Description*

Psychodermatology aims to erase the border between the physical and psychological aspects of people struggling with a chronic cutaneous disorder. The negative impacts of conditions such as psoriasis, acne, eczema, alopecia and rosacea are not limited to the visible expression of the disease; they also cause significant emotional and mental distress. Through this subspecialty of dermatology, a biopsychosocial understanding of the context in which skin disease evolves can be achieved, offering patients new perspectives and improved quality of life. 

Embryonic origin

Skin and brain share a common embryonic ectodermal origin. Thus, it is not surprising to find that 35-40% of patients suffering from a chronic dermatological disorder will present psychological symptoms as well 2.

Effects of skin conditions on daily life

The visible aspect of a chronic skin condition is just the tip of the iceberg, as it is the invisible emotions that cause helplessness, feelings of rejection and despair. Individual characteristics and life experiences influence patients' attitude towards their disease. Many people isolate themselves by gradually withdrawing from social interactions, creating a vicious circle of deterioration in their emotional and mental state. In addition, the misunderstanding of others and cultural attitudes amplify distress. Extremely aware of their skin condition, they prefer to stay covered in order to avoid stares and whispers. In some cases, these patients are asked to leave public places such as a community recreation center or swimming pool when their condition is mistaken for a contagious rash. And each time, the vicious circle tightens more tightly around them, potentially creating anxiety-depressive disorders. It is this stigma and rejection that reinforces their feelings of distress, anxiety and low self-esteem. Psychodermatology can equip these patients to understand themselves better and to pay less attention to the judgment of others in order to assert themselves and reconnect with the joy of living.

Effects of everyday life on skin conditions

Stress, depression, social anxiety and various other psychosocial factors can trigger or worsen skin conditions, such as eczema, psoriasis, hives, acne... Thus, a recent job change , excessive work demands, interpersonal relationship difficulties, separation, bereavement, the difficulty of reconciling professional and personal life, financial problems, moving, the context of a health crisis, etc... are examples where we must heal from the inside out, where the psychological suffering hides behind the dermatological manifestation.

The hidden face of a psychological/psychiatric disorder

In patients with obsessive-compulsive disorder, the compulsions manifest themselves by washing hands frequently which produces a skin irritation that can, a priori, be confused with a contact allergy. Patients may also compulsively pull out body hair. In some cases, patients have an unshakeable belief that they are infested with microorganisms, insects, worms, mites, or lice. So they start scratching which in turn causes self-inflicted lesions. Others may feel the morbid need to damage their own body, by deliberately injuring it in order to feign disease, without aiming for direct benefit.

When the skin gets carried away

Some patients have painful perceptions or strange sensations, in the form of tingling or burning. These sensations are often localized in one place or can be perceived anywhere in the body, without an objectifiable pathological explanation. The topography of these cutaneous manifestations is often vague and the description by the patient is colorful and of imprecise quality. The triggers of these sensations are often related to psychoaffective factors.

 Classification of psychodermatological conditions

Psychodermatology practitioners treat the following four categories of skin conditions:

Psychophysiological disorders: In this category stress, emotional trauma and adverse psychosocial factors amplify the manifestation of the rash, such as psoriasis, atopic dermatitis, rosacea, hyperhidrosis, lichen simplex chronicus, urticaria, acne vulgaris and seborrheic dermatitis.

· Primary psychiatric disorders: Here the patients do not have a primary dermatological disorder. These are self-inflicted lesions secondary to a psychological disorder. This category includes delusional parasitosis, neurotic excoriations, excoriated acné and obsessive-compulsive spectrum disorders such as trichotillomania , factitious disorder, anorexia and bulimia. It should be noted that the majority of these patients do not realize that they have a psychiatric disorder causing the skin conditions and are very reluctant to consult a mental health professional.

· Secondary psychiatric disorders: Patients in this category develop psychological disorders related to their dermatological condition. The unsightly appearance caused by certain skin diseases has a significant effect on the patient's psychological well-being. Patients often feel uncomfortable discussing this negative psychosocial impact and the role of the dermatologist becomes paramount in addressing the psychological component.

· Sensory skin syndromes: These are conditions characterized by unpleasant sensations in the skin: tingling, itching, burning of the tongue, female genitalia or scalp, or non-specific pruritus. There is no apparent organic evidence of a skin disorder.

Treatment

Treatment in psychodermatology is based on various psychotherapy techniques in combination, if necessary, with targeted pharmacotherapy. The main psychotherapy techniques are: cognitive-behavioural, psychodynamic, humanistic, interactional therapy, hypnosis, etc. The arsenal of prescription drugs is vast and used sparingly, only in the event of need: antidepressants, anxiolytics, antihistamines, etc.

 Conclusion

Thus, the main objectives of psychodermatology are to study the emotional impacts that the condition of a patient's skin can create in order to help the patient overcome them and reduce the threats to wellbeing. The ultimate goal is to help the patient develop adaptive mechanisms they can use when a recurrence occurs.

Role of stakeholders

A multidisciplinary approach specifically adapted to each patient, emphasizing the improvement of the quality of life, is essential for comprehensive management of the patient. According to several surveys, dermatologists are poorly equipped to know how to treat patients with psychodermatological disorders. In addition, the lack of insight on the part of the patient to recognize the underlying psychological aspect of their skin disease, and the reluctance to consult a mental health professional represent major obstacles to improving their state of health.

* Source :  with the permission of Dr Mohammad Jafferany, professor of Psychodermatology, Psychiatry and Behavioral Sciences at Central Michigan University , author of the "Handbook of Psychodermatology-Introduction to Psychocutaneous Disorders" , Springer Nature Switzerland AG 2022                                            

Scientific publications in the field of psychodermatology

Psychiatric and psychologic aspects of chronic skin diseases

Rachel Christensen ,Mohammad Jafferany (March 2023)

Key Points : Chronic skin diseases can substantially impact a patient's physical, psychologic, and social well-being. Physicians may play a critical role in identifying and managing the psychologic sequelae of the most common chronic skin conditions. Acne, atopic dermatitis, psoriasis, vitiligo, alopecia areata, and hidradenitis suppurativa are chronic dermatologic diseases that put patients at high risk for symptoms of depression, anxiety, and decreased quality of life.

Both general and disease-specific scales exist to assess the quality of life in patients with chronic skin disease, the most common being the Dermatology Life Quality Index. The general management approach to the patient with chronic skin disease should incorporate acknowledgment and validation of the patient's struggles, patient education on the potential impact of disease and prognosis; medical management of the dermatologic lesions; coaching on stress management; psychotherapy. Psychotherapies include talk therapy (i.e., cognitive behavioral therapy), arousal-reducing therapies (i.e., meditation, relaxation), and behavioral therapies (i.e., habit reversal therapy). Improved understanding, identification, and management of the psychiatric and psychologic aspects of the most common chronic skin conditions by dermatologists and other healthcare providers may positively affect patient outcomes.

Estimated Frequency of Psychodermatologic Conditions in Alberta, Canada

 Tarek Turk , Marlene Dytoc (2020)

Key Points :

1.Our province-wide retrospective study of patients in dermatological care in Alberta, Canada showed that more than a quarter of dermatology patients in Alberta were concurrently prescribed psychotropic medications, implying high rates of psychodermatologic and/or concurrent mentahealth conditions in dermatology...Our results highlight several challenges in psychodermatology, one of which is underreporting

2.Assessment and improvement of quality of care for psychodermatologic conditions can be planned to establish informed interventions including multidisciplinary psychodermatology units, training programs, and patient information resources. These interventions, particularly multidisciplinary clinics, can narrow several gaps in psychodermatology such as underreporting, underrecognition, and the lack of knowledge on epidemiological characteristics of psychodermatologic disorders, which is highlighted in our paper, as well as several literature reviews.

How to set up a psychodermatology clinic

 S. Aguilar‐Duran (2014)

Key Points

: 1. Psychodermatology is a discipline that during the past few years has become more popular as a result of the high prevalence of patients with chronic cutaneous conditions that impair their quality of life, and an increase in the number of psychiatric patients with skin involvement attending general dermatology clinics.

2.The overall number of units remains low. Previous obstacles to adequate psychodermatology provision included lack of funding and interest, long consultation times and poor training.

3. There are available courses provided in the UK and Europe, which provide an insight into this subspecialty. By increasing exposure to psychodermatology, the likelihood of trainees choosing this as a subspecialty in the future rises. Increasing the number of units also provides training opportunities for interested clinicians and healthcare professionals.

4. Introducing psychodermatology clinics regionally will result in improved care for patients with psychocutaneous disease, and will also support clinicians. This will in turn prove financially sustainable, as patients will be seen by the correct services in a timely fashion. For those clinicians and health professionals who have an interest in psychodermatology, such services will allow them to pursue their interests in a more formal role, improving their job satisfaction and meeting training needs.

Psychodermatology: An evolving paradigm

Swapna Bondade1, Abhineetha Hosthota, R Bindushree, P Raghul Raj1(2022)

Key Points :

1.The prevalence of mental disorders in patients with skin diseases is estimated between 30% and 60%. Eighty-five percent of patients with skin conditions reported that psychologic aspects of their skin condition played a significant role in their illness.In the first systematic study of mental disorders among people with skin diseases conducted by Hughes et al., a higher prevalence of mental disorders among dermatological clinic patients than among the general population was observed.

2.Some goals that should be targeted while treating patients with psychodermatological disorder include:Reduce physical distress , Detect and improve sleep disturbances,Detect and treat psychiatric symptoms such as depression and anxiety, Manage social isolation/withdrawal, Improve self-esteem, Improve functioning.

3.Both nonpharmacological and pharmacological therapeutics have been used successfully. Psychotherapy, cognitive behavioral therapy, hypnosis, stress management techniques, relaxation training, transcendental meditation, and biofeedback are some of the nonpharmacological approaches that have been successfully employed. Pharmacological drugs used include antidepressants, anxiolytics, antipsychotics, immunosuppressants, antihistamines, oral or systemic corticosteroids, and other topical medications. The choice of a drug is based on psychopathology that can be compulsion, psychosis, anxiety, or depression . The most commonly used are selective serotonin reuptake inhibitors, serotonin–norepinephrine reuptake inhibitors, mood stabilizers, and antipsychotics. Antipsychotics can be used either to augment the efficacy of other medicines or as monotherapy in certain conditions such as delusions of parasitosis and trichotillomania. Other commonly used psychiatric medications include gabapentin in postherpetic neuralgia, naltrexone for pruritus, and lamotrigine/topiramate to treat skin picking.

4.To improve the training sessions of dermatologists in the field of psychiatry by having rotational postings for better understanding of the psychodermatological disorders. Workshops, continued medical education, and webinars would improve the knowledge of specialists of all three specialties, thus heightening the skill and knowledge in approach and management of these patients.

A review of psychocutaneous disorders from a psychotherapeutic perspective—Toolkit for the dermatologist

Mary Zagami, Edward Klepper (2023)

Key Points :

Psychotherapeutic interventions :

 1. Cognitive behaviour therapy (CBT) - CBT is a type of talk therapy that aims to challenge and change distorted thoughts, beliefs, attitudes, and resulting behaviours in order to improve emotional regulation and develop coping strategies

2. Desensitization

 3. Exposure and response prevention

4. Acceptance-enhanced behavioural therapy

5. Mindfulness/meditation

 6.Dialectical behaviour therapy (DBT)-A form of CBT where the therapist treats the patient as an ally. The therapist works together with a patient as their advocate but also points out their abnormal psychosocial behaviour and makes recommendations on improving this behaviour. This form of therapy uses multiple tools to achieve these goals including having the patient do a diary, practice meditation and other supplemental therapies to achieve the goal of emotional balance Supplemental therapies: 1.Acupuncture 2. Art therapy 4. Biofeedback 5.Hypnosis 6. Journaling/diary

 7.Psychoeducation-insightful information to help patients and family members 8. Yoga

Psycho pharmacological therapy: 1. Antidepressants (Selective serotonin reuptake inhibitors (SSRIs)- citalopram, dapoxetine escitalopram, fluoxetine fluvoxamine, paroxetine sertraline, voritioxetine Serotonin and norepinephrine reuptake inhibitors (SNRIs) (duloxetine, venlafaxine, milnacipran) Tricyclic antidepressants (TCAs)- amitriptyline,amoxapine, desipramine, doxepin, imipramine, nortriptyline, protriptyline, trimipramime Monamine oxidase inhibitors (MAOIs)- selegiline, isoarboxazid, phenelzine, tranylcypromim ) 2. Anxiolytics-benzodiazepines-(Alprazolam,chlordiazepoxide, clonazepam, clorazepate, diazepam, estazolam, flurazepam, lorazepam) 3. Anxiolytics (buspirone) 4. Opioid antagonist-naltrexone 5.Antipsychotics (pimozide, olanzapine, risperidone, aripiprazole, paliperidone) 6.Anticonvulsants (oxcarbazepine) 7.Other: lithium,N-acetylcysteine, lamotrigine

Dermatologists would instruct patients to complete the self-screening, print out their responses or upload into a patient portal. These questionnaires provide the dermatologist with easily interpretable data that can aid in proper diagnosis and course of treatment of dermatologic conditions with underlying psychiatric comorbidities. At this point, the patient would be referred to a mental health practitioner for a more in-depth work-up and psychiatric treatment. For example, pruritus intensity has been found to correlate with the severity of depression.134 Treating underlying depression and other psychiatric disorders may streamline treatment and achieve better control of symptoms such as pruritus. Regarding the primary psychiatric disorders with dermatologic manifestations, patients will typically see specialists other than the psychiatrist, such as the dermatologist, to address their medical concerns.6 Since the patient may be reluctant or flat out refuse to see a psychiatrist, the dermatologist can the information above to guide potential treatment modalities....For patients highly resistant to a psychiatric evaluation, these authors believe it would be beneficial if there was a mechanism in place whereby a dermatologist, or any health care provider, could consult with a psychiatrist to aid in implementation of therapy with the aim of transfer of care to that psychiatrist.

Psychodermatology: An Overview of History, Concept, Classification, and Current Status

Ravindra Neelakanthappa Munoli(2020)

Key Points : 1. multiple subspecialties have shaped up in psychodermmatology: Pediatric psychodermatology: Geriatric psychodermatology: Trichopsychodermatology ( This field focuses on psychological and social aspects of hair hair loss and excess of hair in terms of role of stress on hair disorders, addressing stigma/psychological conditions related to hair loss/excess and quality of life impacted by these.) Psychodermato-oncology (Skin cancer is the most common type of cancer worldwide, and disfigurement, stigma, anxiety, depression, guilt, and fear of death are commonly encountered conditions. This subspecialty addresses psychological impact of skin cancer and the role of stress in the development of skin cancers).Cosmetic psychodermatology:( With the surge in interest in cosmetic procedures and associated psychological aspects in recent decades, cosmetic dermatologists felt the need of tailor-made training in basic psychosocial evaluation, cultural understanding, expectations, and previous experiences). Tropical psychodermatology (Tropical skin diseases (infectious or noninfectious), associated psychosocial aspects and quality of life are focused in this subspecialty) Sports psychodermatology:( Psychosocial impact of commonly seen skin conditions in exercise and sports (inflammations, aberrant growths, trauma) on performance is addressed by this subsection) Environmental psychodermatology: (This explores the interaction between skin, environment, and stressors.)

 2.In patients visiting dermatology clinics, 30–40% had associated psychiatric disorders as comorbidity.

3.Physical or mental stress has an important role in immunoprotection, immunoregulation, and immunopathology in psychodermatological disorders and can lead to exacerbation of dermatoses. Neuroendocrine and neuroimmune dysregulations by stress are at the core of autoimmune or inflammatory dermatologic disorders which suggests a bidirectional relationship concept of psychosomatic disorders.

4.Dedicated psychodermatology clinics are still in infancy in many countries; however, training programs can consider orientaing and preparing psychiatrists, dermatologists, and psychologists to evaluate and address psychosocial impact of dermatoses with an aim to improve quality of life of patients.

Psychodermatology liaison clinic in India: a working model                            

Nupur Goyal, Shrutakirthi Shenoi (2017)

Key points:Literature reports suggest that up to 30% of dermatology patients have associated psychiatric co-morbidity. A psychodermatology liaison (PD) clinic is essential to deal with such patients, which is almost non-existent in the Indian scenario...Nearly 33% of the patients attending our psychodermatology liaison(PD) clinic had psychiatric co-morbidity, the commonest being an adjustment disorder

Psychodermatology: An Indian perspective                                                                                                                     Shrutakirthi D Shenoi , Smitha S Prabhu (2018)

Key points : Psychodermatology, a relatively neglected branch of dermatology in India, refers to a holistic approach to skin diseases involving not only the mind and skin, but also the cutaneous effects of psychologic stress. Among many Indian people, culture, religion, the belief in karma, and the tendency to prefer indigenous medical systems can all have a major impact on lifestyle, as well as the approach to managing various diseases, including dermatologic conditions...The first dedicated psychodermatology liaison clinic was established in 2010 in Manipal, India. The common problems encountered have been anxiety, dysthymia, and depression, especially in patients with psoriasis, vitiligo, and urticaria.

Pharmacological Interventions for Primary Psychodermatologic Disorders: An Evidence Mapping and Appraisal of Randomized Controlled Trials

Tarek Turk  , Chaocheng Liu , Esther Fujiwara  , Sebastian Straube , Reidar Hagtvedt , Liz Dennett , Adam Abba-Aji Marlene Dytoc       2023 Feb 20.

Key Points : Few pharmacotherapies for primary psychodermatologic disorders are assessed through controlled trials in the literature. This review serves as a roadmap for researchers and clinicians to reach informed decisions with current evidence, and to build on it to establish guidelines in the future.

Psychopharmacology in dermatology: Five common disorders

Keys Points : Dermatologists often encounter a patient who presents with an illness that overlaps both psychiatric and dermatologic specialties. Psychodermatology patients range from straightforward (ie, trichotillomania, onychophagia, excoriation disorder) to challenging (ie, body dysmorphic disorder) to highly challenging (ie, delusions of parasitosis). Many refuse to see psychiatrists. As such, the only chance that many of these patients will receive treatment is if the dermatologist is willing to prescribe psychiatric medications to them. We review five common psychodermatologic disorders and how to treat them. We discuss some commonly prescribed psychiatric medications and provide the busy dermatologist with a few psychiatric tools in the dermatologic toolbox.

The Psychosocial Impact of Chronic Facial Dermatoses in Adults

Yunus Ozcan 1 , Mehmet Ali Sungur 2 , Begum Yaman Ozcan 3 , Yavuz Eyup 4 , Emin Ozlu 5

Key Points :Chronic facial dermatoses have a detrimental impact on mood and quality of life. Although patients with acne, rosacea, and seborrheic dermatitis have distinct lesions, the outcomes in terms of quality of life, anxiety, and depression are largely similar. Furthermore, these patients report similar levels of social anxiety as a result of their overall appearance.

Dermatological Findings in Body- focused Repetitive Behaviours

Amir Gohari, University of British Columbia, Vancouver, British Columbia, Canada
Joseph M Lam, MD, FRCPC, Department of Pediatrics, Department of Dermatology and Skin Sciences, University of British Columbia, Vancouver, British Columbia, Canada

Journal of Current Clinical Care Volume 13, Issue 2, 2023

Key Points :

Body-focused repetitive behaviours (BFRBs) are common yet poorly understood conditions with significant mental and physical implications. Dermatological findings associated with BFRBs can be atypical, and recognizing them can be very beneficial. This paper reviews the dermatological findings associated with BFRBs, including habit-tic nail deformity, onychophagia, onychotillomania, trichotillomania, lip/cheek biting, dermatillomania, and compulsive washing. Recognition of these classic dermatological signs can help clinicians differentiate them from other common dermatological conditions. Body-focused repetitive behaviours require multidisciplinary management, and derma- tology can contribute to their recognition and treatment.

In fact, despite BFRBs affecting around 15% of college students,6,7 32% of dermatolo- gists surveyed in Washington State reported having no training on this condition and 49% reported only limited or partial training regard- ing BFRB.