COMMENTARY

How to Manage Patients With Dermatologic Delusional Disorders

Mio Nakamura, MD; John Y.M. Koo, MD

Disclosures

August 11, 2015

In This Article

Building Rapport

First, it is important to establish a strong therapeutic rapport between the dermatologist and the patient. When the patient presents to the dermatologist's office, it is highly likely that he or she has already been seen by other physicians, including dermatologists, and is disillusioned with the care received. It is very easy for the patient to project this negativity onto the new provider.

Therefore, it is helpful for the dermatologist to start the encounter with as much positive energy as possible. If the patient persists in harboring a negative perception of the provider, the dermatologist may need to clearly distinguish him- or herself from the previous providers.

Ultimately, the only therapy that has consistently been shown to work for dermatologic delusions in our experience, as well as in the literature, is antipsychotic medications.[1,2,5] However, it is very difficult to institute this therapy in reality. Patients may not be willing to see a psychiatrist for their presumed skin disease, and the responsibility to initiate therapy therefore probably lies with the dermatologist.

Until a good relationship is established, it is best for the provider not to put pressure on him- or herself or on the patient to discuss antipsychotic treatment options. It is absolutely critical to avoid confrontational and argumentative interactions. Patients are experiencing a "living hell" that is made worse by a lack of validation from healthcare providers who cannot appreciate their degree of suffering. They have probably encountered many care providers who have trivialized or invalidated their concerns.

It may take several interactions focused on support and empathy before the patient comes to trust the dermatologist, thereby making it possible to begin discussing therapeutic options. During this time of relationship-building, the dermatologist should be as enthusiastic as possible in conducting thorough skin examinations, as well as examination of any specimen brought in by the patient.

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