Department of Dermatology, University of Pennsylvania, Philadelphia, PA, USA
Philadelphia Center for Psychoanalysis, Philadelphia, PA, USA
Psychocutaneous disorders involve a unique and somewhat difficult patient population, whose treatment requires the use of drugs unusual to the dermatologist and a significant investment of the clinician’s time. This paper describes an effective interpersonal approach and appropriate drug therapy for patients with delusional disorders and dermatitis artefacta, as well as outlines the expectable course and prognosis in each.
anxiety disorder, delusional parasitosis, dermatitis artefacta, psychocutaneous disease, psychophysiologic disorder
Patients who present with delusional parasitosis or dermatitis artefacta are not easy for dermatologists to work with. Each
is a skin manifestation of a psychiatric disorder that represents a psychological defense – a way for the patient to avoid the acknowledgment of psychiatric pathology.
Delusions of Parasitosis1
The delusions seen in dermatology are Â“systematizedÂ” or non-bizarre – i.e., they are fixed beliefs that, though false, control the patientÂ’s feelings and behavior in ways that are wholly consistent with the content of those beliefs. Delusions of parasitosis associated with cutaneous dysesthesia are the most common, but the possible delusional beliefs, including the Morgellons phenomenon, are legion, and each responds to the same treatment approach. Patients with systematized delusions function adequately in other aspects of life, but comorbid anxiety, depression, and somatizing disorders are common.
Having had many prior unsuccessful consultations, the delusional patient is often defensive, angry, and distrusting. Frequent office visits will help to establish rapport. Empathy is crucial and confrontation must be avoided, but one must
also not permit oneself to collude with the content of the belief. The patient desperately wants answers. In responding, it is important that one sit down and face the patient, accept that what is described is what the patient is experiencing, but be truthful, not critical, yet optimistic.2,3
“We do not know the cause, but we have treatments that are effective” or “We have seen other patients with similar symptoms, and whatever is the cause, there are changes in the skin that we can treat” are possible answers.
A complete physical examination is important and any specimens offered must also be examined, or if appropriate, referred to an entomologist. Drug abuse and systemic disease must be ruled out, and if a biopsy seems indicated, the patient should be asked to choose the site and to also agree that only one specimen will be taken.
As the skin is emotionally overvalued, intensive topical measures are helpful (e.g., tar or bleach baths, emollients, and antibiotics as indicated). As well, topical agents, such as pramoxine hydrogen chloride cream or lotion, may be used to provide temporary relief of any dysesthesia.
Antipsychotic drugs are the first-line treatment. Much smaller doses than those used to treat more severe psychiatric disorders are effective, and side-effects are minimal if the drug is introduced at a low dose and titrated up gradually. Care must be taken not to alarm the patient when introducing a psychotropic drug. Stress to the patient that relief of symptoms in the skin is the goal, and perhaps cite aspirin, which has many different actions, as a parallel. Be frank about possible side-effects, but urge the patient not to read the package insert, as much of the information contained does not apply with such a low dose.
Though pimozide has long been the drug of choice,1,2,4
recent literature suggests that newer atypical antipsychotics
are equally as effective, but possibly safer. Risperidone and
aripiprazole are preferable to olanzapine, which may cause
considerable weight gain, and quetiapine, which is very
sedating. This observer, like Munro,4 has found pimozide (at
under 5 mg daily) to be effective, predictable, and induced
minimal side-effects in approximately 30 patients treated
over a three-month period. To date, tardive dyskinesia and
cardiac arrhythmias have not been reported in dermatology
patients, and electrocardiograms are not suggested if the
dose is under 10 mg per day.2 Clearly, care must be taken in
patients with cardiac problems. With good rapport, one may
gradually introduce the idea of psychiatric referral. This may
occasionally be accepted if suggested, perhaps, as a way to
help the patient handle this life-altering disorder.
Caution the patient not to discontinue the drug unilaterally,
lest symptoms return and trust be shaken. With compliance,
a favorable response may be observed as early as one or two
weeks, which can be evidenced by improved affect and less
obsessional symptom involvement. These changes will auger a slow steady resolution and the drug can then be gradually
tapered after the patient is symptom-free for two to three
From 50-90% of patients are reported to have near or full
symptom resolution, with improved functioning,4 and any
psychiatric and physical comorbidities tend to improve in
parallel. Long-term follow-up is not often possible, but while
remissions of variable length occur and cure is reported, it is
likely that in many cases somatic delusions of this type can
be regarded as a life-long disorder, requiring episodic periods
of treatment throughout life.
Dermatitis artefacta refers to skin lesions produced by the
patient, under the veil of secrecy, to satisfy an unconscious
need to be taken care of.5 Though much less common
than the delusional disorders, it is possible that the quoted
0.03% incidence of dermatitis artefacta in dermatology
patients5 may be an underestimate. Characteristically,
the patient with dermatitis artefacta appears remarkably unconcerned, and somewhat bewildered, in face of lesions
that are morphologically bizarre, often geometric in outline,
destructive, and reportedly of sudden, mysterious yet fully
formed appearance. The condition must be distinguished
from neurotic excoriations and Munchausen’s syndrome, as
the psychopathology, and therefore the treatment, is different
in each case. Patients with neurotic excoriations usually have
depression or anxiety with obsessive-compulsive features;
those with Munchausen’s syndrome have a sociopathic
personality, while patients with dermatitis artefacta are
most commonly diagnosed with the borderline personality
|Possible Side Effects
Incidence weight gain
|Note: Interaction with ketoconazole
|Table 1. The use of psychotropic medications in dermatology
*These are off-label uses. In the doses usually prescribed in dermatology, the incidence of side-effects is no greater than with a placebo.
Patients with this disorder are particularly difficult to work
with. The female to male ratio is 3:1, and though any age may
be affected, the onset is most often observed in adolescence
or early adult life. Characteristically, these patients are filled
with rage and very manipulative in the pursuit of a profound
need to be taken care of. Should the treating physician
answer that need in a way that pleases, the relationship can
be quite positive, but one miss-step is likely to release the
full intensity of irreversible rage. For this reason, doctorshopping
One should set limits from the start and not allow oneself to
be manipulated into acceding to demands for extra time or
special services. Short weekly visits are helpful to establish
a rapport. One can show caring through empathy with the
evident pain and discomfort, the time expended on taking
care of the lesions, and the negative impact of the problem on
the lives of the patient and their family.
Therapeutic and Prognostic Considerations
As with delusional patients, underlying systemic disorders
must be ruled out, a limited number of biopsies performed,
and appropriate topical and antibiotic therapies instituted.
When the patient is an adult, confrontation is usually
counterproductive and will likely contribute to further doctorshopping.
With children, however, confrontation can be very
helpful, particularly if the patient is interviewed alone and
separate from the parents.6 Whilst dermatologic support is
important, borderline patients are best treated psychiatrically,
though a recommendation for psychiatric referral must be
approached very judiciously.
Medication, as a first step, will be more readily accepted if
it is suggested as an aid in handling the difficult disorder,
and, after some discussion, initiated through a joint decision.
The antipsychotics are the drugs of choice and aripiprazole
has an advantage in that it also has antidepressant properties.
Unfortunately, despite careful preparation, psychiatric
referral is often not possible, and though the prognosis is
a little better in the younger patient, for the vast majority
of individuals with dermatitis artefacta, doctor-shopping
becomes a way of life, and suicides do occur.
Because patients with delusional parasitosis and dermatitis
artefacta do not accept the need for psychiatric treatment,
they fall either to the lot of the dermatologist or receive no
help at all. An optimal approach includes frequent short
clinic visits, expression of empathy, affirmation that the skin
itself is involved, and low dose antipsychotic drugs. With
compliance, remissions of varying length occur, but both
disorders are likely to last life-long.
- Freudenmann RW, Lepping P. Delusional infestation. Clin Microbiol Rev 22(4):690-732 (2009 Oct).
- Lee CS. Delusions of parasitosis. Dermatol Ther 21(1):2-7 (2008 Jan-Feb).
- Harth W, Gieler U, Kusnir D, et al. Clinical management in psychodermatology. Berlin: Springer-Verlag, p11-35 (2009).
- Munro A. Delusional disorder: paranoia and related illnesses. Cambridge: Cambridge University Press, p227-41 (1999).
- Millard LG, Cotterill JA. Psychocutaneous disorders. In: Burns T, Breathnach S, Cox N, Griffiths C (eds). Rook?s textbook of dermatology. 7th ed. Oxford: Blackwell Science, vol 4, p61.24-61.28 (2004).
- Koblenzer CS. Psychodermatology of girls and women. In: Parish LC, Brenner S, Ramos-e-Silva M (eds). Women?s dermatology: from infancy to maturity. New York: Parthenon Publishing Group, p10-27 (2001).