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Psychiatry, dermatology patients can overlap.

Dermatologists may be the first medical professionals to see patients with some types of psychiatric disorders, so an understanding of the skin manifestations that can occur with these conditions is important.

Some skin conditions have psychiatric consequences. Some psychiatric conditions first manifest as dermatologic conditions. And for other disorders, there is a complex interplay between the skin and the mind, Dr. Gordon Strauss noted at the seminar.

The patients most likely to present to a dermatologist are those with delusions of parasitosis, factitial dermatitis, neurotic excoriations, trichotillomania, and borderline personality disorder.

Dr. Strauss, a professor of psychiatry at the University of Louisville in Kentucky, divided psychodermatologic disorders into three categories: primary psychiatric disorders, secondary psychiatric disorders, and psychophysiologic disorders.

Patients with delusions of parasitosis believe their skin is infested with insects or parasites. They will often bring in samples of sloughed skin or hair as evidence of their infestation. Studies have found that these delusions are most common in women older than age 50 years.

One frequent characteristic of these patients is that they may go from physician to physician in an attempt to get treatment, but they will not go to a psychiatrist. This may put dermatologists in the unusual position of prescribing antipsychotic medication. Pimozide may be particularly helpful for delusions of parasitosis, said Dr. Strauss.

Neurotic excoriations are breaks in the skin from picking or scratching. Patients usually will not deny that they caused the problem, but some will. An important clue in patients who deny causing the excoriations will be that there are none in areas of the body that are hard to reach.

Factitial dermatitis, defined as the intentional production of dermatologic signs, is similar to neurotic excoriations, but the lesions will typically be more elaborate than those in neurotic excoriations, and the patient will always deny causing them. Studies suggest that factitial dermatitis is three to eight times more common in women than in men, with a peak incidence during adolescence and young adulthood. It also is commonly seen in health care workers and in patients with psychosis or mental retardation.

Patients also may visit a dermatologist for treatment of alopecia, which, if it is irregular and ill defined, may be a sign of trichotillomania. If there is any question, a biopsy usually will be definitive.

Dermatologists will rarely see patients with borderline personality disorder (BPD), and that is fortunate because these patients are notoriously difficult, Dr. Strauss noted. Patients with BPD tend to be emotionally intense and labile. They are insecure and very sensitive to actual, threatened, or imagined abandonment. They are easily bored and may seek excitement by creating drama. Dermatologists may become involved in caring for a patient with BPD when he or she engages in self-mutilation such as cutting or burning.

Secondary psychiatric disorders are common in patients with primary dermatologic conditions. Depression can be a side effect of isotretinoin treatment, for example. Anyone with a disfiguring skin disease may suffer from an anxiety disorder, with social anxiety disorder leading the pack, he noted.

Finally, Dr. Strauss listed dermatology-related psychophysiologic disorders, in which the mind affects the skin and vice versa. Among the most common are alopecia areata, acne, eczema, hyperhidrosis, psoriasis, seborrheic dermatitis, and urticaria.

Dr. Strauss acknowledged owning stock in Allergan, Eli Lilly, Merck, Pfizer, and Wyeth.

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Author:Finn, Robert
Publication:Clinical Psychiatry News
Date:Jan 1, 2010
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