Clinical Cases in Psychocutaneous Disease (Clinical Cases in Dermatology)

Both arising from ectoderm, the skin and the nervous system are connected by more than just their common origins. The skin is one of the major avenues by which humans perceive the world, and, in turn, are perceived by it. When these perceptions go awry, great distress may result. When the skin is markedly affected by a primary dermatologic condition, psychological sequelae in the form of comorbidity often follow, greatly impacting patient quality of life.

The central nervous system CNS can influence the health of other organ systems, including the skin. Psychophysiologic mechanisms for this interaction range from the stress responses mediated by neuroadrenal connections and associated changes in immunologic function, to the systemic and local action of various neuropeptides and neurohormones. Therefore, in the absence of a psychiatry liaison clinic in the dermatologic setting, 4 the dermatologist must be familiar with the most common of these diagnoses, their clinical manifestations both psychological and dermatologic , and the basic principles of treatment.

When approaching these issues, it is important to explore psychiatric, and particularly psychotic, symptoms as well as compliance with medications. Collateral informants such as family members can be quite helpful if the patient grants permission. Lastly, the effects of patient symptoms on familial and social life can be of much assistance in understanding the issues to be addressed.

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[Full text] Common psychocutaneous disorders in children | NDT

Koblenzer, 5 psychocutaneous diseases can be classified on the basis of their primary etiology as:. Primary psychogenic disorders, which can present with a variety of symptoms and behaviors, usually characterized by self-injury, that can lead to perceived or actual dermatologic conditions, or Primary dermatologic disorders that can be either triggered or amplified by contextual causes e. In some instances, the psychiatric comorbidities are not merely the result of the detrimental aspects of skin, but are associated to the pathophysiology of the dermatological disease itself.

There are various other conditions that can provide a challenge in management, including postinflammatory hyperpigmentation, melasma, scarring, alopecias, and pseudofolliculitis barbae.

Clinical Cases in Skin of Color

If these skin disorders are not diagnosed and treated properly, the initial lesions can become darker as they heal, and the darker spots can last for years in some cases. Clinical Cases in Skin of Color. Clinical Cases in Infections and Infestations of the Skin. Clinical Cases in Autoimmune Blistering Diseases. Clinical Cases in Psoriasis.

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Clinical Cases in Phototherapy John Koo. Figure 1 Skin lesion on the frontal area of the face, mechanically induced by a toy, in a 4-year-old girl. Figure 2 Pigmented post-inflammatory lesions on the chin of a small boy, induced by continuously rubbing the area with marker pens. It is very important to differentiate dermatitis artefacta, where self-inflicted injuries are unconscious, from:.

This entity has been described in the medical literature under various synonyms, ie, epidermotillomania, neurotic excoriations, emotional excoriations, nervous scratching artifact, dermatillomania, and para-artificial excoriations Figure 3. Figure 3 Self-induced cutaneous lesions on a year-old girls stomach inflicted by a sharp pencil.

Acne excoriata is considered by several authors to be the same entity as skin picking syndrome, 2 although there is ongoing discussion with regards to the identification of these entities Figure 4.

Figure 4 Acne excoriata self-induced lesions on the face using a magnifying mirror. Neurotic excoriations are seen in patients with impaired impulse control and more frequently observed in females, although cases in children have been reported. The skin lesions result from self-injury in order to reduce emotional tension. The clinical picture is quite characteristic, with excoriations and superficial erosions, sometimes covered by crusts, scars, and hyperpigmentation, and most often produced by a sharp instrument.

Cutaneous lesions result from the intense impulse of harming the skin. Psychiatric examination and treatment is mandatory because neurotic excoriations can be the first sign of an extensive list of psychiatric disorders, including depression, anxiety, body obsessive—compulsive disorder, body dysmorphic disorder, borderline personality disorder, and hypochondriasis.

From the dermatology point of view, trichotillomania is a nonscarring alopecia induced by repetitive self-pulling of the hair. On clinical examination, different hair lengths are noticed, with broken hairs, new growth, no desquamation, and a negative pull test Figure 5. Psychiatric criteria include existence of nervousness associated with pulling the hair, and relief afterward as a result of reducing tension, depression, and anger.

Trichotillomania should be differentiated from obsessive—compulsive disorder where pulling the hair is an obsessive impulse.

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It commonly affects the scalp, but other hairy regions can be affected, including the eyebrows, eyelashes, and even the pubic hair. In small children, trichotillomania is mainly diagnosed on the scalp. Trichoteiromania is characterized by breaking the hairs by rubbing or scratching the scalp in a repetitive way. Pseudoknuckle pads are hypertrophic lesions localized to the dorsal aspects of the finger joints, more often unilaterally, caused by habitual chewing, rubbing, or sucking the fingers Figure 6 , and is the expression of a psychiatric disorder, eg, mental retardation, bulimia nervosa self-induced vomiting in girls , or obsessive behavior.

Figure 6 Pseudoknuckle pads on the left hand of an year-boy with severe mental retardation.

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Factitious cheilitis is a common observation in pediatric dermatology patients with compulsive disorders. The main mechanism is licking the lips, with or without biting, followed by development of an irritant contact dermatitis and a characteristic clinical picture Figure 7A — C. Figure 7 A Lip-lickers dermatitis in a 4-year-old boy. B Cheilitis artefacta in a year-old girl with secondary eczematization. C Small ulcerations on the lower lip of an 8-year-old girl, self-induced by biting. Onychophagia is nail biting or chewing with swallowing of nail fragments, and is often diagnosed in children.

In small children, onychophagia can be associated with thumb-sucking or secondary irritant dermatitis, infection, inflammation, and even malformation of the digits.