Special Report: Psychodermatology: Bridging Dermatology and Psychiatry
Understanding the complex psychological and psychosocial dimensions of dermatologic diseases is essential for delivering effective care for patients with psychocutaneous disorders—and involves a multidisciplinary approach that includes appropriate psychological assessment and treatment.
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Psychodermatology explores the intricate relationship between the skin and the psyche. It is well-established that psychological comorbidities are present in more than one-third of dermatological patients. A cross-sectional, multicenter study conducted in 13 European countries found that 10% of dermatological patients had depression, compared with 4.3% of controls. Anxiety was reported in 17.2% of patients, while suicidal ideations were noted in 12.7% of patients. Psoriasis, atopic dermatitis, eczema, and leg ulcers were among the diseases most associated with these psychiatric comorbidities.
Psychosocial issues commonly associated with chronic skin conditions, such as psoriasis, atopic dermatitis, and vitiligo, often stem from low self-esteem, body image concerns, social isolation, and stigmatization. These issues significantly impact quality of life, with profound effects on social interactions, sexual health, and employment. The psychosocial burden is typically more severe for chronic conditions such as acne or psoriasis compared with acute dermatological issues such as rashes. Factors like age, gender, ethnicity, and family history further modulate the extent of this impact. For example, younger individuals with atopic dermatitis or girls or women with unhealthy or excessive cosmetic skin concerns, such as a preoccupation with having absolutely no freckles or minor wrinkles, may experience different psychological challenges than those with more visibly apparent or chronic skin conditions.
Patients’ personality traits and life circumstances also influence how they perceive their skin disease. Those with obsessive-compulsive traits may be more prone to skin-picking, while individuals with borderline personality disorder may be more vulnerable to self-harming behaviors. The societal stigma attached to skin diseases such as psoriasis and vitiligo—which are often wrongly considered contagious—adds another layer of psychological distress, leading to isolation, guilt, and shame. These psychological burdens extend beyond the skin condition itself, affecting relationships, sexual health, financial stability, and overall mental well-being. As a result, chronic dermatologic conditions are linked to higher rates of depression, anxiety, and even suicidal ideation.
Neuro-Immune-Cutaneous-Endocrine Model
The role of psychoneuroimmunology in the etiology of psychocutaneous disorders and the psychosocial impact of skin diseases is extensively documented in current literature. The connection between the skin and the nervous system originates in embryological development, when the ectoderm—the outermost of the three germ layers—gives rise to the skin, neurons, and pigment cells.
The neuro-immune-cutaneous-endocrine (NICE) model explains how various neuromediators, hormones, cytokines, and feedback loops interact to regulate skin functions. In the skin, nerve fibers may secrete neuromediators such as substance P, vasoactive intestinal peptide, somatostatin, calcitonin-gene-related peptide, gastrin-releasing peptide, neuropeptide Y, peptide histidine-isoleucine, neurotensin, neurokinins A and B, bradykinin, acetylcholine, catecholamines, endorphins, and enkephalins. Neurohormones such as prolactin, melanocyte-stimulating hormone, and adrenocorticotrophic hormone are also expressed in the skin.
Disruptions in this model, particularly in inflammatory skin disorders, can exacerbate conditions such as psoriasis, atopic dermatitis, acne vulgaris, and urticaria. Neurochemical activation of mast cells plays a key role in the initiation and worsening of these diseases, suggesting a potential link between immune responses, stress, and the pathophysiology of skin conditions.
Case Study: Sara, 16
Sara is a 16-year-old adolescent girl who was referred to a psychiatrist from a local dermatology office because of recurrent skin lesions of unknown etiology that have worsened after her mother died of substance use two years prior. She tries to cover the lesions with a cosmetic concealer. Upon removal of concealer, some lesions appear as angular cut marks while others appear as sharp geometrical shapes.
Sara lives with her grandmother and has not seen her father for several years. She initially provides a vague history and says that she did not create the lesions herself, but she does say that she is experiencing high amounts of stress.
Upon further discussion, Sara says that she was raped by one of her classmates at a sleepover at a friend’s house two years before her referral. She reports occasional flashbacks and nightmares associated with her sexual trauma. Sara has had occasional stomach aches but does not have any significant events in her medical history, and she does not take any medications.
Based on her clinical picture, a diagnosis of dermatitis artifacta is made, with the other differential diagnoses being neurotic excoriations, pyoderma gangrenosum, allergic contact dermatitis, and malingering.
Sara is prescribed 10 mg of fluoxetine per day as well as daily topical applications of antibiotics and 1% hydrocortisone cream. She is initially provided six weekly sessions of cognitive behavioral therapy followed by psychodynamic therapy and family therapy along with her grandmother. Her lesions show signs of improvement starting in the third week and completely resolve in six weeks. She continues her psychodynamic and family therapy for the next three months.
Classification of Psychocutaneous Disorders
While there is no universally accepted classification system for psychocutaneous disorders, several frameworks have been proposed. One such classification system, originally proposed by John Y. M. Koo, M.D., and Chai Sue Lee, M.D., and later modified by several other investigators, divides psychodermatological conditions into:
•
Psychophysiological disorders: Skin conditions exacerbated or precipitated by psychological stress, such as psoriasis, acne vulgaris, atopic dermatitis, and rosacea.
•
Primary psychiatric disorders: Conditions in which skin manifestations are self-induced, including dermatitis artefacta, trichotillomania, body dysmorphic disorder, and neurotic excoriations.
•
Secondary psychiatric disorders: Emotional problems caused by having a visible skin disease, such as acne excoriée, vitiligo, psoriasis, and alopecia areata.
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Cutaneous sensory syndromes: Unpleasant cutaneous sensations, such as itching, burning, or stinging, without a clear dermatological or psychiatric diagnosis (e.g., idiopathic scalp itching).
A newer international classification developed by the European Academy of Dermatology and Venereology and the European Society of Dermatology and Psychiatry divides psychodermatological disorders into two major groups: primary mental health disorders affecting the skin and primary skin disorders associated with mental health, with further subdivisions based on visible or nonvisible skin lesions (Table 1).
| Primary mental health disorders affecting skin | Primary skin disorders linked with mental health | ||||
|---|---|---|---|---|---|
| Visible skin lesions | Non-visible skin lesions | Visible skin lesions | ± Visible skin lesions | ||
| Psychotic disorders | Somatic symptom and related disorder | Primary dermatoses | Functional skin disorders | ||
| OCD spectrum disorders | | Triggered by stress | Not triggered by stress | Visible lesions | Non-visible lesions |
| Non-substance-related addictive disorders | | | | | |
| Non-suicidal self-inflicted disorders • Non-denined bx • Denied bx | | | | | |
Source: Ferreira, et al., 2024
Common Psychocutaneous Disorders
Although most skin disorders cause some degree of physical and/or emotional distress, some conditions are more severe—and more common—than others.
Alopecia areata may be closely related to emotional stress and influenced by psychological factors as part of its pathophysiology. Patients commonly experience depression, anxiety, and low self-esteem. The condition can be particularly distressing for children, who may face bullying and social rejection.
Atopic dermatitis may have a significant impact on both children and parents. In early infancy, the disease can interfere with the bonding process between mother and child. Babies with atopic dermatitis may be too irritable to hold, which may frustrate parents and other caregivers. Over time, children with atopic dermatitis may develop low self-esteem and experience social isolation, and their parents may have feelings of helplessness. Older children may experience bullying and disruptions in social and sporting activities.
Delusions of parasitosis involve a firm belief that the body is infested with organisms. Treatment often involves antipsychotic medications and a nonconfrontational, empathetic approach to patient care.
Dermatitis artefacta is characterized by self-inflicted lesions that are usually symmetrical and located in areas easily accessible to the patient’s dominant hand. These lesions often have sharp geometrical borders and are a result of unconscious motives to cope with stress, often in individuals with underlying psychiatric conditions such as depression, obsessive-compulsive disorder (OCD), or psychosis. Sometimes patients give themselves these lesions as an appeal for help.
Psoriasis is one of the most common psychophysiological disorders. Patients with psoriasis often experience impaired quality of life, low self-confidence, anxiety, depression, and stigmatization. The inflammatory nature of psoriasis may also contribute to psychiatric comorbidities by affecting TH17 cells in the brain, leading to depression-like behaviors.
Vitiligo, often associated with significant social stigma, is a common secondary psychiatric disorder. Affected individuals may experience increased rates of depression, social discrimination, and feelings of isolation. The psychological impact of vitiligo may be more profound in girls and women because of cultural beauty standards that promote even skin tone and coloration.
Case Study: Karen, 57
Karen is a 57-year-old woman referred by her dermatologist after Karen said that bugs were crawling under her skin. She presents with a nine-month history of itching, crawling, and biting sensations on her skin. She has received empiric treatment for possible scabies (five rounds of permethrin cream and three rounds of oral ivermectin) and has also washed her clothes and bedding five times, but the symptoms persist.
Karen insists that there is a parasite with three eyes and 10 legs infesting her. Multiple providers, including dermatologists, family physicians, and her primary care provider, have not been able to identify a parasite. No one around her or in her family has similar symptoms.
She does not report any travel history. Her past medical history is significant for hypertension. She works as a high school teacher. Her current medications include triamcinolone 0.1% ointment, permethrin cream, and losartan.
Karen brings a plastic baggie to her appointment that contains numerous hairs, skin flakes, and bits of debris. She says that they are parasites she captured and is highly convinced that these parasites are crawling on her all the time, but especially at night, so that she is unable to sleep.
Upon clinical examination, there are numerous erosions, small ulcerative lesions, scratch marks, and hyper- and hypopigmentation on different parts of Karen’s body. Based on Karen’s history, skin lesions, and lack of other pathology, the tentative diagnosis is delusional infestation. Differential diagnoses considered included substance use (amphetamines, cocaine, narcotics), use of dopamine agonists (pramipexole, cabergoline, ropinirole, piribedil), underlying medical conditions (thyroid disorders, vitamin B12 deficiency, diabetes, skin infection, neurologic disorder), and primary psychiatric disorder (schizophrenia, depression with psychotic features).
The psychiatrist discusses the potential use of antipsychotics to help Karen’s symptoms. Karen states that these medications are used in schizophrenia, and she is not schizophrenic. The psychiatrist explains that these medications are used for conditions like schizophrenia but are also very effective for treating Karen’s current symptomatology. Karen hesitantly accepts the idea of starting an antipsychotic medication.
The psychiatrist orders pretreatment tests, including complete blood count, comprehensive metabolic panel, hemoglobin A1c, thyroid function, vitamin B12 level, and toxicology screens. All labs comes back within normal limits. Karen is prescribed risperidone 0.5 mg daily for six weeks along with doxepin 25 mg at bedtime and local treatment of her ulcerative lesions with bandages. At her two-month follow-up, the majority of her lesions are resolved, and Karen is not as convinced that parasites are still crawling under her skin.
Management of Psychocutaneous Disorders
The management of psychodermatological conditions requires a comprehensive and empathetic approach. Psychiatrists should ensure that patients’ concerns are heard and validated, and thoroughly assess the psychological impact of the skin condition. There should always be a suspicion of underlying psychopathology behind the skin disease. Screening for depression, anxiety, and other mental health disorders according to the DSM-5 is essential.
Patients may be feeling the effects of stigma regarding both their skin disorder and their referral for mental health assessment and treatment. The basic rules of management include being neutral, nonjudgmental, and nonconfrontational, using an interview style. Patients may not offer their history upfront, but developing a rapport and bond may help them disclose any background of physical, emotional, or sexual abuse in childhood that may have predisposed them to psychocutaneous disorders.
The management of psychocutaneous disorders often involves a combination of psychotropic medications, such as selective serotonin reuptake inhibitors (SSRIs) for depression and anxiety, and antipsychotics for conditions like delusions of parasitosis. Cognitive behavioral therapy, including habit reversal therapy, has proven effective in treating behaviors like skin-picking and trichotillomania.
Psychodermatological disorders like trichotillomania and skin-picking disorders are mostly associated with anxiety and depression. SSRIs like fluoxetine, escitalopram, and sertraline help with the symptoms. Habit-reversal therapy combined with one of these SSRIs has proven helpful for these conditions.
Antipsychotics like risperidone, olanzapine, and pimozide have shown significant improvement in patients with delusional infestation, although routine indicators such as weight, metabolic side effects, and lipid profile must be monitored on a regular basis. Pimozide is an older antipsychotic that needs further monitoring in terms of cardiac side effects; pretreatment EKG is desirable.
Dermatological Side Effects
A variety of psychotropic medications may cause dermatological side effects, and many dermatological medications may cause psychiatric side effects (Table 2).
| Adverse Effect | Medication |
|---|---|
| Acneiform rashes | Antidepressants, quetiapine, risperidone, carbamazepine, lamotrigine, lithium, topiramate |
| Alopecia | SSRIs, olanzapine, risperidone, carbamazepine, lamotrigine, lithium, valproic acid |
| Erythema multiforme | Bupropion, duloxetine, fluoxetine, paroxetine, sertaline, clozapine, risperidone, carbamazepine, gabapentin, lamotrigine, valproic acid |
| Exfoliative dermatitis | Amitriptyline, clomipramine, notriptytiline, mirtazapine, quetiapine, risperidone, carbamazepine, lithium |
| Fixed drug eruptions | Antidepressants, antipsychotics, carbamazepine, gabapentin, lithium |
| Hyper and hypopigmentation | Tricyclic antidepressants, antipsychotics, carbamazepine, gabapentin, lamotrigine |
| Photosensitivity | Escitalopram, fluoxetine, paroxetine, sertraline, tricyclic antidepressants, antipsychotics, carbamazepine, lamotrigine |
| Pruritus | Bupropion, SSRIs, antipsychotics, benzodiazepines, buspirone mood stabilizers |
| Psoriasiform rashes | Escitalopram, fluoxetine, venlafaxine, quetiapine, risperidone, carbamazepine, lithium, valproic acid |
| Rashes | Clomipramine, SSRIs, antipsychotics, benzodiazepines, carbamazepine, gabapentin, lamotrigine, lithium, topiramate, valproic acid |
| Seborrheic dermatitis | Fluoxetine, lithium, olanzapine, paroxetine, venlafaxine, clozapine, haloperidol, risperidone, carbamazepine, valproic acid |
| Steven-Johnson syndrome/toxic epidermal necrolysis | Bupropion, duloxetine, fluoxetine, paroxetine, sertraline, clozapine, quetiapine, carbamazepine, lamotrigine, valproic acid |
| Urticaria, angioedema | Antidepressants, antipsychotics, benzodiazepines, mood stabilizers |
| Vasculitis | Fluoxetine, paroxetine, sertraline, clozapine, haloperidol, carbamazepine, lamotrigine |
SOURCE: Weber, et al., 2020
For example, isotretinoin (Accutane), which is used for treatment-resistant acne, may cause depression, suicidal thoughts and behaviors, mood swings, and manic psychosis. However, since the reports of severe depression and suicidal ideations, an FDA “black box” warning has been put on the label of isotretinoin. Currently, any patient planning to take isotretinoin must have a psychiatric evaluation for depression before the medication can be prescribed.
Similarly, corticosteroids, which are often used for treating inflammatory skin conditions, have been associated with cognitive impairment, mood disorders, depression, delirium, and psychosis.
Future Directions
Psychodermatology underscores the significant interplay between the skin and mental health. Understanding the complex psychological and psychosocial dimensions of dermatologic diseases is essential for effective patient care. A multidisciplinary approach that includes appropriate psychological assessment and treatment is crucial in improving the quality of life for patients with psychocutaneous disorders.
Pursuing dual-board certification in dermatology and psychiatry represents one potential avenue for cultivating expertise in the interdisciplinary field of psychodermatology. However, this path is not without substantial challenges, particularly the considerable time investment required and the intricate task of integrating two specialties.
For those who do not seek dual certification, participation in psychodermatology-focused workshops, conferences, or specialized training programs offers an alternative means of gaining insight into this complex domain. Moreover, fostering collaborative relationships between dermatologists and mental health professionals within clinical environments can serve as a catalyst for mutual knowledge exchange, thereby advancing both understanding of psychodermatological conditions and the quality of patient care. ■
References
Christensen RE, Tan I, Jafferany M: Recent advances in trichotillomania: a narrative review. Acta Dermatovenerol Alp Pannonica Adriat 2023; 32(4):151-157.
Dalgard FJ, Gieler U, Tomas-Aragones L, et. al.: The psychological burden of skin diseases: a cross-sectional multicenter study among dermatological out-patients in 13 European countries. J Invest Dermatol 2015; 135(4):984-991.
Ferreira BR, Jafferany M: Classification of psychodermatological disorders. J Cosmet Dermatol 2021; 20(6):1622-1624.
Ferreira BR, Vulink N, Mostaghimi L, et al.: Classification of psychodermatological disorders: proposal of a new international classification. J Eur Acad Dermatol Venereol 2024; 38(4):645-656.
Jafferany M, Ferreira BR, Abdelmaksoud A, et al.: Management of psychocutaneous disorders: a practical approach for dermatologists. Dermatol Ther 2020; 33(6):e13969.
Koo JYM, Lee CS: General approach to evaluating psychodermatological disorders, in Psychocutaneous Medicine. Edited by Koo JYM, Lee CS. New York, NY, Marcel Dekker Inc., 2003, pp 1-29.
Misery L: Skin, immunity, and the nervous system. Br J Dermatol 1997; 137(6):843-50.
Weber MB, Recuero JK, Almeida CS: Use of psychiatric drugs in dermatology. An Bras Dermatol 2020; 95(2):133-143.
Biographies
Mohammad Jafferany, M.D., is professor of psychodermatology, psychiatry, and behavioral sciences at Central Michigan University College of Medicine and president of the Association for Psychocutaneous Medicine of North America.
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Published In
Psychiatric News
History
Published online: 24 February 2025
Published in print: March 1, 2025 – March 31, 2025
Keywords
- Psychodermatology
- Psychiatric comorbidities
- Psychocutaneous disorders
- Psoriasis
- Atopic dermatitis
- Vitiligo
- Eczema
- Leg ulcers
- Acne vulgaris
- Skin-picking
- Depression
- Anxiety
- Suicidal ideation
- Neuro-immune-cutaneous-endocrine (NICE) model
- Neuromediators
- Neurohormones
- Urticaria
- Rosacea
- Dermatitis artefacta
- Trichotillomania
- Body dysmorphic disorder
- Neurotic excoriations
- Excoriée
- Alopecia areata
- Idiopathic scalp itching
- Delusions of parasitosis
- Selective serotonin reuptake inhibitors (SSRIs)
- Antipsychotics
- Cognitive behavioral therapy
- Manic psychosis
- Delirium
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