schizophrenia. A student insisted that his pubic hair had become so stiff and wirelike that it caused him discomfort. In an elderly patient dernentia should be considered.
This is a rare condition. Dermatologists are more likely to see patients who complain that their axillae, genitals or feet smell excessively badly. They share the same personality make-up as patients with other types of dermatological delusional disease. They are best managed by a competent psychiatrist.
Patients phobic about dirt and bacteria may present to dermatologists with hand eczema induced by repeated hand washing and the final psychiatric diagnosis is usually of an obsessional neurosis.
Pantients who are phobic about warts may also be encountered. Such patients are afraid to touch anything in the consulting room, and indeed the hospital. They wear gloves when shopping or filling their car with petrol...
Phobia about pigmented lesions has also become more common since the recent publicity carnpaigns about the early diagnosis of malignant melanoma.
Syphilophobia and other related phobias: Such patients, with the overvalued idea about the possibility of venereal disease including AIDS and herpes simplex, may be anxious or depressed and a rather obsessional personality trait is also not unusual in this group of patients.
Blushing and erythrophobia: Although blushing itself is normal under certain circumstances, blushing which is grossly excessive in both frequency and extent is sometimes seen in women and may be the cause of considerable embarrassment and give rise to erythrophobia, a compulsive state related to fear of blushing. Fairly frequent flushing can be a manifestation of hyperthyroidism and the distinctive flushing of the carcinoid syndrome must also be excluded.
States of fear, rage, and tension can induce an increase of sweat secretion. Perspiration in the human has two distinct forms: thermal and emotional.
Under conditions of prolonged emotional stress, excessive sweating or hyperhidrosis (to the degree that pools of water drip from the hands onto the floor causing rusting of metal objects and saturation of clothing) may lead to secondary skin changes, rashes, blisters, and infections; therefore, it may underlie a number of other dermatological conditions that are not primarily related to emotions. Hyperhidrosis may be viewed as an anxiety phenomenon mediated by the autonomic nervous system.
The "traffic light phenomenon". One mechanism for relieving everyday irritations is to scratch a little. The motorist stopped at a red traffic light almost invariably scratches some accessible site such as the neck and most of us develop a small itch from time to time during the day which is relieved by slight scratching.
Individuals who develop localized or generalized neurodermatitis may begin in this way, but their itch/scratch cycle gets out of hand. In some individuals intense scratching can induce an ultimate feeling of pleasure and this may be related to the release of opioids centrally.
Some regard pruritus vulvae and pruritus ani, for which no organic cause (such as Candidiasis or Oxyuriasis) can be found, as a form of localized neurodermatitis.
There are data to suggest that enkephalins and endorphins are important as neurotransmitters in the central nervous system in mediating the sensatian of itch because it has been recognized for many years that, although morphine may alleviate pain, it may aggravate itch, as itch and pain are thought to share common neurological pathways. The central elicitation of itch by morphins may result from binding to opioid receptors and this binding may mimic normal physiological binding of endorphins and enkephalins at these receptor sites. Moreover, naloxone, an opioid antagonist, has been found to reduce or abolish histamine-provoked itch.
From the more practical point of view, it has been demonstrated recently that the degree of pruritus in psoriasis correlates with the degree of depressive psychopathology present. A significant proportion of patients with generalized pruritus may be suffering from depression.
Malingering apart, women present with artefacts more commonly than men. Most are adolescents or young adults and many possess some superficial medical knowledge. The patients are often of an inward-looking, self-centred disposition, with emotional immaturity and restricted interests. In such immature personalities a wide variety of recent events and stresses may precipitate the artefactual lesions. Self-inflicted lesions vary widely in their morphology and distribution, and may be difficult to recognize. They will be necessarily in sites readily accessible to the patient's hands and in girls are usually on the face, hands or arms. Individual lesions are often bizarre with irregularly rectilinear outlines and geographical patterning not conforming to any spontaneous pathological process.
The changes seen depend on the methods used to injure t:he skin. These include deep excoriations with the fingernail or a sharp instrument, scarification with a knife or a fragment of glass, the application of caustic chemicals, especially disinfectants, and burning, sometimes with a cigarette. Elastic bands may be used to produce oedema and ulcers. Patients usually deny that they are producing the lesions and sometimes seem oddly indifferent to them: it may be impossible to decide whethere they are truly unconscious of actions performed, perhaps in a "twilight state" and leaving no memories.
Factitious cheilitis (le tic des lèvres) . This is a persistent and often gross crusting and scaling of the lips, which follows continued biting, picking or licking in emotiorally immature or disturbed patients of both sexes.
Psychogenic purpra. This is the deliberate infliction of bruises, a minor but not uncommon form of dermatitis artefacta.
The prognosis seems to be best in young patients who use the artefact to draw attention to a particular problem and who recover when this is solved. Often, however, the artefact is but one incident in a long history of psychiatric illness. Careful observation, perhaps in hospital, including the secure application of occlusive dressings and constant supervision, may be necessary to confirm the diagnosis of dermatitis artefacta, which should be made with reluctance in a stable and mature person.
Direct confrontation with the patient stiould be avoided, but usually it is possible to infer that his or her activities are known but are regarded with understanding and sympathy.
In this disorder, the patients themselves cause recurrences or exacerbations of their existing skin disease. One had worsened her atopic eczema by deliberate contact with horses; another had knowingly taken gluten to which she was intolerant; others had exposed themselves to sunlight, or applied to the skin substances to which they were known to be allergic. Some patients had taken drugs to which they had reacted previously.
Most of the patients are young women who normally receive little sympathy from within their families. Direct confrontation, without any hint of reproach, often proved helpful, in contrast to its usual effect in ordinary dermatitis artefacta.
This condition, perhaps the commonest of the self-inflicted dermatoses, differs from other artefactual conditions as those who suffer from it readily admit to an uncontrollable urge to gouge and pick at their skin. Women are more commonly affected than men. The patients commonly seem to be under stress and may be depressed. The most frequent character traits are hypersensitivity and lack of self-confidence.
Itching may or may not be present. Minor irregularzties in the skin surface are compulsively scratched and picked, most often at bed time, creating even greater irregularities and setting up a viscious circle. Some patients are unaware that they are doing this; others seem to enjoy picking off crusts.
Nalorex [naltrexone] which is known to help some self-injurious patterns in animals, or the tricyclic antidepressant sinequan [doxepin] may be tried in resistant cases.
This disorder occurs predominantly in females. Two subgroups exist: those with some primary acne lesions and those with virtually none. Both groups usually consist of females who "fiddle" with the skin to exacerbate even the srnallest lesions. There is often considerable personality or psychological problem.
Treatment with 1 g per day of tetracycline for 6 months and advice not to pick the spots is of considerable benefit to those females with mild acne. Topical treatment tends to irritate the skin. By markedly reducing the number of lesions the regimen leaves the patient fewer lesions to "play" with. In the group with virtually na acne spots, pimozide (2 mg bd) and appropriate psychotherapeutic procedures may help.
According to DSM-III-R (Diagnostic and Statistical Manual of Mental Disorders, ed 3, revised. Copyright: American Psychiatric Association, Washington, D.C., 1987), the essential feature of trichotillomania (which is classified under impulse control disorders) is the recurrent failure to resist impulses to pull out one's onwn hair. The diagnosis should not be made when hair pulling is associated with a preexisting inflammation of the skin or is in response ta a delusion or hallucination.
Trichotillomania occurs more than twice as frequently in females as in males but below the age of 6 years boys outnumber girls by 3:2 and the peak incidence in boys is in the 2-6 age group. It is seven times more frequent in children than adults. The child develops the habit of twisting hair round his fingers and pulling it. The act is only partially conscious and may replace the habit of thumb-sucking. Emotional deprivation in the maternal relationship is considered important in initiating the habit.
The rarer and more severe form occurs predominantly in females of any age from early adolescence onwards, and most are aged 11-40 years; the peak incidence in females is 11 and 17 years.
In the younger patients the hair pulling tic develops gradually and unconsciously but is not usually denied by the patient. Hair is plucked most frequently from one frontoparietal region. There results an ill-defined patch on which the hairs are twisted and broken at various distances from the clinically normal scalp. The texture and colour of the broken hairs are of course unaffected. One young child plucked the hair of her contemporaries as well as her own! In the more severe form the patient usually consistently denies that she is touching her hair. The patient presents with an extensive area of scalp on which the hair has been reduced to a coarse stubble uniformly 2-3mm long.
Much more unusual is the habit of plucking the eyelashes, eyebrows and beard. The child may also suck and even eat the hair (trichophagy).
Differential diagnosis: The minor form in young children is often confused with ringworm or with alopecia areata. In ringworm the texture of the infected hairs is abnormal and the scalp surface may be scaly. It is wise to examine all cases under Wood's light and also to examine broken hairs under the microscope.
Treatment: Usually support from the dermatologist is sufficient; behaviour therapy is also suggested to be helpful. The problem is that the diagnosis is often rejected by the parents who have not observed the child pulling the hair and find it unacceptable to believe that the problem is self-inflicted.
All diseases of the skin are to some degree psychosomatic (i.e., onset and course are affected by primary psychic factors) or somatopsychic (i.e., resulting in secondary psychological disturbances) or both.
It has been estimated that the effective management of at least one-third of patients attending skin departments depends to some extent upon the recognition of emotional factors. But one should be cautious when incriminating psychological factors as playing the primary and essential pathogenic role in a given skin disease.
It has to be admitted that despite intensive research devoted to these problems, our knowledge of the psychodynamic and peripheral mechanisms involved is still rudimentary. The new subject of "psychoneuroimlnunology" may have much to add here by extending the concept of stress to include changes in susceptibility to infections, in immune responsiveness and even in the pathogenesis of neoplastic disorders.
These areas of overlap between psychiatry and dermatology are important and a competent dermatologist should be able to pick up any emotional and psychological clues and cues which may be advanced by the patient during consultation. For example, it is important to recognize that individuals with skin problems in important body-image areas may be manifestly depressed. The depression may be severe enough to merit treatment with antidepressants and the help of a psychiatrist. A dermatology-psychiatry liaison clinic has proved to be a useful way of introducing dermatologists to the psychological dimension of their subject -- and managing this type of patient, where at times there may be a definite risk of suicide.
Dermatologists should always remember that they are treating "human beings" not "skin disorders". If psychological care of patients with skin disorders cannot guarantee a cure, it can at least offer help in dealing with the disease experience itself.
Bibliography (used to prepare this article):
Demis DJ et al (eds): Clinical Dermatology, 4 vol, Harper & Row, New York, 1979
Fitzpatrick TB et al (eds): Dermatology in General Medicine, 3d ed, 2 vol, McGraw-Hill, New York, 1987
Moschella SL, Hurley HJ Jr: Dermatology, 2d ed, 2 vol, Saunders, Philadelphia, 1985
Rook A et al (eds): Textbook of Dermatology, 5th ed, 4 vol, Blackwell, Oxford, 1992
© Dr. Maged N. Kamel Boulos - MediCAD Multimedia, 1992-98. All rights reserved.