When the itch is more than skin deep

The problem is that psychodermatology can go beyond the trichotillomania or excoriation of severe psychosis and can present with virtually the same symptoms as completely physiologically caused skin conditions.

On Call wondered how quickly dermatologists consider the possibility that psychological issues are playing a role in their patients' conditions, and how they handle that with the patient when they consider psychological factors to be a strong possibility.

Some dermatologists, like Helen A. Mashek, M.D., F.A.A.D., of Newark, Del., don't see the problem very often.

"I don't really see it as an issue unless the patient has a history of psychological disorders. If someone has a condition that doesn't improve when I'm fairly certain I've given them the appropriate treatment, then I consider that perhaps they're not using their medication, or there could be other issues," she says. "Usually, I consider psychological issues when somebody has the typical excoriations or delusions of parasitosis."

Dr. Mashek says she can get those patients once a month or so.

"Patients with delusions of parasitosis are difficult to treat because they don't want to see the appropriate person, which would be a psychiatrist," she notes.

On the other hand, Howard J. Donsky, M.D., F.A.A.D., in Rochester, N.Y., considers psychological factors frequently.

"For example, if someone comes in with warts, I probably don't think of psychological causes at all. If, however, a patient has a condition I know is often aggravated by stress, I think of it very quickly. Examples of that would be acne, psoriasis, eczema, urticaria. Infections - probably not; reactive type conditions, probably 'Yes.'"

Dr. Donsky thinks most dermatologists keep psychological stressors in mind, but says other specialties frequently miss the possible association.

"If you think about people having ulcers or high blood pressure, nobody blinks when you say stress will make that worse. Yet, here we get into skin conditions which should really be more obvious than internal problems, and people sometimes have a difficult time grappling with it."

It's not that Dr. Donsky considers psychological influences the primary cause of skin problems.

"Usually, most of these things end up being a combination of factors. An example would be a fast food worker who gets oil vapor all over their skin, and at the same time his boss is on his case. Which is the major factor? It's up for grabs."

Reading the clues

According to Robert A. Norman, D.O., in Tampa, Fla., a number of conditions can be included under a general finding of "neurodermatitis."

"Think of neurodermatitis as an umbrella term and beneath that you have things like lichen simplex chronicus or delusions of parasitosis.

"I just had a patient with bumps all over her arms - and it's not from a physical cause because you see the lesions are in all different states of healing, whereas typical rashes will heal in a more symmetrical pattern. With lichen simplex chronicus, patients don't get bumps and then scratch them, they scratch and then bumps erupt."

In Portland, Ore., Lisa S. Turner, M.D., F.A.A.D., agrees that often there are palpable hints of psychological stressors.