Ch. 17- Psychocutaneous Diseases

Question 1

What are the 4 main categories of psychodermatological conditions

Answer 1

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)

Question 2

What are the 4 main categories of psychodermatological conditions

Answer 2

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)

Question 3

Name 4 first line treatments for MDD

Answer 3

SSRI e.g. sertraline
SNRI e.g. venlafaxine, duloxetine
Mirtazapine- α2-Adrenergic agonist; 5-HT2 antagonist
Bupropion-Norepi/dopamine reuptake inhibitor

Question 4

What are 3 first line treatments for GAD (categorieS)

Answer 4

SSRI, SNRI and now gabapentionoids

Question 5

Which anti-depressant least amount of weight gain

Answer 5

Fluoxetine

Question 6

Which is better for avoiding sexual dysfunction SSRI or SNRI?

Answer 6

SNRI

Question 7

First line treatment for OCD- There are 3

Answer 7

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

Question 8

What type of d/o is delusions of parasitosis

Answer 8

Delusional d/o, not schizophrenia or psychosis

Question 9

What is the DSM-5 criteria for delusions of parasitosis

Answer 9

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

Question 10

What is the matchbox sign

Answer 10

Patients frequently bring in bits of skin, lint, and other samples that they believe represent “parasites”,

Question 11

How does delusions of parasitosis present

Answer 11

Fixed belief of parasites invading their skin

Sensation of itching, burning or crawling on their skin

clinically may have excoriations, lichenification PN or ulcers

Question 12

What is Morgellons disease

Answer 12

Variant of delusions of parasitosis

A hallmark of this disorder is that patients claim to observe “ fibers ” exuding from their skin,

Question 13

What is the formication

Answer 13

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

Question 14

What is the traditional first line treatment for delusional parasitosis

Answer 14

Pimozide
-opioid antagonism also thought to help in addition to antipsychotics

Question 15

What is current 1st line treatment for delusional parasitosis

Answer 15

Second gen/atypical antipsychotic eg. risperidone, olanzapine, quetiapine, ariprazole

Question 16

Name 5 concerning side effects of antipsychotics

Answer 16

Sedation
QT prolongation
Weight gain
Increased lipids
Diabetes
Increased prolactin
Extra-pyramidal symptoms

Question 17

What is the presentation of trichotillomania

Answer 17

-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.

Question 18

What are 4 trichoscopic findings of trichotillomania

Answer 18

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

Question 19

What is the mainstay treatment trichotillomania?
Name 3 systemic therapies in addition.

Answer 19

Behaviour modification therapy-CBT, habit reversal training

SSRIs
NAC
Olanzapine

Question 20

What is the mainstay treatment trichotillomania?
Name 3 systemic therapies in addition.

Answer 20

Behaviour modification therapy-CBT, habit reversal training

SSRIs
NAC
Olanzapine

Question 21

What is an excoriation disorder?

Answer 21

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

Question 22

Other than treating underlying itch topically, what are 3 systemic treatments for excoriation d/o

Answer 22

1. Doxepin
2. SSRIs
3. N-Acteylcysteine

Question 23

What is the target dose for doxepin for:
1. Depression + itch
2. Itch
3. Elderly w/ itch

Answer 23

1. 100 mg daily for depression
2. Itch-50-75
3. Elderly 10-20

Question 24

What is acne excoriee

Answer 24

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

Question 24

What is acne excoriee

Answer 24

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

Question 25

How does dermatitis artefacta differ from excoriation disorder

Answer 25

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.

Question 26

How does dermatitis artefacta present? What is a clue to the diagnosis?

Answer 26

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

Question 27

What is the treatment approach for dermatitis artefacta

Answer 27

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.