Psychodermatology encompasses disease that involves the
complex interaction between the brain, cutaneous nerves,
cutaneous immune system and the skin.
May be any of the following:
1. Primarily cutaneous disorders that can be influenced by
psychological factors, e.g. psoriasis
2. Primary psychiatric disease presenting to dermatology
HCPs, e.g. Delusional infestation, body dysmorphic
3. Psychiatric illness developing as a result of skin disease, e.g.
depression, anxiety or both.
4. Co-morbidity of skin disease with another psychiatric
disorder, e.g. alcoholism
Term describes situation of an individual who is
disqualified from full social acceptance.
Commonest dermatological situations where stigma is
encountered may be:-
I. Congenital naevae ,e.g. port-wine stain
II. Acquired deformities from developmental disorders,
e.g. tuberous sclerosis
III. Widespread inflammatory skin diseases
IV. Surgical or post-traumatic deformities
Psychiatric disease and learning disabilities
Race and religion
Behavioural and social factors: Alcoholism and
substance misuse, imprisonment
Interventions in dermatological stigmata are concentrated
on firstly the reduction in visibility and secondly the
psychological based approaches to forestall stigmatization
A. Delusional beliefs :
i. Delusional infestation
ii. Olfactory delusion
iii. Morgellons syndrome
B. Obsessive and compulsive disorders:
i. Body dysmorphic disorder
ii. Lichen simplex chronicus and nodular prurigo
iii. Skin picking disorder
iv. Acne excoriee
vi. Onychotillomania and onychophagia
vii. Health anxieties(dirt, infection and wart phobias,
mole and cancer phobias)
C. Eating disorders:
i. Anorexia nervosa
ii. Bulimia nervosa
D. Psychogenic itch:
i. Psychogenic pruritus
E. Factitious skin disease:
i. Dermatitis artefacta
ii. Dermatitis simulata
iii. Dermatological pathomimicry
iv. Dermatitis passivata
vi. Pseudologia fantastica and munchausen syndrome
vii. Fabricated and induced illness
F. Deliberate self-harm:
i. With suicidal ideation
ii. Without suicidal intent
i. Cutaneous disease and alcohol misuse
ii. Depression in dermatological patient
(ekbom disease, delusional parasitosis, parasitophobia,
monosymtomatic delusional hypochondriasis)
It is an uncommon but very disabling condition where the
patient is convinced that he or she is infested with a mite,
parasite, bacteria, worm, insect, virus or animate material.
Crawling sensations on the skin that
may be localized or generalized.
These sensations may be
intermittent, or more often,
persistent and disabling.
The association of an “intrinsic” smell hallucination and a
“contrite” reaction in the absence of a history of preceding
depression’ (though anxiety and depression may be a consequence
More common in young male adults (male : female 4.5 : 1), and
occurs in all ethnic groups. Associated diseases include:
Body dysmorphic disease.
Temporal lobe epilepsy.
A genuine body odour
Temporal lobe epilepsy
Other organic brain disease: Dementia, Parkinson
disease, Brain tumour.
The phenomenon comprises:
• Sensations of crawling, stinging and biting under the skin.
• Sores that do not heal.
• Fiber‐like filaments, granules and crystals that appear on or
under the skin lesions .
• Joint and muscle pain and fibromyalgia.
• Debilitating fatigue.
• Cognitive dysfunction, poor concentration and memory.
Pimozide, risperidone together with topical antiseptics,
systemic antibiotics and (sometimes) phototherapy.
Body dysmorphic disorder
It is characterized by preoccupation with a real or an
imagined defect in physical appearance, or if there is a
slight physical anomaly, concern is out of proportion to the
Occurs in 1-2% of general population
The female to male ratio is 2 : 1, more in adolescents
i. Treatment of skin
ii. Education for patient and family
Lichen simplex chronicus and
Regular rubbing and pressure on the skin produces
characteristic thickened, coarsely grained papules and
nodules with hyperpigmentation.
Sites: Nape and sides of the neck, elbows, thighs,
knees and ankles
Lesions may be in varying stages of evolution, from
early, small, violaceous papules with surface
excoriations to chronic areas that present as
hyperkeratotic plaques with pigment changes,
described as ’dermatological worry beads’.
Skin picking disorder (Dermatotillomania):-
Recurrent picking accompanied by visible tissue
damage and functional impairment.
Clinical features:-Lesions may be quite deep extending
into the dermis. Older lesions show pink or red scars,
some of which may be hypertrophic. Chronic lesions
may also show atrophic scars.
Common particularly in adolescent girls under
It is a variant of skin picking disorder with the lesions
largely confined to the face i.e. around the hairline,
forehead, pre-auricular cheek and chin areas.
Acné excoriéeAcute excoriations and chronic, scarred,
atrophic lesions due to pathological
picking on face, neck and shoulders
Cognitive Behavioural Therapy and other talk therapies
Selective Serotonin Reuptake Inhibitors
Other antidepressants, e.g. mirtazapine
Term was first used by Hallopeau in 1889.
Derived from the Greek thrix hair, tillein pull out and mania
Morbid craving to pull out hair.
a. Recurrent pulling out of one’s own hair resulting in hair loss.
b. An increasing sense of tension immediately before pulling out
hair or when attempting to resist behaviour.
c. Pleasure, gratification or relief when pulling out the hair.
d. Disturbance is not better accounted for by another mental
e. Disturbance provokes clinically marked distress and/or
impairment in occupational, social or other areas of functioning.
Short, irregular, broken and
Plucking activity are centrifugal
from a single starting point or
linear, in wave-like activity.
Ball-like aggregations of fibre-
like materials( hair) in stomach
and small intestine.
Swallowed hair is retained
within folds of gastric mucosa.
A trichobezoar with a tail that
extends at least to the jejunum.
Endoscopic image of a trichobezoar extending into the
Anorexia and Bulimia nervosa
Anorexia nervosa must
satisfy the criteria for:-
1. An inability to maintain
the normal or minimum
weight for age and height
coupled with an intense
fear of gaining weight; the
BMI is less than 17.5
2. A distorted perception of
weight, size and body
Bulimia nervosa is defined
by the following:
1. Recurrent and compulsive
overeating episodes (binge
2. Recurrent and inappropriate
compensatory behaviour in
order to avoid gaining weight;
these include induced
vomiting and abuse of
diuretics and laxatives
3. Binge eating and weight
occurring at least twice per
week for 3 months
4. Self-esteem affected by weight
and body configuration.
Xerosis and pruritus.
Russell’s sign (knuckle pads from chewing the skin
overlying the knuckles)
Nutritional disease: Pellagra, Dermatitis
enteropathica, Anaemia and hair loss secondary to
Cutaneous microvasculature: Raynaud phenomenon,
Acrocyanosis and Perniosis.
Hair abnormalities: Hypertrichosis, Hair loss.
Pruritus is a multifactorial symptom.
Misery and colleagues have proposed diagnostic
criteria for psychogenic pruritus. There are three
1. Localized or generalized pruritus sine material.
2. Chronic pruritus (>6 weeks).
3. Absence of a somatic cause
ii. Topical steroids
iv. Behaviour oriented therapy(Habit reversal treatment)
1. Tricyclics(doxepin, amitriptyline)
2. SSRIs (fluoxetine, citalopram)
3. Phototherapy, Photochemotherapy
4. Cooling creams e.g. 2%menthol
1. Mood stabilizing antidepressents(trazadone, duloxetine)
Definition by DSM-5
A. Falsification of physical or psychological signs and
symptoms, or induction of injury or disease,
associated with identified deception.
B. The individual presents himself or herself to others
as ill, impaired or injured.
C. The deceptive behaviour is evident even in the
absence of obvious external rewards.
D. The behaviour is not better explained by another
mental disorder such as a delusional disorder or
another psychotic disorder.
Caused entirely by actions of fully aware (i.e. not
consciously impaired) patient on the skin, hair, nails,
scalp or mucosae.
Occurs in children from age of 8 years onwards, pre-
pubertal children having an equal sex ratio, rising to
3:1 female predominance in early teens. In adults F>M.
Due to psychosocial stress of a major life event
1. Physical signs
2. Fabricated story that accompanies it
patient often describes :
Sudden appearance of lesions with little or no
No complete description of genesis of individual skin
Commonest site are face (cheeks) in 50% children, dorsa of
Most frequently of non-dominant limb, mostly on covered
Lesions are polymorphic, bizarre, clearly demarcated from
surrounding normal skin and can resemble many
inflammatory reactions in skin
Crude, angulated, destructive processes with a tendency to
a linear configuration, Circular erosions or blisters of a
uniform size, as result of thermal, chemical or
Dermatitis factitia. Crude, linear, angulated
and destructive factitious dermatitis
straight edges and sharp angulation
Non‐healing wound after surgery with characteristic
central ’interference haemorrhage’.
showing the drip sign
Factitious cheilitis due to repeated lip
sucking. Factitious nail disease
Glue applied to look like herpes zoster
Young Diogenes syndrome; accretions of facial keratin and debris
Fabricated and induced illness
Münchausen syndrome by proxy where the illness in a
child is fabricated by the parent, usually the mother
The most common presentations are:
Bleeding and bruising (44%),
Central nervous system depression (19%),
With suicidal ideation Without suicidal intent
Self‐mutilating behaviour is
often grouped with other
behaviours, such as
hanging or jumping from
heights, as ’parasuicide’ or
It is the self‐injurious
behaviour, or self‐mutilation,
occurring outside the context
of conscious suicidal ideation
• Selective Serotonin Reuptake Inhibitors
• Dopamine antagonists
• Opiate antagonists
• Mood stabilizers,