Psycho cut disorder

1. PSYCHOPHYSIOLOGIC
DISORDERS

2. Skin conditions that are triggered by or can fluctuate in clinical severity
according to the emotional state:
Psoriasis
Atopic dermatitis
Acne excoriee
Hyperhidrosis
Urticaria
Recurrent herpes simplex infection
Seborrheic dermatitis
Oral aphthosis
Rosacea
Pruritus

3.  Skin disorders that represent an accentuated physiological
response –
• Hyperhydrosis
• Blushing
• Telogen effluvium
 Skin diseases with a high incidence of psycho-emotional
factors –
• Pruritus
• Urticaria
• LSC
• Atopic dermatitis
• Acne
• Rosacea
• Psychogenic Purpura
• Alopecia areata
• Psoriasis
• Seborrheic
dermatitis
• Lichen planus
• Herpes
• Eczema

4. Pathophysiology: The principal mediators of stress-induced cutaneous
changes are CRH, ACTH, cortisol, catecholamines, prolactin, substance P,
nerve growth factor (NGF), interleukins, and cytokines which induce a series
of physiological and behavioral changes —>inflammation, pruritus, and
aging.
Persistent stress—> body or mind does not get time to repair and the acute
inflammatory responses are replaced with humoral inflammatory responses
which have pro-allergenic and pro-autoimmune effects.

5. Atopic Dermatitis (AD)
Stress—> increases the secretion of inflammatory mediators, e.g.,
interleukins, TNF-alfa and -gamma—> further damage the skin barrier
AD - a/w stigmatization, social withdrawal, anxiety, depression among
patients and their caretakers—> further exaggerate signs and symptoms of
AD —-> a chain reaction such as the itch-scratch cycle —> worsens the
treatment outcome of the patient
Psoriasis
Psoriasis begets stress and stress begets psoriasis
Stress—> increases the level of neuroimmunomodulators like substance P,
CGRP, VIP —> trigger or induce psoriasis flares through neurogenic
inflammation
Also pts require almost twice the duration for clearance of psoriasis by
PUVA compared to those with low-stress levels
Some patient—> exacerbation of psoriasis due to their inability to elicit an
appropriate immunosuppressive response to stress through the
upregulation of cortisol

6. Facial Dermatoses
(Acne, Rosacea, Seborrheic Dermatitis)
Since Present on the uncovered parts of the body where it cannot be hidden
—> a/w more psychological distress
Vicious cycle—> facial dermatosis is triggered or worsened by stress, and
exacerbation itself is a major stress inducer
Acne: can either be psychosomatic (influenced by psychologic distress or
psychiatric disease) or be somatopsychic (provoke psychologic problems)
• Mechanism: skin has its own HPA axis and CRH which act as central
coordinators for neuroendocrine and behavioral responses to stress CRH,
CRH-binding protein, CRH-receptors.
• Receptors for other mediators of stress are detected in sebocytes, which
control the sebocyte activity during stressful events.

7. Rosacea: triggered by factors that increase flushing such as emotions,
laughter, and embarrassment
• Also, rosacea patients experience a significantly higher intensity of
stress from critical life events than those without rosacea
Seborrheic dermatitis: some studies have shown that SD is precipitated
by stress, anxiety, and depression, and the presence of these factors
portends a poor prognosis in SD patients

8. Herpes Simplex
Stress—>triggering recurrences of herpes labialis and genital herpes
Females have a stronger association with oral herpes than genital
Psychological distress —> stimulates release of cortisol and the
catecholamines —> favor a shift from Th1 to Th2 cytokine production—>
immunosuppression and HSV reactivation

9. SECONDARY PSYCHIATRIC
DISORDERS (DERMATOLOGIC
DISORDERS WITH PSYCHIATRIC
SYMPTOMS)

10. • Disorders of the psyche or mind which occur due to skin conditions
• Psychological symptoms because of the skin disease, usually
disfigurement
• Includes –
Alopecia
Vitiligo
Leprosy
Acne
Sharma et al [2003] have studied and compared the psychiatric morbidity
in five chronic and disfiguring diseases
 Psoriasis
 Chronic urticaria
 Leprosy
 Vitiligo
 Lichen simplex chronicus

11.  Overall prevalence of psychiatric morbidity was found to be
39%
 Common symptoms were
 Depression [13%]
 Anxiety [11%]
 Suicidal ideations [16%]
 Somatization [13%]
 Interpersonal conflict [10%]
 Suicidal attempts [3%]
 Psychiatric morbidity was higher in psoriasis [53%]
compared to vitiligo [16%]
 Depression reported in 23% psoriasis patients and in 10%
of vitiligo patients

12. Psoriasis
• Increased risk of depression and suicidality compared to the general
population
• A/w poor treatment adherence, therapeutic response, and outcomes
• Depression in patients with psoriasis is also associated with increased
risk of myocardial infarction, stroke, and cardiovascular death, especially
during the acute depression; thus quality of life of all the patients of
psoriasis should be assessed irrespective of the PASI or psoriasis
severity
Vitiligo
• They suffer stigmatization or be ashamed of their body and have a
negative self-image and low self-esteem which may be devastating for
their social lives.
• The prevalence of psychiatric morbidity varies from 25% (India) to 35%
(UK).

13. Atopic Dermatitis
• They develop secondary psychological problems due to the
appearance of their diseased skin and severe intractable pruritus.
• High levels of stigmatization, social withdrawal, anxiety, and depression
among patients and their caregivers.
• Children—> AD causes irritability, clingy behavior, sleep disturbance,
anxiety, and depression which also affects the family members —> who
suffer from depression, sleep deprivation, and loss of work —>
eventually disrupts the physical and mental health of the family.
• Adults—> difficulties in interpersonal as well as sexual relations —>
irritability and sleep deprivation —> decreases their work productivity—
> All these factors lead to depression, anxiety, and suicidal ideation.

14. Alopecia Areata
Scalp hair is the crowning glory of any individual and plays an important
role in social interactions
Psychological distress can trigger the onset of AA and the resultant hair loss
has negative consequences in the form of difficulty in coping with stress,
depression, anxiety, adjustment disorder, paranoid disorder, and negative
self-esteem
Psychiatric morbidity —> more severe in women & children, and in those
with extensive disease.
Suicidal ideation is reported in 60% of patients with AU— 3 times more than
patients with localized AA

15. MISCELLANEOUS
CONDITIONS

16. Cutaneous Sensory Disorders
• Somatisation disorders with either disagreeable skin sensations such as
itching, burning, stinging, or pain (allodynia), and/or negative sensory
symptoms such as numbness or hypoesthesia
• scalp dysesthesia
• atypical facial pain
• burning mouth syndrome
• burning feet
• glossodynia, orodynia: burning sensation in mouth, aggravated by food/liquids
• penodynia, scrotodynia
• vulvodynia- c/o burning & pain in vulva in absence of organic causes
• Notalgia paresthetica- itching & paraesthesia in interscapular region, may
extend to shoulder/chest/back, d/t entrapment of spinal nerves as they
emerge from epaxial ms of the neck.

17. Mx
Patients should be advised to keep a pain diary that records the time of
onset, worsening, etc., along with emotional aspects.
In orodynia and vulvodynia, hidden causes such as candidiasis and lichen
planus should be ruled out. Sexual abuse should also be ruled out.
Treatment includes older TCAs, e.g., amitriptyline and doxepin, which work
well.
Newer TCAs, e.g., imipramine, desipramine, and SSRIs such as fluoxetine
may also be tried

18. PSYCHOGENIC PURPURA SYNDROMES
• Present as spontaneous development of edematous, painful lesions
progressing to ecchymotic patches in 24 hours in the absence of
coagulopathy
• The presence of purpura, bruising or frank bleeding in patients with
severe emotional disturbance
Etiopathogenesis
• autoimmune vasculopathy with sensitization to phosphatidylserine, a
component of erythrocyte stroma
• Initially thought that lesions are due to an autoimmune allergic reaction to
extravasated erythrocytes. Later, it was thought to represent a conversion
reaction in women undergoing severe emotional stress, intense religious
experience, or who are in a dissociative state
• The reaction can extend even to eyes, joints, GIT, and other organs
• Associations include anticardiolipin antibodies, SLE, angioblastic
lymphadenopathy, vasculitis, multiple glomus tumors, and contact with
copper

19. It includes:
Psychogenic purpura (Gardner-Diamond syndrome)
•Anti DNA sensitization syndrome
•Religious purpura (Stigmatization)

20. Gardner-Diamond syndrome
• Auto Erythrocyte Sensitization Syndrome
• Mild trauma/emotional stress leads to very tender bruises, usually
on the arms and legs
• Preceded by burning, stinging, erythema and edema
• Internal bleeding may occur resulting in abdominal pain and
neurological symptoms
• Blood coagulation tests and hemostatic tests are normal. Increased
fibrinolytic activity has been found in some patients
• Injection of the patient’s own erythrocytes can cause ecchymotic
lesions
Diagnosis
• Autoerythrocyte sensitization test involves intradermal injection of
washed erythrocytes and observation for painful ecchymosis at the
site. Modifications include using autologous and heterologous
washed lymphocytes and DNA

21. • Anti – DNA Sensitization Syndrome- this is similar to gardner diamond
syndrome except that here there is a negative intradermal auto-red cell
test but a positive test reaction to intracutaneous injection of DNA
• Religious Purpura-it is a pattern of reaction similar to the above
conditions in which there is periodic bleeding from hands and feet, under
the left breast and forehead.This is a more intense variant, where
spontaneous bleeding appears on the skin, especially on anatomical
areas corresponding to wounds inflicted on Jesus Christ
Treatment
• Management of the underlying psychological stress
• Antihistaminics, topical corticosteroids, and antidepressants

22. Side Effects of Drugs: Psychiatric Side
Effects of Dermatologic Drugs

23. Systemic steroids : induce depression, mania, psychosis, and delirium.
• Sleep disorders and steroid euphoria
• Reversible corticosteroid-induced dementia manifests as poor
concentration, poor memory, and anomic aphasia
Dapsone commonly causes woolly headedness and rarely mania and
psychosis.
Thalidomide is associated with somnolence, and rarely with seizures,
migraine, hallucination, and syncope.
Intravenous immunoglobulin administration often leads to anxiety,
irritability, nervousness, and tremor.

24. Cyclosporin
• Neuropsychiatric effects are dose and duration dependent—> hence
continuing cyclosporine beyond one year is discouraged
• Though neurological effects such as headache, paresthesia, tremors are
more common, posterior reversible encephalopathy syndrome (PRES)
may cause headache, confusion, seizures, loss of vision, and vomiting
Isotretinoin has been associated with depression and suicidality, though
this has been debated recently.
Methotrexate can rarely cause psychosis and mania.
Apremilast can cause dose-dependent low mood.
TNF alpha inhibitors are known to cause psychosis and mania.
Ustekinumab causes Posterior Reversible Encephalopathy Syndrome
(PRES)
Ixekizumab is known to cause low mood.

25. Dermatologic Side Effects of
Psychiatric Drugs

27. THANKYOU