Transcript Document

Skin and Psychiatric Illness
why close association
Skin is accessible-easy target of psychiatric
illness
 Skin is visible-associated with self image
 Skin is sensitive-symptoms are common,
varied, source easily perceived, with a low
threshold for symptoms to occur
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Classification of Skin Diseases and
Psychiatric Disease
1. Primarily Psychiatric Illness
 2. Psychiatric Illness Flares Skin Disease
 3. Primarily Skin Diseases
 4. Skin Disease Flares Psychiatric Illness
 Should a psychiatrist treat these patients?good idea but won’t work if patient won’t
see the psyhiatrist
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Psychiatry and Skin Disorders
1. Primarily Psychiatric Illness
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Primary Psychiatric Disorders
-Trichotillomania
-Neurotic Excoriations
-Acne Excorie Des Jeunes Filles
-Parasitophobia
-Factitial Dermatitis
-Dysmorphic syndrome
-Morgellons
Trichotillomania
 Plucking, twisting, cutting or breaking hair
from scalp or eyebrows
 Diff. Dx
-Alopecia Areata
-Tinea
…Trichotillomania Continued
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Clues
-Female
-<10 y/o
-Localized
-Sharply demarcated
-Symmetric
-Biopsy helpful
Mainly OCD-SSRI’s
Also depression and anxiety
Parasitophobia
(Acarophobia, Formicationsensation of stinging or biting)
Psychosis with firm fixation of a parasitic
infestation
 Must rule out true parasite; i.e., scabies
 “Matchbox Sign”
 No primary skin lesions
 Esp. middle-aged female
 Hypochondriacal monosymptomatic
psychosis, may have a facilitator
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…Parasitophobia Continued
Also schizophrenia, bipolar disorder, psychotic
depression, anxiety disorder, obsessional state
 Organic states
-Cocaine and amphetamine abuse
-MS
-Parkinson’s
-Dementia
-CNS pathology
-B-12 deficiency
 Treatment-pimozide (Orap)
olanzapine (Zyprexa)
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Neurotic Excoriations
Neurosis with excoriations but no primary
skin lesions
 Characteristic linear hypopigmented scars
 Opposite dominant hand side
 Upper back, face, upper extremities
 Acne Excorie Des Juenes Filles is a
common variant
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…Neurotic Excoriations Continued
OCD, depression, anxiety
 Treatment
-Doxepin
-Desipramine
-Buspirone
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Factitial Dermatitis
(Dermatitis Artefacta)
Psychosis with linear, sharply demarcated, bizarre,
excoriations, erosions or ulcerations
 Opposite dominant hand distribution, symmetric,
drop-shaped or panniculitic
 Chronic non-healing wound that only responds to
occlusive dressing
 Malingering (Workman’s comp case)
 Also borderline personality disorder
 Treatment
-Pimozide(Orap)
-Fluoxetine(Zyprexa)
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Dysmorphic Syndrome
Delusion of having an ugly body part,
frequent plastic surgery procedures, hair
loss
 Common (affects up to 1% of the
population)
 Obsessional and depression-may present a
suicide risk
 SSRI’s
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Psychiatry and Skin Disorders
2. Psychiatric Illness Flares Skin
Disease
Psoriasis
 Dyshidrosis
 Atopic Dermatitis
-Lichen Simplex Chronicus
-Prurigo Nodularis
 Alopecia Areata
 Drugs
-Lithium
-Tegretol
Essential Pruritis
Incidence of Emotional
Triggering of Common
Dermatoses
Diagnosis
Proportion with
emotional trigger
(%)
Hyperhidrosis
100
Biologic
incubation
between stress
and clinical
changes
Seconds
Lichen simplex
chronicus
98
Days
Rosacea
94
2 days
…Continued
Dyshidrosis
76
2 days for
vesicles
Atopic
dermatitis
70
Seconds for
itching
Urticaria
68
Minutes
Psoriasis
62
Days
…Continued
Papular acne
vulgaris
Seborrheic
dermatitis
Fungus infection
55
2 days
41
Days
9
Days
Nevi
0
Basal cell
carcinoma
Keratoses
0
0
Prurigo Nodularis
Multiple, very pruritic (paroxysmal), peasized or larger nodules
 Mainly extremities, esp. pretibial
 Heals with scars
 May be strictly an emotional disease
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…Continued
Other causes-atopic, hepatic disease (esp.
hepatitis C), HIV disease, PG, renal failure,
anemia, photodermatitis, gluten
enteropathy, insect bites, pemphigoid
nodularis
 Treatment-steroids (topical, Cordran tape,
intralesional), Dovonex, Taclonex, PUVA,
Accutane, Thalidomide, cyclosporine, UVB
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Lichen Simplex Chronicus
(Neurodermatitis Circumscripta)
Severe paroxysmal pruritus producing welldemarcated, localized lichenified plaque
 Skin becomes thick and leathery and can
mimic psoriasis
 Esp. posterior neck (females), ankles
(males),genitalia, rectum,external auditory
canal, pretibial
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… LSC Continued
Associated with stress and anxiety
 Treatment
-Steroids (potent topicals, intralesional,
Cordran tape)
-Zonalon (topical doxepin)
-Occlusion (Unna wrap)
-J and J Wound Care Treatment
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Psychiatry and Skin disorders
3. Primarily Skin Disease
-Acne
-Vitiligo
-Alopecia Areata
-Psoriasis
Psychiatry and Skin Disorder
4. Skin Disorder Flares Pychiatric
Illness
-Drugs
-Systemic and topical corticosteroids
-Accutane
-Depression
Morgellon’s Disease
8,263 registrant household’s in the mongellon’s
research foundation
 5,890 hits on google
 1st described in 2002 by Mary Leito (biologist)
 Mayo Clinic
-Nonentity
-Specific condition with cause to be determined in
future
-Delusional parasitosis
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…Morgellons Continued
Crawling, biting, stinging sensation
 Fibers on or under skin
 Persistent skin disease
-rash
-sores
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Scientists take on Morgellons disease
KC Star
1/19/08
After years of complaints from patients, the U.S. Centers for Disease Control and Prevention
recently launched a study into a bizarre — and possibly delusional — condition known as
Morgellons.
Around 2002, the agency started hearing from a handful of patients about the unexplained
condition in which sufferers typically feel crawling sensations and observe fibers coming out
of their skin. It now receives about 1,200 inquiries a year about the disease.
The study will look at patients in Kaiser Permanente’s Northern California network, because the
area has been a hot spot of reported cases.
“We are really at the beginning, I think, of a learning curve about what this condition is and all of
its potential manifestations,” said Michele Pearson, a CDC physician who is the study’s
principal investigator.
“Those who suffer from this condition, as well as the family members and physicians who
provide care to them, have questions, and we want to help them find meaningful answers.”
About 11,000 families in the United States and several countries overseas have registered their
illnesses with the Morgellons Research Foundation, a group started by Mary Leitao, a
Pittsburgh mother who found an abnormal rash on her son in 2001.
She named the disease after a reference in a 17th-century French medical text of “strange hairs”
sprouting from children’s backs.
Leitao said she hopes the study will help legitimize the disease, which many doctors have
diagnosed as delusional parasitosis and treated with anti-psychotic medications
Final Words of Advice
Patience
 Empathy
 Honesty
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