The current management of delusional parasitosis and dermatitis artefacta.

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.

Dermatitis artefacta. Clinical features and approaches to treatment.

In dermatitis artefacta, the patient creates skin lesions to satisfy an internal psychological need, usually a need to be taken care of. The clinical presentation is characteristic, and differs from that of neurotic excoriations, delusional disorders, malingering, and Munchausen's syndrome. Munchausen's syndrome by proxy is a form of dermatitis artefacta. Except where disease is mimicked, lesions that do not conform to those of known dermatoses are shrouded in mystery, appearing fully formed on accessible skin, within the context of a characteristic psychological constellation. The patient is friendly but bewildered, and the relatives, angry and frustrated. Because of lack of diagnostic stringency, quoted female-to-male ratios range from 3:1 to 20:1, with the highest incidence of onset in late adolescence to early adult life. Most patients have a personality disorder; borderline features are common. The patient's denial of psychic distress, and negative feelings aroused in healthcare personnel, make management difficult. Limit-setting for the protection of both the physician and patient; creation of an accepting, empathic, and nonjudgmental environment; and close supervision of symptomatic dermatologic care will permit development of a therapeutic relationship in which psychological issues may gradually be introduced, that may occasionally permit psychiatric referral. Issues of etiology should be sidestepped because confrontation is counter productive. When psychiatric referral is refused by the patient, the use of psychotropic drugs by dermatologists is helpful and appropriate. The upper dose range of selective serotonin reuptake inhibitors (SSRIs), or low dose atypical antipsychotic agents, may be effective. Except in mild transient cases triggered by an immediate stress, the prognosis for cure is poor. The condition tends to wax and wane with the circumstances of the patient's life. Lesions can be kept to a minimum, the patient can be protected from unnecessary and intrusive studies, and society can be protected from escalating and unnecessary expenditure of medical resources if, rather than discharging the patient, the dermatologist continues to see the patient on an ongoing basis for supervision and support, whether or not lesions are present. Research studies are necessary to document more accurately the expectable cause, treatment outcome, and prognosis for this group of patients.

Itching and the atopic skin.

Itching is one of the major diagnostic criteria of atopic dermatitis and one of its most troublesome symptoms. The symptom of itching may reflect skin disease, internal disease, or emotional disease. Although itching is symptomatic of many inflammatory and psychophysiologic dermatoses, in atopic dermatitis it is a cardinal feature of the disease. Effective control of itching can go a long way towards controlling the eruption itself; it can also make a major contribution to the physical and emotional well-being of the patient and the patient's total environment.

Neurotic excoriations and dermatitis artefacta.

Patients with different psychiatric disorders produce artefacts on the skin, each requiring a different therapeutic approach. These different disorders are outlined briefly. The clinical picture, pathology, psychopathology, differential diagnosis, treatment, course, and prognosis of dermatitis artefacta and neurotic excoriations are reviewed in greater detail.

Psychotherapy for intractable inflammatory dermatoses.

BACKGROUND: Most patients with inflammatory dermatoses respond to conventional treatment. Recalcitrance may indicate underlying emotional factors after infection, contact allergy, and noncompliance have been ruled out. Psychiatric treatment has been reported to be effective. OBJECTIVE: The purpose was to determine whether insight-oriented psychotherapy, by effecting last change, would provide long-term cutaneous and psychiatric improvement. METHODS: On the basis of emotional distress attributed to a recalcitrant inflammatory dermatosis, four patients were referred for psychiatric evaluation. The effect of adding insight-oriented psychotherapy as the only change in the treatment regimen of each patient was studied. Each patient served as his or her own control. RESULTS: In each patient clearing of the previously recalcitrant dermatosis accompanied psychiatric improvement. CONCLUSION: In selected cases of recalcitrant inflammatory dermatoses, insight-oriented psychotherapy may provide lasting cutaneous improvement and improved life adjustment and psychologic well-being.

Managing the 'difficult' patient in the dermatology office.

Certain dermatology patients present management problems. It is important for dermatology nurses to understand and implement strategies to facilitate interaction between these difficult patients and help to create a therapeutic environment.

Chronic cutaneous dysesthesia syndrome: a psychotic phenomenon or a depressive symptom?

A 54-year-old woman had a 4-month history of sensitivity to all forms of light. Evaluation revealed no detectable abnormalities. A diagnosis of chronic cutaneous dysesthesia syndrome was made, and the patient experienced slow, steady resolution with oral pimozide. We discuss the classification, diagnostic categories, treatment principles, and prognosis of this disorder and summarize our experience with 13 other patients.