Psychiatry, Dermatology Need Meeting of Minds

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 mental health.

Andrea Sandoz, M.D., a clinical senior instructor in psychiatry, pediatrics, and dermatology at Rochester, works in Tausk's clinic once a week.

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.

Group Treatment Program Starting

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 mirror.

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 home.

“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 habit.

Reducing Medication Dosages

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.

Parasitosis Delusions Studied

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 Original article: Multidisciplinary Team to Study Controversial Skin Disorder). ▪