Among patients seeing dermatologists, one-third or more experience
depression or anxiety related to their skin disorder.
Some disorders have both skin and psychiatric manifestations. Skin picking,
hair pulling, and excessive hand washing, for example, often reflect an
underlying obsessive-compulsive disorder. Stress may contribute to flares of
common chronic skin disorders such as psoriasis, atopic eczema, herpes
simplex, and acne.
Patients who seek a dermatologist's help often define their problem as"
medical," however, and resist referral to a psychiatrist,
Francisco Tausk, M.D., a professor of dermatology and psychiatry at the
University of Rochester School of Medicine, said at the annual meeting of the
American Academy of Dermatology in San Antonio in February.
Bringing a psychiatrist into the dermatology clinic, Tausk said, may enable
these patients to get comprehensive care that improves both their skin and
Andrea Sandoz, M.D., a clinical senior instructor in psychiatry,
pediatrics, and dermatology at Rochester, works in Tausk's clinic once a
Many patients ask Tausk to stay while she talks with them, Sandoz told
Psychiatric News. That validates their skin condition, she said, and
gives patients support. "I try to engage patients in treatment by
focusing on their discomfort and suffering, and exploring ways to ease
that," Sandoz said.
Sandoz contacts the patient's primary care physician to enlist his or her
help in encouraging patients to pursue the recommended treatment. She
prescribes psychotropic medications for some patients and refers others to
psychiatrists for more intensive treatment.
Sandoz and Tausk are embarking on a group treatment program for patients
with compulsive skin picking, a form of self-injury that may lead to ulcerated
patches on the face, arms, legs, or other easily accessed body parts.
This problem, which occurs mainly in women, often starts with a persistent
skin eruption that prompts itching, Tausk said. "The more people pick,
the more they itch. A vicious cycle ensues."
In a regimen adapted from one used to treat obsessive-compulsive disorder,
groups of about eight patients will meet for 60 to 90 minutes once a week for
eight weeks. Sandoz and Tausk will provide instruction in habit reversal,
suggesting, for example, that patients squeeze a ball, fiddle with a string of
beads, or focus on breathing when they feel the urge to pick. The researchers
will advise patients to stop frequently checking their appearance in a
They also will teach techniques of relaxation, guided imagery, and
self-hypnosis. Tausk prefers to instruct patients individually in
self-hypnosis; he tapes the session and gives patients the tape to use at
"Patients with compulsive skin picking often feel ashamed of their
behavior," Sandoz said. "It's a secretive condition. They find
relief in learning it has a name and that they are not alone." She hopes
group members will support each other as they work toward curtailing their
In other research, Tausk and colleagues hope to harness brain-body
interaction to improve medication therapy regimens.
In a study funded by the National Institute of Arthritis and
Musculoskeletal and Skin Diseases, the researchers seek to capitalize on
conditioned immunosuppressive responses to reduce the cumulative amount of a
corticosteroid medication commonly used to treat psoriasis, a chronic
inflammatory skin disease.
All participants initially will take the immunosuppressant drug
cyclosporine daily until their skin becomes at least 75 percent clear,
according to a standard psoriasis severity index. Patients then will be
randomized to three groups. One group will continue taking the typical dosage
of medication every day (5mg/kg/day). The second and third groups will take
the same dosage but only every fourth day. The second group will take nothing
on the intervening three days, while the third group will take a placebo on
those three days.
Tausk's group treats patients for four months, or until they experience a
50 percent recurrence, and then follows them for two years. The researchers
hypothesize that patients receiving the standard dosage will maintain their
improvement, while those receiving one-quarter of the typical dosage plus
placebo will do better than those taking the lower dosage alone.
If skin clearing can be maintained with a lower dosage of medication, Tausk
said, patients also would have a lower risk of kidney damage, high blood
pressure, and other medication-associated adverse effects.
People who believe they are infested with parasites, despite lack of
evidence, may require several visits to establish trust before a dermatologist
suggests a psychiatric consultation, Tausk said.
"These individuals bring dust particles, lint, or skin scrapings that
I put under the microscope to show the patients that no insects are
there," Tausk said. "One woman was convinced she had Lyme disease,
so I ordered blood tests to verify that she did not."
"In my experience, biopsies do not help," he said. "When
the biopsy is negative, the patient insists it was performed in the wrong
place or was not deep enough.
"Patients with delusions of parasitosis have an unshakable conviction
that they are infested," Tausk noted. Some have called the exterminator
so many times that the exterminator refuses to return. Some have sued their
landlord for failure to eradicate pests. Some have moved.
"The parasites follow them," he said. "Patients say, 'The
parasites must have been in my clothes.'"
Tausk added, "I tell these patients, 'I don't see any infestation,
but something is bothering your nerves. We have to deal with that.'" In
some patients, medications such as aripiprazole curb the delusions or reduce
the patient's discomfort.
It is still unclear whether the self-diagnosed condition called morgellons
represents delusions of parasitosis, as Tausk said many dermatologists
believe, or a novel disorder. Responding to about 1,200 inquiries from the
public in 2007, the Centers for Disease Control and Prevention launched a
study of morgellons in January (see Multidisciplinary Team to Study
Controversial Skin Disorder). ▪