Ch. 17- Psychocutaneous Diseases Flashcards
What are the 4 main categories of psychodermatological conditions
Primary psychiatric d/o: Primary psych d/o with dermatologic manifestations e.g. delusions parasitosis
Secondary psych d/o: Skin condition that results in secondary psych condition e.g. acne with depression
Psychogenic pruritus and dyesthesia : in which the patient presents with a purely sensory complaint (e.g. pruritus, burning, stinging) without evidence of a primary skin disease or underlying medical condition
Psychophysiologic disorders , in which a primary skin disorder (e.g. atopic dermatitis) is exacerbated by emotional factors (e.g. anxiety)
What are the 4 main categories of psychodermatological conditions
Primary psychiatric d/o: Primary psych d/o with dermatologic manifestations e.g. delusions parasitosis
Secondary psych d/o: Skin condition that results in secondary psych condition e.g. acne with depression
Psychogenic pruritus and dyesthesia : in which the patient presents with a purely sensory complaint (e.g. pruritus, burning, stinging) without evidence of a primary skin disease or underlying medical condition
Psychophysiologic disorders , in which a primary skin disorder (e.g. atopic dermatitis) is exacerbated by emotional factors (e.g. anxiety)
Name 4 first line treatments for MDD
SSRI e.g. sertraline
SNRI e.g. venlafaxine, duloxetine
Mirtazapine- α2-Adrenergic agonist; 5-HT2 antagonist
Bupropion-Norepi/dopamine reuptake inhibitor
What are 3 first line treatments for GAD (categorieS)
SSRI, SNRI and now gabapentionoids
Which anti-depressant least amount of weight gain
Fluoxetine
Which is better for avoiding sexual dysfunction SSRI or SNRI?
SNRI
First line treatment for OCD- There are 3
SSRI- all except escitalopram and citalopram approved
Clomipramine (TCA that also inhibits serotonin and NE reuptake)
SNRI-less evidence
*Generally need higher doses e.g. fluoxetine 80-120 mg, normally 60 mg for depression/GAD
What type of d/o is delusions of parasitosis
Delusional d/o, not schizophrenia or psychosis
What is the DSM-5 criteria for delusions of parasitosis
1) the delusion must be present for ≥1 month; (2) the patient does not exhibit impaired functioning or bizarre behavior apart from the impact of the delusion;
(3) the delusion cannot be attributable to the effects of a substance, medication, medical condition, or other psychiatric disorder
What is the matchbox sign
Patients frequently bring in bits of skin, lint, and other samples that they believe represent “parasites”,
How does delusions of parasitosis present
Fixed belief of parasites invading their skin
Sensation of itching, burning or crawling on their skin
clinically may have excoriations, lichenification PN or ulcers
What is Morgellons disease
Variant of delusions of parasitosis
A hallmark of this disorder is that patients claim to observe “ fibers ” exuding from their skin,
What is the formication
tactile HALLUCINATION involving the sensation of “bugs” crawling within or biting the skin
Do not believe caused by infestation
often in drug use like meth or cocaine SUD
What is the traditional first line treatment for delusional parasitosis
Pimozide
-opioid antagonism also thought to help in addition to antipsychotics
What is current 1st line treatment for delusional parasitosis
Second gen/atypical antipsychotic eg. risperidone, olanzapine, quetiapine, ariprazole
Name 5 concerning side effects of antipsychotics
Sedation
QT prolongation
Weight gain
Increased lipids
Diabetes
Increased prolactin
Extra-pyramidal symptoms
What is the presentation of trichotillomania
-hairs of varying lengths distributed within the area of alopecia, with uninvolved areas appearing completely normal
hairs are sometimes referred to as “irregularly irregular”. Lesions are often single and can be large; the vertex and parietal scalp are the most common sites 3 . Patients may try to conceal the hair loss with make-up, scarves, hats, or wigs.
What are 4 trichoscopic findings of trichotillomania
irregularly broken hairs
coiled hairs
the “V-sign” (two hairs broken at the same level in one follicle)
flame hairs (wavy hair residues), and follicular hemorrhages
What is the mainstay treatment trichotillomania?
Name 3 systemic therapies in addition.
Behaviour modification therapy-CBT, habit reversal training
SSRIs
NAC
Olanzapine
What is the mainstay treatment trichotillomania?
Name 3 systemic therapies in addition.
Behaviour modification therapy-CBT, habit reversal training
SSRIs
NAC
Olanzapine
What is an excoriation disorder?
a conscious, repetitive, and uncontrollable desire to pick, scratch, or rub their skin, which results in characteristic lesions
DSM criteria similar to trichotillomania
1) recurrent skin picking, resulting in skin lesions; (2) repeated attempts to decrease or stop the picking; (3) significant distress or impaired functioning related to the picking; and (4) no underlying medical condition or other mental disorder that explains the picking
Other than treating underlying itch topically, what are 3 systemic treatments for excoriation d/o
- Doxepin
- SSRIs
- N-Acteylcysteine
What is the target dose for doxepin for:
1. Depression + itch
2. Itch
3. Elderly w/ itch
- 100 mg daily for depression
- Itch-50-75
- Elderly 10-20
What is acne excoriee
Acne excoriée is a subset of excoriation disorder in which the picking is directed at acne lesions. The underlying acne is often mild but accompanied by extensive excoriations that may lead to scarring
What is acne excoriee
Acne excoriée is a subset of excoriation disorder in which the picking is directed at acne lesions. The underlying acne is often mild but accompanied by extensive excoriations that may lead to scarring
How does dermatitis artefacta differ from excoriation disorder
Dermatitis artefacta represents a type of factitious disorder within the broad DSM-5™ category of somatic symptom and related disorders 3 . Patients inflict cutaneous lesions upon themselves to satisfy a psychological need of which they are usually not consciously aware. If asked, the patients deny having any role in creating the skin lesions.
How does dermatitis artefacta present? What is a clue to the diagnosis?
Angulated edges and unusual shapes! But can present like many other lesions
The morphology ranges from vesicles and bullae to purpura to subcutaneous emphysema to erosions and ulcerations. A clue to the diagnosis is unusual shapes, particularly with angulated edges, that suggest an external method of induction
What is the treatment approach for dermatitis artefacta
Given the nature of the disorder, it may be more fruitful to provide a supportive environment early in the doctor–patient relationship and then advance to the psychological aspects of the disease at subsequent visits.
Antidepressant, antianxiety, or antipsychotic medications (see Table 7.1 ) may be indicated when affected individuals have an underlying psychiatric disorder.
