Psychosis Only Skin Deep

Mr. A was a 22-year-old man in basic training with the military. On the 12th day of training, he was found waking other soldiers in their bunks while on guard duty. He was unresponsive to commands, talking only in riddles and puns. The results of a mental status examination were significant for a blunted affect and poverty of thought. There was no evidence of a sleep disturbance or a flight of ideas. Mr. A was admitted to the hospital to rule out a psychotic disorder.

Mr. A"s medical history revealed that he had sought medical care 3 days before for a rash. There was no personal or family psychiatric history. He was outgoing and socially involved, displayed no occupational difficulties, and maintained close friendships until his admission.

The results of Mr. A’s physical examination were notable for a maculopapular, erythematous, crusting rash over his upper body and feet. There were no vesicles, pustules, or target lesions. His nails were thickened and had V-shaped scalloping. His drill sergeant revealed that the marines had recently exercised without shirts and rested in the sun with their boots off. Mr. A’s father told us of his own history of Darier’s disease, which is exacerbated by exposure to the sun. A skin biopsy of Mr. A’s lesions revealed abnormal keratinization and loss of epidermal adhesion with acantholysis, which was consistent with keratosis follicularis, or Darier’s disease.

Mr. A was removed from exposure to the sun and treated with topical isotretinoin. On his fourth day in the hospital, 4 mg/day of risperidone was added to help his disorganized thought process. His symptoms faded by the 12th day of admission, and he displayed no further psychotic symptoms. He was discharged with a diagnosis of psychotic disorder secondary to Darier’s disease.