Psychiatrists May Help Skin Disorders Clear Faster

Delusions, most commonly of being infested by parasites, also bring patients to dermatologists, Sylvia Garnis-Jones, M.D.C.M., a dermatologist who runs Canada’s only psychodermatology clinic at McMaster University in Hamilton, Ontario, noted at both the AAD and APA meetings. She is president of the Association for Psychocutaneous Medicine of North America.

Delusions focused on the skin often are quite specific and may appear in people without other evident psychopathology. Some patients imagine their appearance or body odor offends others. Some worry excessively about having a life-threatening or sexually transmitted disease.

Patients with body dysmorphic disorder may have excessive concerns about minor variations in skin color or texture, ordinary moles, or thinning hair. Some spend hours each day checking and examining their “defects,” often with magnifiers. The attention they give their skin often interferes with other activities. Their distress may reach delusional proportions.

Dermatologists need to rule out organic causes such as pernicious anemia, a brain tumor, and temporal lobe epilepsy, Garnis-Jones said, along with effects of psychostimulants or alcohol withdrawal. They also rule out cutaneous pathology. These tactics are necessary, she said, to gain the patient’s trust.

It’s important not to confront these patients, she advised. A dermatologist initially may limit comments to noninterpretative ones, saying, for example, “I don’t see any parasites today.” Patients’ physical discomfort, she noted, protects them from even greater emotional discomfort, yet serves as their entrée into the medical system. Dermatologists may have to deal with such patients on a somatic level for several visits before raising psychological issues.

The main focus of treatment, she said, is symptom relief. While these patients typically resist referral to a psychiatrist, some may agree to see a psychopharmacologist if told this person is an expert in medications that can help them cope better with work or family problems or “reduce sensitivity of nerve endings.” Therapy usually involves antipsychotic medications, often in addition to SSRIs.

Psychiatrists may find it useful to refer some patients to dermatologists, too, she continued. A contact dermatitis or a chronic undiagnosed skin disorder such as lichen planus may have been the trigger for self-mutilation or delusions involving the skin.

Patients who label their problems as dermatological often are unaware of their inner life and how feelings may be affecting their skin, said Iona Ginsburg, M.D., a psychiatrist in private practice and an associate clinical professor of psychiatry in dermatology at Columbia University College of Physicians and Surgeons, New York. She also spoke at both the AAD and APA meetings.

Patients may interpret a suggestion to see a psychiatrist as indicating that the dermatologist thinks they are crazy or wants to get rid of them, she said. These patients often visit numerous dermatologists in search of help. Their notorious reluctance to see psychiatrists, Ginsburg said, is prompting growing interest by dermatologists in psychotropic medications.

Dermatologists need to tell patients that they take the symptoms seriously and that they see the problem is causing distress, she said. They also need to reassure patients they will continue to provide dermatologic care.

Patients who have delusions or mutilate themselves belong in a psychiatrist’s office, Ginsburg said. Patients with body dysmorphic disorder are at high risk for depression and suicide.

Those who aggravate their illness by picking, digging, or other behaviors; those whose illness worsens with life upsets; and those with comorbid anxiety, depression, or social phobia also may benefit from psychiatric help. Patients who have burning, itching, stinging, and other sensory disturbances of the skin without medical findings, Ginsburg said, often insist their symptoms must have an organic basis. Such patients often visit neurologists too.

Ginsburg advised dermatologists to see patients several times to build a therapeutic alliance before referring them to a psychiatrist. She suggested they ask patients’ permission to phone the psychiatrist to pave the way for them and request a phone call from them afterward.

While a consultation-liaison department at a medical center facilitates dermatologist-psychiatrist collaboration, Ginsburg said, psychiatrists with an interest in skin disorders could contact dermatologists in their community directly.

Although half of all prescriptions for psychotropic medications are written by nonpsychiatrists, dermatologists receive little training in prescribing such drugs, John Koo, M.D., said at the AAD meeting. Koo, who directs the dermatology drug research unit at the University of California, San Francisco, School of Medicine, said SSRIs, mood stabilizers, antipsychotics, and other psychiatric medications benefit patients with many skin disorders.

Some psychotropic medications have side effects that may help or interfere with treatment of certain skin disorders, said Koo, who also is a psychiatrist. Anticholinergic side effects of antianxiety medications, for example, may benefit anxious patients who sweat excessively. Lithium, in contrast, makes psoriasis worse.

The clinical severity of a skin disorder shows little correlation with the disorder’s emotional impact on the patient, said Richard Fried, M.D., Ph.D., who is both a dermatologist and a clinical psychologist practicing in Yardley, Pa. Skin diseases often have a negative impact on self-esteem and interpersonal relationships, he said at both the AAD and APA meetings.

Many skin disorders have a capricious course. Rosacea, psoriasis, acne, herpes virus infections, and others may flare in response to stress. When skin diseases are chronic, Fried said, organic and psychogenic symptoms typically overlap.

Patients benefit from not only traditional dermatological treatment, Fried said, but also from adjunct therapies. People with psoriasis who learned to meditate showed a faster and greater response to phototherapy than those not using the technique. People with rosacea who flush can learn to break their psychocutaneous cascade with relaxation techniques. Self-hypnosis and biofeedback can enhance treatment compliance by making patients feel more empowered. Self-help books can validate common emotions. “Indulgence” therapies, such as massage, Fried said, may enhance a patient’s overall sense of well-being.

The power of the doctor-patient relationship for patients whose skin disorder has a psychogenic component, he added, often is underestimated. “Telling them, ‘I don’t know if I can cure you, but I believe I can help you get better,’ ”Fried said, “often helps right then and there.”