By Tue “Felix” Nguyen, Marie Vu and Caroline Zhu

A BRIDGE BETWEEN THE MIND AND THE SKIN

By Tue “Felix” Nguyen, Marie Vu and Caroline Zhu

Introduction

Like many medical disciplines, dermatology intersects with other specialties to coordinate patient care optimally. An overlap that has been emerging for years is the relationship between the skin and the mind. Since both systems are inherently complex, medical professionals are continuing to investigate this association to better understand how it impacts our patients. Psychodermatology, a multidisciplinary subspecialty, focuses on integrating the principles of dermatology, psychiatry and psychology to approach patients holistically. The origins of psychodermatology can be traced throughout history. Hippocrates (460 - 370 BC), the father of modern medicine, recorded how stress affects the skin and described a hair-pulling disorder later to be known as trichotillomania.1 The book, Diseases of the Skin, written by English dermatologist and surgeon William James Erasmus Wilson in 1846, highlights various skin conditions such as alopecia areata, pruritus and hyperhidrosis which are strongly influenced by the human psyche.1

In modern medicine, dermatologic patients continue to have additional mental burdens. The incidence of psychiatric disorders in dermatologic patients is about 30-60%.2 Recognizing the psychosocial implications in skin disease is important; patients with refractory skin disease may have an underlying psychiatric disorder that needs to be addressed in order to improve therapeutic outcomes. In this article, we will explore the following three categories encompassed by psychodermatology: 1. Psychophysiologic disorders 2. Psychological problems caused by skin disorders 3. Primary psychiatric disorders with dermatologic symptoms

Psychophysiologic Disorders

Psychophysiologic disorders are dermatologic diseases that are worsened by stress or other emotional states. Examples of these conditions include eczema, acne, alopecia areata and hyperhidrosis. When interviewing patients about their chief complaints, patients may be unaware of how stress and anxiety can impact the skin. Thus, physicians should investigate any recent stressors for exacerbating factors. The percentage of patients reporting emotional disturbances accompanying their skin condition varies, but the range is estimated to be around 50% to greater than 90%.3

In conjunction with treating the skin condition, counseling patients to adopt various stress-relieving and relaxation techniques may be beneficial to reduce the number of acute flares. If conservative management is insufficient, psychological pharmacotherapy such as benzodiazepines, SSRIs or other psychotherapies may be needed.4

Psychological Problems Caused by Skin Disorders

Skin diseases are often associated with secondary psychological comorbidities such as depression and anxiety, as well as what some have termed “subsyndromal morbidities”: embarrassment, shame and low self-esteem.5 This association has also been demonstrated through several well-designed studies.

In 2004, a group of investigators conducted a life-quality study on a population of over 18,000 Norwegian adults with a self-reported skin morbidity. The group found significant impacts on social problems and a strong association with depression in patients with skin disease.6 Similar findings were reported in a survey study of 8,000 adults, which identified a sustained association between skin problems and poor emotional health, despite adjusting for psychiatric diseases.7 Additionally, an analysis on patients with psoriasis discovered a correlation between psychiatric disturbances and severity of skin findings. The authors noted that even with clinical improvement, psychological suffering could persist.8

The pediatric population is also greatly affected by this relationship between skin disorders and secondary psychological problems. For instance, acne severity in adolescents has been correlated with depression and anxiety, and has even been suggested to increase suicide risk.9,10

Through the demonstration of the relationship between skin diseases and secondary psychiatric disorders, these studies highlight the importance for clinicians to consider evaluation for and concomitant management of psychological comorbidities in patients with skin disease.

Primary Psychiatric Disorders with Dermatologic Symptoms

Patients with primary psychiatric disorders can also present with skin manifestations. However, any observable skin lesions are not of dermatologic etiology and are usually self-induced. Two disorders that fall under this category are discussed: delusions of parasitosis and trichotillomania. Delusions of parasitosis11 is a condition in which an individual has delusions of parasitic infestation on the skin from mites, lice, fleas, spi-

ders or other organisms. The cause of this condition is unknown and most commonly occurs in middle-aged white women; however, all individuals can still be affected. Characteristic symptoms of delusions of parasitosis include sensations of itching, burning, crawling and biting that may lead to extensive excoriation of the skin. Additional signs include a patient history of frequently visiting different physicians with no resolution of symptoms, as well as keeping specimens in a small container or bag with clinic visits. Such specimens typically include fragments of hair or skin with no clear evidence of the inciting organisms. A diagnosis is made through exclusion of other true infestations or conditions that may induce the sensation of itchiness, such as drug abuse. Treatment of patients with delusions of parasitosis should involve dermatologists, psychiatrists and entomologists, as patients are often convinced of the existence of their infestation. It is important to gain patient trust before initiating any pharmacotherapy, which may occur over repeated visits. Antipsychotics have been used to treat delusions of parasitosis, but not as solo therapy. Patients should receive additional support and attention in order to properly manage their condition.

Trichotillomania12 is an obsessive-compulsive related disorder characterized by urges to repeatedly pull one’s hair, resulting in subsequent hair loss especially in areas such as the scalp. An associated phenomena includes trichophagia, in which affected individuals ingest their own hair. The cause of trichotillomania is not well-understood; however, individuals with this condition experience significant emotional distress, often impairing social and occupational functioning. In many cases, it usually occurs in adolescence and symptoms may occur in a cyclic manner. The two main forms of treatment for trichotillomania include pharmacotherapy and psychotherapy. While there are currently no FDA-approved drugs for trichotillomania, there is preliminary evidence that shows beneficial treatment effects with clomipramine, n-acetyl cysteine and olanzapine.13 Of these different medications, n-acetyl cysteine is the most well tolerated with fewer significant side effects. Psychotherapy in the form of cognitive behavioral therapy aims to treat individuals through habit reversal, awareness training and stimulus control.

Conclusion

Dermatologic diseases and psychiatric disorders work synergistically to impair our patients’ quality of life. Although it is easy to overlook any present mental disorders when interacting with dermatologic patients, physicians are encouraged to anticipate psychiatric comorbidities. For the future of dermatology, psychodermatology may play a more prevalent role in patient care as it acknowledges the bridge between the mind and the skin.

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Tue “Felix” Nguyen, Marie Vu and Caroline Zhu are medical students at UT Health San Antonio who are interested in dermatology. They all serve as officers for the medical school’s Dermatology Interest Group.