Knowing psychocutaneous illnesses aids treatment

National report - Patients suffering from psychocutaneous illnesses are more likely to see dermatologists than any other physicians, yet dermatologists are perhaps the physicians least prepared to address these problems, says John Y. M. Koo, M.D., professor and vice chairman of dermatology at the University of California, San Francisco Medical Center and director of the department's psoriasis treatment center, phototherapy unit and clinical research unit.

A field of conditions

For starters, he says psychophysiological disorders include skin conditions that flare with emotional stress. Examples include acne, eczema, hives and psoriasis.

Patients with primary psychiatric disorders, on the other hand, have "absolutely nothing wrong with their skin, nails or hair," says Dr. Koo, who is board-certified in dermatology and psychiatry.

Instead, he says these patients suffer primarily from a psychiatric disorder that causes them to perhaps pick their skin (neurotic excoriation) or pull out their hair (trichotillomania). Delusions of parasitosis also fall into this category, he says. Such patients' primary problems are psychogenic, their skin manifestations all self-inflicted, Dr. Koo adds.

Secondary illness

Often overlooked is the category of secondary psychiatric illnesses, or psychological problems that occur secondary to disfigurement, he says.

If the patient has extensive vitiligo on his or her face and happens to be a dark-skinned individual, that person can easily become depressed and sociophobic, Dr. Koo explains.

Chronic cutaneous sensory problems represent a fourth category of psychocutaneous illnesses.

"Because skin is a very sensitive organ," he explains, "often patients will present at a dermatologist's office with itching, burning and other sensations, but they have no rash."

In such cases, Dr. Koo says, "A million-dollar workup reveals nothing, yet they have the sensations."

Underlying psychopathology

Another way to analyze psychodermatologic problems is to identify the underlying psychopathology, which he says commonly takes one of the following forms:

Dr. Koo says that while many other psychiatric diagnoses exist, "These four are most relevant for the skin."

A patient who is anxious can experience a flare-up of genuine skin disease such as eczema, "Or they might become so anxious that they pull out their own hair," or bite their nails, he says.

Therefore, Dr. Koo says, "Anxiety can easily aggravate all kinds of skin conditions - both real and self-induced."

Similarly, he says depression can lead to picking behavior. By the same token, Dr. Koo notes that some patients suffer from delusions of an unspecified bad smell or foreign material in their skin that they attempt to dig out.

He says he also suspects Morgellons patients, who claim to suffer from symptoms including nonhealing skin lesions and unusual structures therein, are probably delusional, largely because they tend to be very peculiarly fixated on their self-diagnosis.

However, he says the term Morgellons "can be very useful for us because it's more neutral" than telling a patient he or she is delusional.