Psychodermatology: An Opportunity for Collaboration Among Health Care Professionals

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CATEGORY 1 CME

Premiere Date: February 20, 2025

Expiration Date: August 20, 2026

This activity offers continuing education (CE) credits for:

1. Physicians (CME)
2. Other

All other clinicians either will receive a CME Attendance Certificate or may choose any of the types of CE credit being offered.

ACTIVITY GOAL

To inform readers of the opportunity for collaboration with dermatologist, psychologist, and social worker peers to improve patient mental health.

LEARNING OBJECTIVES

1. Recognize the field of psychodermatology, exploring challenges and barriers in meeting clinical demand.
2. Emphasize the importance of multidisciplinary collaboration and the benefits of integrated psychodermatology services, as well as the emerging role in consultation-liaison psychiatry.

TARGET AUDIENCE

This accredited CE activity is intended for psychiatrists, psychologists, primary care physicians, physician assistants, nurse practitioners, and other health care professionals who seek to improve their care for patients with mental health disorders.

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Physicians’ Education Resource, LLC designates this enduring material for a maximum of 1.5 AMA PRA Category 1 Credits.™ Physicians should claim only the credit commensurate with the extent of their participation in the activity.

This activity is funded entirely by Physicians’ Education Resource, LLC. No commercial support was received.

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Psychodermatology is an interdisciplinary field bridging dermatology and psychiatry, necessitating collaboration among a diverse group of health care professionals, including psychiatrists, dermatologists, psychologists, and social workers. This overlap in specialties and professions underscores a holistic approach to patient care. References to psychodermatology appear in textbooks¹ and scholarly articles in peer-reviewed dermatology journals.^2-6 Annually, international professional associations, such as the Association for Psychocutaneous Medicine of North America and the European Society for Dermatology and Psychiatry, host their respective conferences.⁴

TABLE 1. Top 20 Referral Diagnoses.

Despite the increasing number of specialized clinicians and the development of psychodermatology clinics, the task of meeting the escalating clinical demand remains a challenge. In certain clinics, the care team might just include a psychologist or a dermatologist, leading to a potential knowledge gap among clinicians and a lack of comprehensive care. Furthermore, there is a global shortage of extensive outcomes data from psychodermatology clinics, which impedes the development of effective treatment strategies. The field of psychodermatology is gaining recognition as a crucial component within consultation-liaison psychiatry. By tackling the significant challenges and barriers we face, we aspire to see this field evolve into a larger area within consultation-liaison psychiatry. This expansion could foster a collaborative approach among multiple clinicians and facilitate comprehensive and effective care for patients with psychodermatologic conditions.

Common Dermatologic Conditions Frequently Seen and/or Referred to Psychiatry

Data from the Wisconsin Psychocutaneous Clinic indicate that 808 patients were referred to the clinic from May 2002 to February 2018.⁷ Table 1 lists the top 20 referral diagnoses as provided by the referring clinicians. The predominant referral reason was skin picking, noted in 401 patients (49.6%). Pruritus (itching) was the second most common referral cause, seen in 119 patients (14.7%), followed by delusional disorder in 88 patients (10.9%).⁷

Table 2 delineates the ultimate psychiatric diagnoses rendered on these patients.⁷ Skin-picking disorder was the most common final diagnosis, impacting 417 patients (51.6%). Notably, despite just 8 patients being referred for psychotic depressive disorder and none for anxiety disorders, the subsequent prevalent final diagnoses were depressive disorders, affecting 343 patients (42.5%), and anxiety disorders, affecting 227 patients (28.1%), ranking second and third on the final diagnosis list.⁷

With that in consideration, the significant prevalence of anxiety and depressive disorders that cooccurs (and may often underlie) the skin condition often remains unrecognized and thus untreated. The psychological impact of skin conditions is substantial, and it is crucial to acknowledge the bidirectional relationship between dermatologic and psychiatric illnesses. Anxiety and depressive disorders can intensify skin problems (mechanism as summarized in Table 3)^8,9 and skin problems can, in turn, exacerbate anxiety and depressive disorders, creating a cycle that can significantly diminish quality of life.

A comprehensive study conducted across multiple centers and involving dermatology outpatients from 13 European countries revealed that, among various dermatologic diagnoses, only patients with psoriasis showed a significant correlation with suicidal thoughts. The strongest links with depressive and anxiety disorders were observed in patients with psoriasis, atopic dermatitis, hand eczema, and leg ulcers. These findings highlight an additional significant burden associated with skin diseases and carry substantial implications for clinical practice.¹⁰

TABLE 2. Final Psychiatric Diagnoses.

Risk of Substance Use Disorders

Numerous patients report that when symptoms of depressive and anxiety disorders remain undiagnosed and/or inadequately treated, they often lead to self-medication with psychoactive substances. Patients resort to alcohol, tobacco, and/or cannabis for temporary relief from their psychological distress and/or to escape their physical discomfort. However, this approach frequently results in regret, as patients may come to realize that substance use does not address the underlying cause of their distress. Moreover, some patients continue to use these substances despite the onset of depressive disorder and/or suicidal ideation. This can lead to suicide attempts or even death, trapping them in a vicious cycle that further deteriorates their mental and physical health.

A retrospective comparison study analyzing a deidentified dataset from the electronic medical records of a university-affiliated hospital indicated a high prevalence of major depressive disorder (MDD) among patients with psoriasis (31.73%) or systemic lupus erythematosus (SLE) (42.66%). Among these patients with comorbid MDD, fewer than half were treated with antidepressants (39.70% for patients with psoriasis, 41.64% for patients with SLE). Additionally, patients with SLE and psoriasis, who also had comorbid MDD, were more likely to be diagnosed with substance use disorders (SUDs) involving tobacco, alcohol, opioids, cannabis, and other substances, with tobacco use disorder being the most prevalent SUD.^11,12 Furthermore, the presence of coexisting depressive and/or anxiety disorders with SUDs may lead to a suboptimal compliance with therapeutic guidelines, which can exacerbate the poor prognosis of dermatologic conditions.

Referring patients with comorbid psychiatric illness to psychiatry for comprehensive management is essential. This step can address the underlying emotional distress and offer coping strategies, potentially reducing the severity of the skin condition. Such a holistic approach to treatment is vital for enhancing overall well-being.

The Prevalence of Primary Psychodermatologic Disorders

Primary psychodermatologic disorders (PPDs) refer to skin conditions primarily influenced by psychological elements, rather than being secondary manifestations of other dermatologic diseases. The management of PPDs presents significant challenges. A systematic review aimed to assess the global prevalence of PPDs revealed that pathologic skin picking is the most common condition. Prevalence rates in the general population range from 1.2% to 11.2%, with higher rates observed in psychiatric settings (10.5% to 38.5%) and dermatologic settings (21.9% to 58.9%). The highest prevalence (64.7%) was observed among patients receiving treatment for concurrent body dysmorphic disorder and acne.¹³ Hence, it is crucial to evaluate for skin-picking disorders in both primary care and dermatologic settings, particularly for patients presenting with unusual skin lesions and signs of psychological distress. Behavioral psychotherapies, including cognitive behavior therapy, habit reversal therapy, and acceptance-enhanced behavior therapy, have demonstrated efficacy in mitigating skin-picking behaviors.^14,15

TABLE 3. The Bidirectional Relationship Between Dermatologic and Psychiatric Illnesses.

For psychotic psychodermatologic disorders, such as delusional parasitosis (Morgellons disease), the situation is even more complex. Even when there is visible improvement in skin lesions due to the application of topical and oral medications, the lack of psychiatric intervention (including psychotherapy) can potentially exacerbate the condition if the root behavior issues attributable to psychotic illness continue untreated. The importance of psychiatric collaboration in the treatment process cannot be overstated. However, paradoxically, these are often the very patients who are most resistant to psychiatric referrals, even when they are most needed. This resistance not only perpetuates the stigma associated with psychiatric illness and treatment but also poses significant barriers to effective intervention.

A recent review highlighted the significance of antipsychotics as primary treatment options.¹⁶ Pimozide, a first-generation antipsychotic, has been found to be useful for treating patients experiencing delusional symptoms in dermatology settings.¹⁷ This may be because it has no official US Food and Drug Administration psychiatric indication, making it more acceptable to patients who might object to being prescribed a medication for a specific psychiatric indication. Additionally, pimozide is typically used at a low dose of 3 mg or less per day, which minimizes concerns about tardive dyskinesia and presents a lower risk of metabolic syndrome compared with many second-generation antipsychotics.

FIGURE 1. Case Vignette, Fewer Lesions. Photos used with patient permission.

Case Vignette

“Helen,” a 51-year-old woman with a history of depressive disorder, fibromyalgia, and excoriation (skin-picking) disorder, presented to the pain clinic for fibromyalgia management. Notably, she reported that her repetitive skin-picking disorder emerged following an experience in an abusive intimate relationship.

Helen had never been treated for her excoriation disorder and was not on any psychotropic medications. Upon examination, she exhibited erythematous papules with accompanying excoriations and adjacent scarring on the anterior chest, upper back, bilateral arms, and legs. She was initiated on naltrexone 4.5 mg/day for fibromyalgia.

Three months later, Helen returned to the pain clinic for a follow-up. She reported that naltrexone had improved her excoriation disorder, and she felt a reduced urge to scratch her skin. On examination, the areas previously affected by erythema and excoriation were healing, and there were fewer new lesions (Figure 1).

A month following this visit, Helen was advised to discontinue naltrexone due to an upcoming outpatient procedure with another medical service. In the interim, her skin-picking disorder intensified (Figure 2). When her procedure was over, she resumed naltrexone. Upon her return to the pain clinic 2 months later, she reported a perceived improvement in her excoriation disorder and expressed a desire to continue naltrexone.¹⁸

FIGURE 2. Case Vignette, Skin-Picking Disorder Intensified. Photos used with patient permission.

When/How to Communicate With Dermatologists

As we all know, psychotropic medications, including antidepressants, mood stabilizers, and antipsychotics, have the potential to cause dermatologic adverse effects, ranging from mild to severe. Psychiatrists face challenging decisions when managing these adverse effects, such as whether to continue monitoring symptoms if skin lesions emerge, adjust the dose, immediately stop the medication, refer the patient to a dermatologist, or to direct the patient to the emergency department for urgent care. These decisions also affect whether the patient may consider reattempting this medication in the future.

Therefore, managing these adverse effects requires careful consideration of several factors, including the severity and type of the skin reactions (eg, local vs widespread, single or multiple different types of rashes), the psychiatric condition being treated (where risks and benefits should be carefully weighed), and/or the availability of alternative medications. Educating patients about the early signs of skin reactions and ensuring they understand the importance of prompt reporting can significantly improve the management process. The collaboration among psychiatrists, dermatologists, and other health care professionals is essential for a multidisciplinary approach, facilitatingoptimal patient outcomes.

Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN), the most severe form of SJS, are infrequent but serious mucocutaneous reactions, typically induced by medications, including the central nervous system-active medications antipsychotics, antidepressants, anticonvulsants, and barbiturates. These conditions can escalate rapidly and pose a significant threat to life. The importance of early identification and meticulous monitoring cannot be overstated. It is imperative to maintain effective communication and seek advice from a dermatologist for further treatment and recommendations.

It is important to note that carbamazepine carries a boxed warning for serious and potentially life-threatening dermatologic reactions, including SJS/TEN. The warning advises screening for the presence of the HLA-B*15:02 allele before initiating carbamazepine, particularly in patients of Asian descent, including Native Americans.¹⁹ This screening might also be considered for other anticonvulsants, such as lamotrigine, phenytoin, and oxcarbazepine. The presence of this allele is associated with a significantly increased risk of developing SJS/TEN when exposed to these medications. Therefore, if the allele is present, alternative treatments should be considered.

Recommendations

It has been demonstrated that integrated psychodermatology services in Europe have led to superior, faster, and more cost-effective clinical results for patients experiencing psychodermatologic conditions.²⁰ Meanwhile, such services are still evolving in the United States. These multidisciplinary psychodermatology services necessitate a comprehensive approach and cooperation among a wide range of health care professionals. Close monitoring and timely referrals are key to effective management. Where feasible and invited, clinicians can be in an excellent position to aid in the growth of patient advocacy and education in the field of psychodermatology.

Xiaofeng Yan, MD, PhD is a resident physician in the Department of Psychiatry and Behavioral Sciences at the University of California, Davis Medical Center, in Sacramento, California.

James A. Bourgeois, OD, MD is vice chair of hospital psychiatry services at the University of California, Davis Medical Center, Sacramento, California.

References

1. Koo JYM, Lee CS. Psychocutaneous Medicine (Basic and Clinical Dermatology). 1st edition. CRC Press; 2003:376.
2. Christensen RE, Jafferany M. Unmet needs in psychodermatology: a narrative review. CNS Drugs. 2024;38(3):193-204.
3. Roberts JE, Smith AM, Wilkerson AH, et al. “Psychodermatology” knowledge, attitudes, and practice among health care professionals. Arch Dermatol Res. 2020;312(8):545-558.
4. Marshall C, Taylor R, Bewley A. Psychodermatology in clinical practice: main principles. Acta Derm Venereol. 2016;96(217):30-34.
5. Kroumpouzos G. Psychocutaneous medicine: a psychopathology-based, problem-focused approach. Clin Dermatol. 2023;41(1):1-4.
6. Altaha L, Jafferany M, Khan A. Psychocutaneous medicine in Iraq: current status and recommendations. Prim Care Companion CNS Disord. 2022;24(2):21m03077.
7. Mostaghimi L. Psychocutaneous medicine clinic: Wisconsin experience. J Acad Consult Liaison Psychiatry. 2021;62(5):522-527.
8. Arck PC, Slominski A, Theoharides TC, et al. Neuroimmunology of stress: skin takes center stage. J Invest Dermatol. 2006;126(8):1697-1704.
9. Tausk F, Elenkov I, Moynihan J. Psychoneuroimmunology. Dermatol Ther. 2008;21(1):22-31.
10. Dalgard FJ, Gieler U, Tomas-Aragones L, et al. The psychological burden of skin diseases: a cross-sectional multicenter study among dermatological out-patients in 13 European countries. J Invest Dermatol. 2015;135(4):984-991.
11. Yan X, Varghese KJ, Bourgeois JA. Prevalence of substance use disorders among patients with psoriasis and co-morbid major depressive disorder. J Acad Consult Liaison Psychiatry. 2024:S2667-2960(24)00090-9.
12. Varghese KJ, Dellenbaugh A, Cao F, et al. Prevalence of substance use disorders among patients with systemic lupus erythematous and major depressive disorder. JEADV Clin Pract. 2023;2(4):864-866.
13. Turk T, Liu C, Straube S, et al. The global prevalence of primary psychodermatologic disorders: a systematic review. J Eur Acad Dermatol Venereol. 2022;36(12):2267-2278.
14. Lochner C, Roos A, Stein DJ. Excoriation (skin-picking) disorder: a systematic review of treatment options. Neuropsychiatr Dis Treat. 2017;13:1867-1872.
15. Yedidi RS, Koo J, Murase JE. Habit reversal therapy for skin picking disorder. Cutis. 2023;111(4):192-193.
16. Katamanin O, Jafferany M. Psychological interventions in the treatment of delusional parasitosis: a brief review. Int J Dermatol. 2024;63(5):580-584.
17. Brownstone N, Koo J. Why is pimozide uniquely useful for the treatment of delusional patients in dermatology? J Dermatolog Treat. 2022;33(3):1779.
18. Varghese K, Yan X, Cao F. Low-dose naltrexone for excoriation disorder. Cureus. 2024;16(3):e55336.
19. Amstutz U, Shear NH, Rieder MJ, et al; CPNDS clinical recommendation group. Recommendations for HLA-B*15:02 and HLA-A*31:01 genetic testing to reduce the risk of carbamazepine-induced hypersensitivity reactions. Epilepsia. 2014;55(4):496-506.
20. Misery L, Schut C, Balieva F, et al. White paper on psychodermatology in Europe: a position paper from the EADV Psychodermatology Task Force and the European Society for Dermatology and Psychiatry (ESDaP). J Eur Acad Dermatol Venereol. 2023;37(12):2419-2427.