A comprehensive presentation about Psychocutaneous disorders taken from Rook's textbook of dermatology, along with tables and pictures. Useful for dermatologists and other healthcare professionals.

1. By: DR. SAIMA IDREES
PGR Dermatology

2. INTRODUCTION
 Psychodermatology encompasses disease that involves the
complex interaction between the brain, cutaneous nerves,
cutaneous immune system and the skin.

3. Skin–psyche interactions
May be any of the following:
1. Primarily cutaneous disorders that can be influenced by
psychological factors, e.g. psoriasis
2. Primary psychiatric disease presenting to dermatology
HCPs, e.g. Delusional infestation, body dysmorphic
disorders
3. Psychiatric illness developing as a result of skin disease, e.g.
depression, anxiety or both.
4. Co-morbidity of skin disease with another psychiatric
disorder, e.g. alcoholism

4. Stigma
 Term describes situation of an individual who is
disqualified from full social acceptance.
 Commonest dermatological situations where stigma is
encountered may be:-
Physical deformities:-
I. Congenital naevae ,e.g. port-wine stain
II. Acquired deformities from developmental disorders,
e.g. tuberous sclerosis
III. Widespread inflammatory skin diseases
IV. Surgical or post-traumatic deformities

5.  Psychiatric disease and learning disabilities
 Race and religion
 Behavioural and social factors: Alcoholism and
substance misuse, imprisonment
Interventions in dermatological stigmata are concentrated
on firstly the reduction in visibility and secondly the
psychological based approaches to forestall stigmatization

6. Classification
A. Delusional beliefs :
i. Delusional infestation
ii. Olfactory delusion
iii. Morgellons syndrome

7. B. Obsessive and compulsive disorders:
i. Body dysmorphic disorder
ii. Lichen simplex chronicus and nodular prurigo
iii. Skin picking disorder
iv. Acne excoriee
v. Trichotillomania/trichotillosis
vi. Onychotillomania and onychophagia
vii. Health anxieties(dirt, infection and wart phobias,
mole and cancer phobias)

8. C. Eating disorders:
i. Anorexia nervosa
ii. Bulimia nervosa
D. Psychogenic itch:
i. Psychogenic pruritus

9. E. Factitious skin disease:
i. Dermatitis artefacta
ii. Dermatitis simulata
iii. Dermatological pathomimicry
iv. Dermatitis passivata
v. Malingering
vi. Pseudologia fantastica and munchausen syndrome
vii. Fabricated and induced illness

10. F. Deliberate self-harm:
i. With suicidal ideation
ii. Without suicidal intent
G. Others:
i. Cutaneous disease and alcohol misuse
ii. Depression in dermatological patient
iii. suicide

11. Delusional Beliefs

12. Delusional infestation
 (ekbom disease, delusional parasitosis, parasitophobia,
monosymtomatic delusional hypochondriasis)
 It is an uncommon but very disabling condition where the
patient is convinced that he or she is infested with a mite,
parasite, bacteria, worm, insect, virus or animate material.
Epidemiology
• Incidence
• Age
• Sex
• Ethnicity
Associated diseases:

13.  Itching
 Biting
 Burning or
 Crawling sensations on the skin that
may be localized or generalized.
 These sensations may be
intermittent, or more often,
persistent and disabling.
Clinical Features

15. Investigations
 Skin Biopsy
 MRI Brain
Specimen sign

16. Management

17. Olfactory delusions
(Bromidrosiphobia,Cacosmia, Phantosmia)
The association of an “intrinsic” smell hallucination and a
“contrite” reaction in the absence of a history of preceding
depression’ (though anxiety and depression may be a consequence
of ORS)
 More common in young male adults (male : female 4.5 : 1), and
occurs in all ethnic groups. Associated diseases include:
 Depression.
 Obsessive–compulsive disorders.
 Body dysmorphic disease.
 Dementia.
 Temporal lobe epilepsy.

18. Differential diagnosis
 A genuine body odour
 Trimethylaminuria
 Temporal lobe epilepsy
 Other organic brain disease: Dementia, Parkinson
disease, Brain tumour.

19. Management

20. Morgellons syndrome
The phenomenon comprises:
• Sensations of crawling, stinging and biting under the skin.
• Sores that do not heal.
• Fiber‐like filaments, granules and crystals that appear on or
under the skin lesions .
• Joint and muscle pain and fibromyalgia.
• Debilitating fatigue.
• Cognitive dysfunction, poor concentration and memory.
Treatment :
Pimozide, risperidone together with topical antiseptics,
systemic antibiotics and (sometimes) phototherapy.

22. Obsessive and
compulsive behaviour

23. Body dysmorphic disorder
 It is characterized by preoccupation with a real or an
imagined defect in physical appearance, or if there is a
slight physical anomaly, concern is out of proportion to the
anomaly.
 Occurs in 1-2% of general population
 The female to male ratio is 2 : 1, more in adolescents
 Management:
i. Treatment of skin
ii. Education for patient and family
iii. SSRIs
iv. CBT
v. Antipsychotics

25. Lichen simplex chronicus and
nodular prurigo
 Regular rubbing and pressure on the skin produces
characteristic thickened, coarsely grained papules and
nodules with hyperpigmentation.
 Sites: Nape and sides of the neck, elbows, thighs,
knees and ankles
 Lesions may be in varying stages of evolution, from
early, small, violaceous papules with surface
excoriations to chronic areas that present as
hyperkeratotic plaques with pigment changes,
described as ’dermatological worry beads’.

26. Lichen simplex chronicus

27. Skin picking disorder (Dermatotillomania):-
 Recurrent picking accompanied by visible tissue
damage and functional impairment.
 Clinical features:-Lesions may be quite deep extending
into the dermis. Older lesions show pink or red scars,
some of which may be hypertrophic. Chronic lesions
may also show atrophic scars.

28. Management
Lichen simplex chronicus Skin picking disorder

29. Acné excoriée
 Common particularly in adolescent girls under
emotional stress
 It is a variant of skin picking disorder with the lesions
largely confined to the face i.e. around the hairline,
forehead, pre-auricular cheek and chin areas.

30. Acné excoriéeAcute excoriations and chronic, scarred,
atrophic lesions due to pathological
picking on face, neck and shoulders

31. Management
 Topical retinoids/antibiotics
 Systemic antibiotics
 Habit reversal
 Cognitive Behavioural Therapy and other talk therapies
 Selective Serotonin Reuptake Inhibitors
 Isotretinoin
 Phototherapy
 Other antidepressants, e.g. mirtazapine
 Mood stabilizers
 Lasers
 Hypnosis

32. Trichotillomania/Trichotillosis
 Term was first used by Hallopeau in 1889.
 Derived from the Greek thrix hair, tillein pull out and mania
madness.
 Morbid craving to pull out hair.
 Diagnostic criteria:-
a. Recurrent pulling out of one’s own hair resulting in hair loss.
b. An increasing sense of tension immediately before pulling out
hair or when attempting to resist behaviour.
c. Pleasure, gratification or relief when pulling out the hair.
d. Disturbance is not better accounted for by another mental
disorder.
e. Disturbance provokes clinically marked distress and/or
impairment in occupational, social or other areas of functioning.

33. Clinical features:
 Short, irregular, broken and
distorted hair.
 Plucking activity are centrifugal
from a single starting point or
linear, in wave-like activity.
Trichobezoar :
 Ball-like aggregations of fibre-
like materials( hair) in stomach
and small intestine.
 Swallowed hair is retained
within folds of gastric mucosa.
Rapunzel Syndrome:
 A trichobezoar with a tail that
extends at least to the jejunum.
Trichotillomania

34. Endoscopic image of a trichobezoar extending into the
pylorus

35. Rapunzel Syndrome

36. Investigations
 Diagnosis is clinical
 Scalp biopsy is rarely needed to distinguish trichotillosis
from scarring Alopecia.
 Barium contrast and CT scan:-gastrointestinal bezoars

37. Management
 Habit reversal
 CBT
 SSRIs
 Hair weaves
 Hair extensions
 Treatment of any iron deficiency
 Treatment of keloid
 Mood stabilizers (e.g. gabapentin and pregabalin)
 Antipsychotics
 Topiramate
 Phototherapy

38. Onychotillomania and
Onychophagia

39. Cutaneous phobias
• Fear of contamination, e.g. dirt phobia, germ phobia, wart
phobia
 Fear of malignancy, e.g. cancer phobia, mole phobia

40. Eating Disorders

41. Anorexia and Bulimia nervosa
 Anorexia nervosa must
satisfy the criteria for:-
1. An inability to maintain
the normal or minimum
weight for age and height
coupled with an intense
fear of gaining weight; the
BMI is less than 17.5
kg/m2
2. A distorted perception of
weight, size and body
configuration
3. Amenorrhea
 Bulimia nervosa is defined
by the following:
1. Recurrent and compulsive
overeating episodes (binge
eating)
2. Recurrent and inappropriate
compensatory behaviour in
order to avoid gaining weight;
these include induced
vomiting and abuse of
diuretics and laxatives
3. Binge eating and weight
reduction behaviours
occurring at least twice per
week for 3 months
4. Self-esteem affected by weight
and body configuration.

42. Cutaneous manifestations
 Xerosis and pruritus.
 Russell’s sign (knuckle pads from chewing the skin
overlying the knuckles)
 Nutritional disease: Pellagra, Dermatitis
enteropathica, Anaemia and hair loss secondary to
iron deficiency.
 Cutaneous microvasculature: Raynaud phenomenon,
Acrocyanosis and Perniosis.
 Hair abnormalities: Hypertrichosis, Hair loss.

43. Psychogenic Pruritus

44. Psychogenic itch
 Pruritus is a multifactorial symptom.
 Misery and colleagues have proposed diagnostic
criteria for psychogenic pruritus. There are three
compulsory criteria:
1. Localized or generalized pruritus sine material.
2. Chronic pruritus (>6 weeks).
3. Absence of a somatic cause

45. Management
First line:
i. Emollients
ii. Topical steroids
iii. Antihistamines
iv. Behaviour oriented therapy(Habit reversal treatment)
Second line:
1. Tricyclics(doxepin, amitriptyline)
2. SSRIs (fluoxetine, citalopram)
3. Phototherapy, Photochemotherapy
4. Cooling creams e.g. 2%menthol
Third line:
1. Mood stabilizing antidepressents(trazadone, duloxetine)

46. Factitious skin
disease

47. Definition by DSM-5
A. Falsification of physical or psychological signs and
symptoms, or induction of injury or disease,
associated with identified deception.
B. The individual presents himself or herself to others
as ill, impaired or injured.
C. The deceptive behaviour is evident even in the
absence of obvious external rewards.
D. The behaviour is not better explained by another
mental disorder such as a delusional disorder or
another psychotic disorder.

48. TYPES
 Dermatitis artefacta
 Dermatitis simulata
 Dermatological pathomimicry
 Dermatitis passivata
 Malingering
 Pseudologia fantastica and Münchausen syndrome

49. Dermatitis artefacta
 Caused entirely by actions of fully aware (i.e. not
consciously impaired) patient on the skin, hair, nails,
scalp or mucosae.
 Occurs in children from age of 8 years onwards, pre-
pubertal children having an equal sex ratio, rising to
3:1 female predominance in early teens. In adults F>M.
 Due to psychosocial stress of a major life event

50. Clinical features
 2 characteristics:-
1. Physical signs
2. Fabricated story that accompanies it
 patient often describes :
 Sudden appearance of lesions with little or no
prodrome.
 No complete description of genesis of individual skin
lesions.

51.  Commonest site are face (cheeks) in 50% children, dorsa of
hands, forearms
 Most frequently of non-dominant limb, mostly on covered
skin
 Lesions are polymorphic, bizarre, clearly demarcated from
surrounding normal skin and can resemble many
inflammatory reactions in skin
 Crude, angulated, destructive processes with a tendency to
a linear configuration, Circular erosions or blisters of a
uniform size, as result of thermal, chemical or
instrumental injury

52. Dermatitis factitia. Crude, linear, angulated
and destructive factitious dermatitis
straight edges and sharp angulation
of lesions.

53. Non‐healing wound after surgery with characteristic
central ’interference haemorrhage’.
Dermatitis factitia
showing the drip sign

54. Clinical variants
 Factitious cheilitis.
 Factitious nail disease.
 Hair artefact.
 Witchcraft syndrome.
 Constriction artefact.
 Purpura artefact.
 Dermal artefact.
 Postsurgical artefact.

55. Factitious cheilitis due to repeated lip
sucking. Factitious nail disease

56. Glue applied to look like herpes zoster
Dermatitis simulata

57. Dermatitis passivata
 Young Diogenes syndrome; accretions of facial keratin and debris

58. Fabricated and induced illness
 Münchausen syndrome by proxy where the illness in a
child is fabricated by the parent, usually the mother
The most common presentations are:
 Bleeding and bruising (44%),
 Central nervous system depression (19%),
 Apnoea (15%),
 Diarrhoea (11%),
 Vomiting (10%),
 Fever (10%)
 Rash(9%).

59. Deliberate self‐harm

60. With suicidal ideation Without suicidal intent
 Self‐mutilating behaviour is
often grouped with other
behaviours, such as
self‐poisoning, attempted
hanging or jumping from
heights, as ’parasuicide’ or
’deliberate self‐harm’
 It is the self‐injurious
behaviour, or self‐mutilation,
occurring outside the context
of conscious suicidal ideation
Treatment:
• Selective Serotonin Reuptake Inhibitors
• Dopamine antagonists
• Opiate antagonists
• Mood stabilizers,
• β‐blockers
• Analgesics

61. THANKYOU