Skin and Psychiatric Illness why close association Skin is accessible-easy target of psychiatric illness Skin is accessible-easy target of psychiatric illness Skin is visible-associated with self image Skin is visible-associated with self image Skin is sensitive-symptoms are common, varied, source easily perceived, with a low threshold for symptoms to occur Skin is sensitive-symptoms are common, varied, source easily perceived, with a low threshold for symptoms to occur

Classification of Skin Diseases and Psychiatric Disease 1. Primarily Psychiatric Illness 1. Primarily Psychiatric Illness 2. Psychiatric Illness Flares Skin Disease 2. Psychiatric Illness Flares Skin Disease 3. Primarily Skin Diseases 3. Primarily Skin Diseases 4. Skin Disease Flares Psychiatric Illness 4. Skin Disease Flares Psychiatric Illness Should a psychiatrist treat these patients?- good idea but won’t work if patient won’t see the psyhiatrist Should a psychiatrist treat these patients?- good idea but won’t work if patient won’t see the psyhiatrist

Psychiatry and Skin Disorders 1. Primarily Psychiatric Illness Primary Psychiatric Disorders Primary Psychiatric Disorders -Trichotillomania -Trichotillomania -Neurotic Excoriations -Neurotic Excoriations -Acne Excorie Des Jeunes Filles -Acne Excorie Des Jeunes Filles -Parasitophobia -Parasitophobia -Factitial Dermatitis -Factitial Dermatitis -Dysmorphic syndrome -Dysmorphic syndrome -Morgellons -Morgellons

Trichotillomania  Plucking, twisting, cutting or breaking hair from scalp or eyebrows Diff. Dx Diff. Dx -Alopecia Areata -Alopecia Areata -Tinea -Tinea

…Trichotillomania Continued Clues Clues -Female -Female -<10 y/o -<10 y/o -Localized -Localized -Sharply demarcated -Sharply demarcated -Symmetric -Symmetric -Biopsy helpful -Biopsy helpful Mainly OCD-SSRI’s Mainly OCD-SSRI’s Also depression and anxiety Also depression and anxiety

Parasitophobia (Acarophobia, Formication- sensation of stinging or biting) Psychosis with firm fixation of a parasitic infestation Psychosis with firm fixation of a parasitic infestation Must rule out true parasite; i.e., scabies Must rule out true parasite; i.e., scabies “Matchbox Sign” “Matchbox Sign” No primary skin lesions No primary skin lesions Esp. middle-aged female Esp. middle-aged female Hypochondriacal monosymptomatic psychosis, may have a facilitator Hypochondriacal monosymptomatic psychosis, may have a facilitator

…Parasitophobia Continued Also schizophrenia, bipolar disorder, psychotic depression, anxiety disorder, obsessional state Also schizophrenia, bipolar disorder, psychotic depression, anxiety disorder, obsessional state Organic states Organic states -Cocaine and amphetamine abuse -Cocaine and amphetamine abuse -MS -MS -Parkinson’s -Parkinson’s -Dementia -Dementia -CNS pathology -CNS pathology -B-12 deficiency -B-12 deficiency Treatment-pimozide (Orap) Treatment-pimozide (Orap) olanzapine (Zyprexa) olanzapine (Zyprexa)

Neurotic Excoriations Neurosis with excoriations but no primary skin lesions Neurosis with excoriations but no primary skin lesions Characteristic linear hypopigmented scars Characteristic linear hypopigmented scars Opposite dominant hand side Opposite dominant hand side Upper back, face, upper extremities Upper back, face, upper extremities Acne Excorie Des Juenes Filles is a common variant Acne Excorie Des Juenes Filles is a common variant

…Neurotic Excoriations Continued OCD, depression, anxiety OCD, depression, anxiety Treatment Treatment -Doxepin -Doxepin -Desipramine -Desipramine -Buspirone -Buspirone

Factitial Dermatitis (Dermatitis Artefacta) Psychosis with linear, sharply demarcated, bizarre, excoriations, erosions or ulcerations Psychosis with linear, sharply demarcated, bizarre, excoriations, erosions or ulcerations Opposite dominant hand distribution, symmetric, drop-shaped or panniculitic Opposite dominant hand distribution, symmetric, drop-shaped or panniculitic Chronic non-healing wound that only responds to occlusive dressing Chronic non-healing wound that only responds to occlusive dressing Malingering (Workman’s comp case) Malingering (Workman’s comp case) Also borderline personality disorder Also borderline personality disorder Treatment Treatment -Pimozide(Orap) -Pimozide(Orap) -Fluoxetine(Zyprexa) -Fluoxetine(Zyprexa)

Dysmorphic Syndrome Delusion of having an ugly body part, frequent plastic surgery procedures, hair loss Delusion of having an ugly body part, frequent plastic surgery procedures, hair loss Common (affects up to 1% of the population) Common (affects up to 1% of the population) Obsessional and depression-may present a suicide risk Obsessional and depression-may present a suicide risk SSRI’s SSRI’s

Psychiatry and Skin Disorders 2. Psychiatric Illness Flares Skin Disease Psoriasis Dyshidrosis Dyshidrosis Atopic Dermatitis Atopic Dermatitis -Lichen Simplex Chronicus -Lichen Simplex Chronicus -Prurigo Nodularis -Prurigo Nodularis Alopecia Areata Alopecia Areata Drugs Drugs -Lithium -Lithium -Tegretol -Tegretol Essential Pruritis Essential Pruritis

Incidence of Emotional Triggering of Common Dermatoses Diagnosis Proportion with emotional trigger (%) Biologic incubation between stress and clinical changes Hyperhidrosis100Seconds Lichen simplex chronicus 98Days Rosacea94 2 days

…Continued Dyshidrosis76 2 days for vesicles Atopic dermatitis 70 Seconds for itching Urticaria68Minutes Psoriasis62Days

…Continued Papular acne vulgaris 55 2 days Seborrheic dermatitis 41Days Fungus infection 9Days Nevi0 Basal cell carcinoma 0 Keratoses0

Prurigo Nodularis Multiple, very pruritic (paroxysmal), pea- sized or larger nodules Multiple, very pruritic (paroxysmal), pea- sized or larger nodules Mainly extremities, esp. pretibial Mainly extremities, esp. pretibial Heals with scars Heals with scars May be strictly an emotional disease May be strictly an emotional disease

…Continued Other causes-atopic, hepatic disease (esp. hepatitis C), HIV disease, PG, renal failure, anemia, photodermatitis, gluten enteropathy, insect bites, pemphigoid nodularis Other causes-atopic, hepatic disease (esp. hepatitis C), HIV disease, PG, renal failure, anemia, photodermatitis, gluten enteropathy, insect bites, pemphigoid nodularis Treatment-steroids (topical, Cordran tape, intralesional), Dovonex, Taclonex, PUVA, Accutane, Thalidomide, cyclosporine, UVB Treatment-steroids (topical, Cordran tape, intralesional), Dovonex, Taclonex, PUVA, Accutane, Thalidomide, cyclosporine, UVB

Lichen Simplex Chronicus (Neurodermatitis Circumscripta) Severe paroxysmal pruritus producing well- demarcated, localized lichenified plaque Severe paroxysmal pruritus producing well- demarcated, localized lichenified plaque Skin becomes thick and leathery and can mimic psoriasis Skin becomes thick and leathery and can mimic psoriasis Esp. posterior neck (females), ankles (males),genitalia, rectum,external auditory canal, pretibial Esp. posterior neck (females), ankles (males),genitalia, rectum,external auditory canal, pretibial

… LSC Continued Associated with stress and anxiety Associated with stress and anxiety Treatment Treatment -Steroids (potent topicals, intralesional, Cordran tape) -Steroids (potent topicals, intralesional, Cordran tape) -Zonalon (topical doxepin) -Zonalon (topical doxepin) -Occlusion (Unna wrap) -Occlusion (Unna wrap) -J and J Wound Care Treatment -J and J Wound Care Treatment

Psychiatry and Skin disorders 3. Primarily Skin Disease -Acne -Acne -Vitiligo -Vitiligo -Alopecia Areata -Alopecia Areata -Psoriasis -Psoriasis

Psychiatry and Skin Disorder 4. Skin Disorder Flares Pychiatric Illness -Drugs -Drugs -Systemic and topical corticosteroids -Systemic and topical corticosteroids -Accutane -Accutane -Depression -Depression

Morgellon’s Disease 8,263 registrant household’s in the mongellon’s research foundation 8,263 registrant household’s in the mongellon’s research foundation 5,890 hits on google 5,890 hits on google 1 st described in 2002 by Mary Leito (biologist) 1 st described in 2002 by Mary Leito (biologist) Mayo Clinic Mayo Clinic -Nonentity -Nonentity -Specific condition with cause to be determined in future -Specific condition with cause to be determined in future -Delusional parasitosis -Delusional parasitosis

…Morgellons Continued Crawling, biting, stinging sensation Crawling, biting, stinging sensation Fibers on or under skin Fibers on or under skin Persistent skin disease Persistent skin disease -rash -rash -sores -sores

Scientists take on Morgellons disease KC Star 1/19/08 After years of complaints from patients, the U.S. Centers for Disease Control and Prevention recently launched a study into a bizarre — and possibly delusional — condition known as Morgellons. Around 2002, the agency started hearing from a handful of patients about the unexplained condition in which sufferers typically feel crawling sensations and observe fibers coming out of their skin. It now receives about 1,200 inquiries a year about the disease. The study will look at patients in Kaiser Permanente’s Northern California network, because the area has been a hot spot of reported cases. “We are really at the beginning, I think, of a learning curve about what this condition is and all of its potential manifestations,” said Michele Pearson, a CDC physician who is the study’s principal investigator. “Those who suffer from this condition, as well as the family members and physicians who provide care to them, have questions, and we want to help them find meaningful answers.” About 11,000 families in the United States and several countries overseas have registered their illnesses with the Morgellons Research Foundation, a group started by Mary Leitao, a Pittsburgh mother who found an abnormal rash on her son in She named the disease after a reference in a 17th-century French medical text of “strange hairs” sprouting from children’s backs. Leitao said she hopes the study will help legitimize the disease, which many doctors have diagnosed as delusional parasitosis and treated with anti-psychotic medications

Final Words of Advice Patience Patience Empathy Empathy Honesty Honesty