Somatization in dermatology

Medically unexplained dermatologic symptoms, such as pruritus, numbness and burning are known as somatization. These cutaneous symptoms can be very difficult to treat because of an absence of an objective explanation and they may not fit neatly into any known dermatological or psychiatric condition. These disorders are more commonly encountered in primary care and in dermatology, rather than in psychiatry. Certain skin disorders, for example, pruritus, could be a manifestation of somatization and others may predispose to somatic symptoms, for example, atopic dermatitis and psoriasis. Although there has been increasing research in the interconnection between psychiatry and dermatology, psychodermatology is a relatively new crossover discipline in clinical practice and recognition of psychodermatological conditions, such as cutaneous somatic disorders, can be difficult. Somatization may occur with or without the existence of a dermatological disease. When a dermatological disorder is present, somatization should be considered when the patient is worrying too much about their skin, spending too much time and energy on it and especially if the patient also complains of many non-cutaneous symptoms. Purely cutaneous somatic conditions include for example, the genital pain syndromes or Gardner-Diamond syndrome, characterized by unexplained bruising, which usually affects women. Effective management tools may include mindfulness therapies, pharmacotherapy with selective serotonin reuptake inhibitors, tricyclic antidepressants and cognitive conduct therapy. Electroconvulsive therapy can also be considered in extremely rare cases for treatment of severe somatization on a background of mood disorders. This paper discusses somatization, its relationship to immunodermatoses and its relevance to clinical practice.

Impact of chronic and recurrent dermatophytosis on quality of life and psychologic morbidity-a cross-sectional study

BACKGROUND

Chronic and recurrent dermatophytosis is adversely effecting the psychosocial well-being of patients.

AIMS

To assess the impact of chronic and recurrent dermatophytosis on quality of life and psychological well-being of patients.

METHODS

We performed a cross-sectional study on patients of chronic and recurrent dermatophytosis aged >12 years. Clinical diagnosis was done, followed by appropriate investigations when required. The patients were made to fill up the questionnaires on Dermatology Life Quality Index, Hospital Anxiety and Depression Scale, and Perceived Stress Scale in English and local languages. The responses were coded with 4-point Likert scale. Statistical analysis was done using MedCal^® V.125.0.

RESULTS

Data of 123 patients were analyzed. Mean DLQI score was 21.4 ± 5.6 and main domain affected was "symptoms and feelings." CRD had an "extremely large effect" on QoL (DLQI score 21-30) in 55.3% patients. Mean HADS-A(anxiety) score was 10.1 ± 3.6, and mean HADS-D(depression) score of participants was 7.8 ± 3.2. Mean perceived stress scale (PSS) score was 18.8 ± 4.3. Involvement of >1 site was a risk factor for higher DLQI score suggestive of "extremely large impact" on QoL (OR 34.02,95% CI 5.7-203.2,p = 0.0001), higher/worsened HADS-A score (OR 5.4, 95% CI 1.2-22.9, p = 0.02), and higher/worsened PSS score (OR 6.1, 95% CI 1.1-34.1, p = 0.04). Persistent disease >1 year (OR 11.5, 95% CI 1.9-67.8, p = 0.007) and male gender (OR 0.3, 95% CI 0.1-0.8, p = 0.01) were significant risk factors for anxiety while BSA involvement >10% was a significant risk factor for moderate to severe perceived stress(OR 13.9, 95% CI 1.5-130.7, p = 0.02).

CONCLUSION

Chronic and recurrent dermatophytosis requires a multidisciplinary approach involving psychiatrists, to reduce the psychological burden.

Psychological Aspects of Hair Disorders: Consideration for Dermatologists, Cosmetologists, Aesthetic, and Plastic Surgeons

Hair loss disorders may cause considerable distress to patients. Although many do not pose a significant medical risk, the sociocultural importance of hair is substantial. Often the extent of hair loss does not correlate to the impact on psychosocial function, thus necessitating an individualized approach. Hair loss disorders are interrelated with mental health and at times exert significant psychological percussions, and therefore, providers should address both medical and psychological aspects of treatment. This review contains a discussion of the impact on quality of life of common hair loss disorders and the psychological approaches that providers may utilize to improve care. The incorporation of psychodermatology and psychotrichology in dermatology and psychiatry residency programs is of vital importance. Dermatology and psychiatry liaison clinics may prove useful in the treatment of these patients.

Alopecia areata: A psychodermatological perspective

BACKGROUND

Alopecia Areata (AA) is an autoimmune dermatological disease that could be influenced by psychological factors as part of the pathophysiology of the illness.

AIMS

This review article aims to report on psychodermatological and psychopathological aspects involved in the etiopathogenesis and comorbidities of AA, as well as on the psychiatric and psychological management of affected patients.

METHODS

We conducted a literature search on PubMed and Google Scholar from January 1980 to May 2021 employing the search terms of alopecia areata, psychological factors, psychological impact, psychodermatology, and psychopathology. All lists of references from the identified articles were screened for further relevant studies. The search was limited to English and Spanish language articles and was supplemented with themed books and book chapters. No specific quality criteria were used for the studies selection.

RESULTS

Several authors have found a high comorbidity rate between AA and mental disorders, concluding that stress and psychological factors are involved in both the development and exacerbation of the illness. More evidences are needed in order to describe the associations between the immune response, stress, and the physiological factors observed in AA patients.

CONCLUSION

AA is a complex illness characterized by multifactorial etiology. An interaction between genetic, autoimmune, hormonal, neural, and psychological factors is supposed. Psychopathological aspects of illness need to be better described and considered in the clinical setting.

A Brief Review of Dermatitis Artefacta and Management Strategies for Physicians

Dermatitis artefacta, an enigmatic entity with often bizarre and widely variable presentations, can be a challenge to diagnose and treat. Although it is classified as a primary psychiatric disorder, patients are often oblivious that the lesions are self-inflicted and thus consult a physician. Therefore, it becomes imperative to be aware of this condition and to build a good rapport with patients so as to counsel them on the need to seek care for their underlying psychiatric stressors. This narrative review focuses on reaching a proper diagnosis, addressing associated psychological morbidity, and formulating treatment approaches.

Psychiatric morbidity, stress and quality of life among geriatric dermatology patients: Therapeutic considerations from an Indian perspective

We aimed to determine the prevalence of psychiatric morbidities, stress and quality of life, the pattern of skin diseases and associated psychosocial factors in geriatric population. Patients aged 60 years and older were recruited. Demographics and dermatological history and findings were collected using a preset Proforma. Geriatric depression scale (GDS), hospital anxiety and depression scale (HADS), perceived stress scale (PSS), and dermatology life quality index (DLQI) were instituted in all the patients. A total of 310 patients were included in the study, 173 males and 137 females. Infectious diseases (39.6%), papulosquamous diseases (17.1%), and eczema (15.5%) were common disorders. 45.5% were depressed and 43.2% had anxiety (hospital anxiety and depression scale). 55.8% had depression (geriatric depression rating scale), 20.3% had high stress and 11% had extremely large effect on DLQI. Divorced/widowed patients experienced more depression (p = 0.037) and had more impairment in quality of life (p = 0.05). Patients living in three generation family experienced more impairment in quality of life (p = 0.000). Our study demonstrated high prevalence of psychiatric morbidities in geriatric dermatology patients. It implies the need of special care with more attention to psychiatric co morbidities. The role of psychiatry-dermatology liaison clinic may benefit these patients.

Complication of Soft Tissue Fillers: Prevention and Management Review

The use of dermal fillers has increased manifold over the past decade, which has been attributed to the ever-increasing need of the population for being young. Fillers have become quite popular both among patients and treating physicians due to their quick and quite predictable results. Filler injection is a safe procedure in the hands of an experienced provider using appropriate technique. Nevertheless, various adverse effects to fillers have been reported that range from mild injection site complications, such as pain and bruising, to severe complications, like tissue necrosis, retinal artery occlusion, and infections. The esthetic provider should be aware of and be able to quickly recognize such complications, and be confident in managing them. In this article we highlight the various adverse effects noted with the use of fillers and discuss prevention and management. J Drugs Dermatol. 2020;19(9):829-832. doi:10.36849/JDD.2020.5084.

Acanthosis nigricans: A review

BACKGROUND

Acanthosis nigricans (AN) is a cutaneous disorder characterized by symmetric velvety hyperpigmented plaques on intertriginous areas like axilla, neck, inframammary, and groin.

AIMS

To summarize the pathophysiology and classification of AN, provide an update of diagnostic testing strategies, and describe the current therapeutic options described so far in the literature for this disease.

METHODS

A comprehensive english language literature search across multiple databases (PubMed, EMBASE, MEDLINE, and Cochrane) for keywords (alone and in combination) was performed. MeSH as well as non-MeSH terms such as "acanthosis nigricans," "classification," "pathophysiology," "diagnosis," "treatment," "topical drugs," "systemic drugs," "chemical peeling," and "lasers" were taken into consideration.

RESULTS

The pathophysiology of AN revolves around a multifactorial stimulation of proliferation of epidermal keratinocytes and dermal fibroblasts. Various types of AN include benign, obesity-associated, syndromic, malignant, acral, unilateral, medication-induced, and mixed-type. Homeostasis model assessment-insulin resistance (HOMA-IR) is a good tool for assessment of insulin resistance. Management involves general measures (weight reduction and addressing the underlying cause, if any), topical drugs (retinoids, vitamin D analogs, and keratolytics), oral drugs (retinoids and insulin sensitizers), chemical peels (trichloroacetic acid), and lasers (Long pulsed alexandrite, fractional 1550-nm erbium fiber, and CO₂ ).

CONCLUSION

Acanthosis nigricans is a treatable condition; however, complete cure and disappearance of lesions are difficult to achieve. Weight reduction is the most scientific and practical management strategy. Long-term studies and further research is warranted in the pathophysiology and treatment of this common condition.

The Spanish version of the Skin Picking Impact Scale (SPIS) and its Short form (SPIS-S)

Introduction: The Skin Picking Impact Scale (SPIS) is a self-report rating scale that assess the psychosocial impact of excoriation disorder. In this study the SPIS was translated into Spanish and its reliability was measured. Similarly, its short version (SPIS-S) has been translated and tested. Methodology: The recruitment has been performed through a survey launched on social media. All subjects were older than18 years and self-reported being diagnosed with an excoriation disorder. 281 individuals were rated for the validation analysis. SPIS has been translated into Spanish and validated through an. Exploratory and confirmatory factorial analysis. Participants have been also scored with the Skin Picking Scale-Revised (SPS-R). Results: On factor at the exploratory factorial analysis has a raw eigenvalue greater than 1, with 65.5% of total variance. The confirmatory analysis confirmed that the scale is one-dimensional. Cronbach’s alpha also confirmed a good internal consistency (?=0.934 for the SPIS and ?=0.882 for the SPIS-S). Scores between the two scales (SPIS and the SPS-R) have shown a good convergence (r=0.592, p<0.0001). Conclusion: The Spanish version of SPIS and its short version show good psychometric properties and adequately reproduce the one-dimensional model of the original English version.

Classification of psychodermatological disorders

Currently, psychodermatological disorders are classified under different criteria exhibiting several limitations, and no single universal classification system exists. Herein, we discuss previous suggested classifications in psychodermatology, highlighting their limitations, and we propose a new classification system, without redundant information and with accurate terminology, incorporating the relevance of the terms "disorder," "disease," and "illness" in psychodermatology. In this new classification, the following three groups are then suggested: "primary psychodermatological disease," to include primary dermatoses, where psychological stress, a psychological mechanism, and/or psychopathology are some of the main elements that are recognized in the etiopathogenesis (which may induce and/or worsen a primary dermatosis); "primary psychodermatological illness," to include skin symptoms, with or without secondary self-induced skin lesions (such as excoriations), without a primary dermatosis, and where psychopathology, psychological characteristics, and/or a neuropathic mechanism, where stress plays a relevant role, are key features responsible for the skin symptoms and the secondary skin lesions; and "secondary psychodermatological disorder," to include medications prescribed in dermatology with psychiatric consequences and medications prescribed in psychiatry with dermatologic consequences. Our goal with this system is to broaden the recognition of psychodermatology and improve patient management, with practical and scientific relevance for dermatologists, psychiatrists, and psychologists working in psychodermatology, but also for general practitioners, physicians from other medical and surgical specialties as well as specialists in esthetic dermatology, who frequently encounter patients with psychodermatological disorders.

Psychodermatology in the Era of COVID-19

The impact of the coronavirus disease 2019 (COVID-19) pandemic on mental health has been reflected in different populations worldwide. It has caused significant psychopathological consequences in general population, healthcare professionals (e.g., dermatologists), patients with COVID-19, and patients with other diagnoses, including skin diseases. The prevalence of psychiatric comorbidities in dermatology has long been reported to be at least 30 percent. It is important to investigate the pandemic's impact on comorbid psychosocial and psychopathological symptoms seen in dermatology, including expected short- and long-term mental health consequences. The authors seek to raise awareness among healthcare professionals of the impact that COVID-19 is having on existing psychodermatological conditions and discuss the practical implications of this relationship in dermatology.

Multidisciplinary and Holistic Models of Care for Patients With Dermatologic Disease and Psychosocial Comorbidity: A Systematic Review

Importance

Psychocutaneous disease affects an underrecognized patient population facing misdiagnosis and a reduced quality of life due to knowledge gaps and insufficient awareness. Clinicians worldwide serve as pioneers in offering specialized care for affected patients through the development of combined clinics. Results yield a framework needed to expand availability and ultimately improve patient outcomes.

Objectives

To report key findings generated from an in-depth analysis of available literature, highlight the importance and benefits of providing multidisciplinary care, and provide structural evidence of existing liaison clinics for more widespread future application.

Evidence Review

To identify data from inception to November 12, 2019, a search was conducted in PubMed and Google Scholar using the following search strategy: psychodermatology clinic OR psychodermatology liaison OR psychodermatology combined OR psychocutaneous clinic OR psychocutaneous liaison OR psychocutaneous combined OR psychiatry dermatology combined OR psychiatry dermatology clinic. Studies were excluded if they were single-patient case reports; if information regarding the number of patients, clinic setup, and presenting conditions was not provided; and if the reports were published in a language other than English.

Findings

A total of 932 studies were screened, and 23 were retained after removal of duplicates and application of inclusion criteria. The combined clinics, varying in structure, design, and setting, provided collective data from 1677 patients in 12 countries worldwide. Results indicate that patients experience barriers in gaining access to care and clinicians lack appropriate knowledge and resources for proper diagnosis and treatment. The implementation of combined clinics provides a cost-reducing avenue in the management of dermatologic disease and psychosocial comorbidity by limiting inaccurate diagnoses, ineffective treatments, unnecessary referrals, and "doctor shopping." Increased patient satisfaction or improved patient outcomes after the use of holistic treatment with pharmacologic and nonpharmacologic therapies was reported by 20 included studies (87%).

Conclusions and Relevance

Examined data from the included clinics illuminate the increased need and demand for specialized care. The ability to provide high-quality integrative patient care, potential utility in medical education, and findings of reduced health care expenditures reflect the need for health care leaders to expand specialized care as key for moving forward. Practical clinic models consist of a well-informed dermatologist for identification of psychocutaneous disease, referral if needed, and treatment based on the physician's individual comfort level. Involvement of multiple specialists, including psychiatrists, psychologists, and residents and preferably within teaching institutions, in consultations and management-related discussions is recommended.

Psychodermatology knowledge and awareness in Chinese dermatologists: Results of a survey study

To assess the knowledge, awareness, practice patterns, and attitudes of Chinese dermatologists toward psychocutaneous disorders and explore their interest in continuing medical education (CME) of psychodermatology. An online survey study was conducted from October to November 2019. The survey questionnaire link was sent to the members of the national and local association of dermatology through a social media App. After confirming the informed consent to enrol in the study, the participants filled out the online questionnaire anonymously. About 1047 dermatologists completed the survey. The most common diagnoses referred to the psychiatrist from Chinese dermatologists were venereal phobia (51.77%), delusion of parasitosis (44.03%), and trichotillomania (32.28%). Compared with dermatologists, Traditional Chinese Medicine (TCM) dermatologists had less training experience on psychodermatologic CME (4.21% vs 8.34% who had attending more than twice CME, P < .05). Although TCM dermatologist experience more frequency with psychodermatology (24.21% TCM vs 15.71% dermatologists), they had lower comfort level in treating psychodermatologic patients (51.58% TCM vs 58.89% dermatologist) (P > .05). While 818 (78.13%) dermatologists never received any training course, 84.53% of the dermatologists expressed interest in attending CME events on psychodermatology. The most popular CME themes of psychodermatology were emotional disorders related to skin diseases, delusion of parasitosis, and trichotillomania. Chinese dermatologists have insufficient knowledge and awareness toward psychodermatology. TCM dermatologists have higher awareness on psychocutaneous diseases compared with dermatologists. Psychodermatology continuing medical education programs should be carried out as soon as possible.

Therapeutic implications of dermoscopic findings in acanthosis nigricans: A clinical and histopathological study

Acanthosis nigricans is associated with numerous systemic disorders. These include endocrinological conditions such as, diabetes, acromegaly, Cushing's syndrome, thyroid dysfunction, as well as metabolic abnormalities like obesity and polycystic ovarian disease. Its association with visceral malignancy is known. Moreover, Acanthosis nigricans is known to be a cutaneous marker of insulin resistance (IR) and hyperinsulinemia. The primary aim of this study was to study clinical and histopathological patterns of acanthosis nigricans and its correlation with dermoscopic patterns and treatment implications. 103 patients clinically diagnosed as acanthosis nigricans were enrolled in the study. Clinical evaluation, dermoscopy, and skin biopsy was done for histopathological evaluation. Consistency was observed in the changes seen on dermoscopy with clinical and histopathological findings. Common dermoscopy findings were Crista Cutis, Sulcus Cutis, Papillary projections, hyperpigmented dots, crypts, and blotching Dermoscopic findings can be correlated with histopathological features. Dermoscopy allows visualization on higher magnification which helps to pick up subtle changes which are not visible to naked eye. Dermoscopy can be a useful tool to distinguish acanthosis nigricans from other pigmentary disorders in patients who are not willing for histopathological examination and helps in treatment making decisions.