Management of Psychodermatologic Disorders

Philip D. Shenefelt, MD, MS


Dermatology Nursing 

In This Article

Primary Psychiatric Disorders Affecting the Skin


Acute or chronic anxiety can worsen a number of skin disorders. In a recent study, 13% of patients at a dermatology clinic had an anxiety disorder (Seyhan et al., 2006). The anxiety may be treated with cognitive-behavioral methods, relaxation training, or self-hypnosis (Scott, 1960). The anxiety may also be treated with anxiolytics (see Table 3).


Delusions of parasitosis, bromhidrosis, or fibers (Morgellons) are monomaniacal delusions specific only to that particular issue. Patients often respond best to typical antipsychotics such as pimozide (Orap®) or to atypical antipsychotics such as olanzapine (Zyprexa®) or risperidone (Risperdal®). Parenterally administered atypical antipsychotics such as risperidone administered weekly were particularly effective, since they substantially increased adherence to treatment (Mercan, Altunay, Taskintuna, Oguteen, & Kayaoglu, 2007).


Primary depression may lead to acts of self-harm to the skin such as scratching, picking, digging, burning, cutting, pulling, tearing, or otherwise harming the skin, hair, or nails (Gupta & Gupta, 2003). In a recent study, 32% of patients at a dermatology clinic had depression (Seyhan et al., 2006). The majority of patients who have self-inflicted dermatoses such as neurotic excoriations suffer from depression with somatization (Gupta, 2006). Treating the depression with an antidepressant (see Table 3 ) (Lee & Koo, 2003) may improve treatment responsiveness for the self-damaging habit.

Dissociative Somatization

Somatic symptoms that seem to have no explainable underlying physical pathology are common both in general medicine and in dermatology. In general medicine, some common functional somatic syndromes include irritable bowel syndrome, fibromyalgia, chronic fatigue syndrome, and interstitial cystitis (Kroenke, Sharpe, & Sykes, 2007). In dermatology, examples include unexplained cutaneous sensory syndromes, and body memories from traumatic stress in post-traumatic stress syndrome. These syndromes may manifest as pruritus, urticaria, or angioedema, self-induced dermatoses such as dermatitis artifacta and trichotillomania associated with dissociative states, and body dysmorphic disorder, where the patient has a somatic preoccupation involving the skin or hair (Gupta, 2006). In patients with acne, 14%-21% have aspects of body dysmorphic disorder (Bowe, Leyden, Crerand, Sarwer, & Margolis, 2007). Generally, functional somatic syndromes are more responsive to active non-pharmacologic treatments requiring active patient participation such as exercise and psychotherapy compared with passive physical procedures and injections. Drugs with central nervous system action generally are more effective than those drugs used to affect peripheral physiologic function (Henningsen, Zipfel, & Herzog, 2007). If antidepressant treatment is ineffective, adding pregabalin (Lyrica®) may be helpful (Harnack et al., 2007). Non-pharmacologic and drug treatments can complement each other.

Impulse Control

Some patients lack impulse control to avoid picking at their skin or twisting and pulling on their hair. Examples include acne excoriée, neurodermatitis, and trichotillomania. In acne excoriée, some patients who pick at their acne are primarily impulsive in their picking. In addition to treating the acne, it is necessary to reduce or stop the picking habit. This may be accomplished with cognitive-behavioral methods or hypnosis and self-hypnosis (Shenefelt, 2004). In neurodermatitis, some patients are primarily impulsive in their picking (Gupta, Gupta, & Haberman, 1986). They may be treated with cognitivebehavioral methods (Rosenbaum & Ayllon, 1981) or hypnosis and selfhypnosis (Scott, 1960). Tricho tillomania is currently classified as an impulse control disorder (Stein et al., 2007). Cognitive-behavioral methods may be of benefit (Rothbaum & Ninan, 1999).


Obsessive-compulsive disorder may be a primary factor in producing skin disease or may exacerbate a preexisting skin disease such as acne, atopic dermatitis, or psoriasis. In a recent study, about 5% of patients at a dermatology clinic had obsessive-compulsive disorder (Seyhan et al., 2006). In acne excoriée, some patients who pick at their acne are primarily obsessive-compulsive in their picking (Shenefelt, 2004). For onychotillomania, self-induced compulsive manipulation causing damage to nails may be a form of obsessive-compulsive disorder (Inglese, Haley, & Elewski, 2004). Some individuals with neurodermatitis seem to fit best into the obsessive-compulsive category (Gupta, 2006). For each of these types of problems, cognitivebehavioral methods may be of benefit as may SSRI antidepressants (Kearney & Silverman, 1990).


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