Primary psychiatric conditions: dermatitis artefacta, trichotillomania and neurotic excoriations.

Primary psychiatric conditions encountered in dermatology include dermatitis artefacta, trichotillomania (TTM) and neurotic excoriations. For these disorders, the primary pathologic condition involves the psyche; therefore, any cutaneous findings are self-induced. Herein, we review common primary psychiatric conditions in dermatology - dermatitis artefacta, neurotic excoriations and TTM - and examine their epidemiology, clinical presentation, differential diagnosis and treatment strategies. For all primary psychiatric disorders, the most effective underlying strategy is to first establish a strong therapeutic rapport with the patient. Various pharmacologic and non-pharmacologic therapies can then be attempted afterwards to successfully manage these patients.

Introduction

“Primary psychiatric disorder” is a term that is used to describe a case in which no primary skin condition exists. Rather, lesions that are observed on the skin are self-induced because the problem is psychological. Examples of conditions within this group of psychodermatological disorders are delusions of parasitosis, onychotillomania, onychophagia, dermatitis artefacta, trichotillomania (TTM) and neurotic excoriations, of which the latter three are possibly the most common primary psychiatric disorders.

Patients with these disorders are more frequently seen in dermatology clinics, as these patients may be unwilling to acknowledge a psychiatric basis for their physical findings. Therefore, for treatment to be effective and timely, it is important for the dermatologist to understand the underlying psychopathology of these conditions. In this article, we provide a review of the three more commonly observed primary psychiatric disorders in psychodermatology – dermatitis artefacta, TTM and neurotic excoriations – and offer treatment recommendations for these unique conditions.

Materials and Methods

We conducted a search of PubMed's Medline database of articles. Articles containing the key terms dermatitis artefacta, trichotillomania, neurotic excoriations and review were reviewed. The search was limited to articles in English. A total of 49 articles spanning from 1945 to 2011 were included in this review.

Results

Dermatitis artefacta

Dermatitis artefacta, also known as factitial dermatitis, is a disorder of self-injurious behavior. A patient with this condition produces cutaneous lesions in order to fulfill an unconscious psychological need. Often, the psychological need is typically one of being taken care of by assuming the role of the sick patient.[1-4]

Epidemiology

Although difficult to determine the exact number of patients with dermatitis artefacta seen by dermatologists each year, one study of patients presenting with primary psychiatric conditions to dermatology clinics found that one-third (35) patients had dermatitis artefacta.[5] In documented case series, there is a female predominance, with a female to male ratio varying between 3 to 1 and 20 to 1.[367] The highest prevalence for the onset of the condition is between adolescence and early adulthood, although any age may be affected.[8] The patient population is also associated with working in or having family members in health-related careers.[38] This may be related to the hypochondriacal tendencies of the patient or that the patient is inclined to learn to falsify ailment through contact with those with actual disease.[8]

Presentation

Patients with dermatitis artefacta frequently present with a vague history, with insufficient details of how the skin lesions first appeared.[9] Often, the patient appears unmoved by the unsightly and bizarre lesions. In contrast, their families are often upset and are critical of how the lesions evolved.[10]

The lesions of dermatitis artefacta themselves are varied as different instruments and methods are used to produce them. However, the lesions tend to be on normal skin and have an atypical morphology without recognizable characteristics of dermatosis. The shape of the lesions may be geometric, angulated, necrotic or appear as linear streaks secondary to application of harmful liquids. Distribution of the lesions varies, as they may be single or multiple, unilateral and bilateral or symmetrical. They may be found on the face, upper trunk and extensor extremities, as these locations are easily accessible to self-injury.

Patients may present with a history of “non-healing” lesions. They may have a worsened surgical excision or minor cutaneous injury, or have mimicked a prior injury.[11-17] They may have also created new lesions on their own by pinching, scraping, picking, suctioning, gouging, slashing, burning, scalding using chemicals, injecting infected or substances that may induce infection into the skin and applying excessive pressure with elastic bands.[21819]

The majority of patients with this condition have borderline personality disorder.[1] Often, these patients have suffered from emotional deficit early in life and also have a history of sexual or physical abuse, and, therefore, they are unable to develop a stable body image. They may suffer profound psychological distress, depression and poor impulse control.[34101520] The act and sensation of self-inducing pain and physical lesions may relieve their inner sense of isolation and distress, and even help them establish boundaries and an identity.[310] Their assumption of the role of an invalid may satisfy their need for dependency.

Differential diagnosis

Dermatological and psychiatric differential diagnosis may be considered. The most common differential diagnosis for dermatitis artefacta is necrotizing vasculitis.[21] Other dermatologic considerations include bullous skin disease, pyoderma gangrenosum, other types of vasculitis, collagen vascular disease and infestation.[181718]

Psychiatric differential diagnosis that may be considered include delusions of parasitosis, obsessive-compulsive disorder (OCD), Munchausen's syndrome, Munchausen syndrome by proxy and malingering.[22] Patients suffering from delusions of parasitosis believe that they have an infestation causing symptoms of formication (crawling, biting and stinging) with or without pruritus. OCD patients have obsessive thoughts and compulsive behaviors. Patients with Munchausen's syndrome, who feign disease to gain attention, tend to have antisocial personality disorder instead of borderline personality disorder, and are predominantly men. Patients with Munchausen syndrome by proxy are caregivers who induce or exaggerate physical injury to another person. Malingering patients feign disease to obtain a secondary gain. Of these psychiatric differential diagnoses, malingering or people who self-induce skin lesions for a secondary gain such as Worker's Compensation Payment or as insurance fraud may be most prevalent. It is of note that malingerers are not considered mentally ill as they know exactly what they are doing. Malingering is a crime, not a disease.

Treatment

The first and most crucial step in effectively managing a patient with a primary psychiatric disorder, including dermatitis artefacta, is to establish strong therapeutic rapport. Establishing trust and honesty in the doctor-patient relationship can increase compliance with physician recommendations for care. In working with these patients, firmly establishing limits to protect boundaries and avoid being manipulated by the patient can reduce resentment and distress.[22] Also, when discussing the cutaneous lesions, it may be helpful to emphasize on stress or depression as a possible mediator in order to avoid counterproductive confrontation about how the lesions were physically developed and can also facilitate the discussion of possibly obtaining help from a psychiatrist.[22]

Specific dermatologic measures for treatment of the cutaneous wounds include debridement and irrigation, topical antibiotics, oral antibiotics or antifungal medications.[23] Occlusive dressing may be used to avert further cutaneous damage. Analgesics can be prescribed with caution as the patient may be vulnerable to drug abuse.

Psychiatric treatment includes a combination of pharmacologic therapies and behavioral therapy. A dialectical behavioral therapy involving a structured behavioral therapeutic program for borderline personality disorder patients is recommended.[23] Psychotropic medications can be directed toward depression and anxiety, often experienced by these patients. Selective serotonin reuptake inhibitors (SSRIs) such as fluoxetine, sertraline, paroxetine and fluvoxamine, in possibly high doses, are typically first-line treatment for compulsive, self-injurious behavior.[22] Anxiolytics such as buspirone and benzodiazepines can be prescribed if anxiety is a dominant feature. Atypical antipsychotics such as pimozide, olanzapine or risperidone can be helpful in treating the self-injurious behavior, and may be used alone or in combination with a SSRI.[22]

Trichotillomania

TTM is characterized by repetitive self-pulling of hair, resulting in hair loss. According to the DSM-IV®-TR diagnostic criteria for TTM, the patient should also experience tension prior to hair pulling or when resisting such behavior, and experience relief after the behavior is complete. In addition, according to the diagnostic criteria, the patient must demonstrate impairment in functioning or significant distress. Dermatologists use a much less complicated definition; namely, any case of self-induced hair loss is TTM, regardless of whether the patient expresses those feelings or not.

No recent, large-scale epidemiological study has been published to determine the prevalence of TTM in the population. However, a survey of 2524 college students demonstrated that the lifetime prevalence rate of TTM was 0.6% for females and males.[24] However, this may be an underestimate of prevalence, as other studies have demonstrated higher prevalence rates in the population exhibiting behaviors that do not meet the full DSM-IV®-TR diagnostic criteria. For example, other studies of college students have shown prevalence rates ranging from 1.0% to 13.3%.[25-29] One study of 59 pediatric patients being seen for alopecia demonstrated that 9.8% (6/59) met the diagnostic criteria for TTM.[30] TTM appears more commonly in females than in males; however, men may have the advantage of more easily feigning the disorder as they can blame hair loss on male pattern baldness and they are more likely to avoid seeking treatment altogether.[1731-34] The initial age of onset is generally between 10 and 13 years.[35]

Despite normal hair density, patients present with different hair lengths, including tapered ends, demonstrating new growth, and blunt ends, representing broken hairs. Hairs may be broken mid-shaft or appear as small black dots or stubbles at the scalp surface. Excoriations may be found on the scalp. However, there should be no scale. The affected region typically has an unusual shape. The pull test is also negative, in which the hair does not pull out of the scalp effortlessly.[36]

Although hair pulling commonly occurs on the scalp, this behavior may be followed by pulling of eyebrows, eyelashes and pubic hair. Pediatric patients commonly pull only from the scalp. Diagnosis of TTM is supported by findings of trichomalacia, characterized by melanin pigment casts, increased density of catagen phase hairs and traumatized hair bulbs without perifollicular inflammation.[35]

TTM can be differentiated from OCD. At least according to the psychiatric definition, these patients pull their hair because the act is gratifying and reduces tension, anger, depression and anxiety. OCD patients, however, pull their hair because it is an unpleasant compulsion. Additionally, in contrast to OCD, TTM is not characterized by obsessive thoughts to perform the act.

A notable dermatological differential diagnosis is alopecia areata. In alopecia areata, the bare regions of the scalp are smooth, and the scalp is often peachcolored.[36] However, in TTM, the scalp feels rough where the hair was pulled. Moreover, in contrast to TTM, the hair-pull test is positive for alopecia areata. Another distinguishing factor is that the nails of alopecia areata may demonstrate stippling in rows, or “Scotch plaid pattern,” but nails of TTM are normal.[36] Other dermatological differential diagnosis for TTM include androgenic alopecia, traction alopecia, alopecia mucinosa, lichen planopilaris, discoid lupus erythematous, pseudopelade, folliculitis decalvans and syphilis.

Treatment of TTM includes pharmacologic and non-pharmacologic therapies. Recommended first-line therapy for this psychiatric condition is administration of SSRIs. Specifically, escitalopram, sertraline, fluoxetine, citalopram and paroxetine can be used as monotherapy. Clomipramine, a tricyclic antidepressant, may also be used.[37] More recently, atypical antipsychotics including risperidone and aripiprazole at low doses have appeared to be beneficial in combination with SSRIs or as monotherapy.[35] For dermatological treatment, topical corticosteroids can improve secondary inflammation, and topical minoxidil may increase the rate of hair re-growth.

Non-pharmacologic therapies include behavior modification through habit reversal therapy, which has been shown to have the highest rate of resolution for TTM.[36] It involves self-monitoring of behaviors, coping strategies, relation therapy, social support and competing responses, such as sitting on hands or clenching fists until the tension resolves. Cognitive behavioral therapy, hypnotherapy and insight-oriented psychotherapy have been effective, especially in the pediatric population.[38] Finally, social support and open communication with the patient and family can be helpful.

Neurotic excoriations

Neurotic excoriations are self-induced skin lesions caused by picking, rubbing, scratching or repetitive itching. Patients have poor impulse control and cannot avoid the desire to scratch. Depression, anxiety and OCD are the most common psychiatric disorders leading to neurotic excoriations. However, the behavior has also been associated with social stressors, including unemployment, financial loss and marital hardships.

Although no large-scale study has been published to provide an accurate incidence rate for this condition, it is estimated that 2% of dermatologic clinic patients have the diagnosis of neurotic excoriations.[23] The predominant patient population includes women, with a mean age of onset between the third to fifth decade.[103940]

The clinical distribution of the excoriations can be an important clue to diagnosis of the condition. Excoriations appear in areas that are easily reachable to the patient. Therefore, the bilateral upper, lateral back area is usually spared. The “butterfly sign” is a characteristic feature, as the areas of sparing where the patient cannot reach bear a resemblance to the shape of butterfly wings.[41] Excoriations are often found on the extensor arm as opposed to the medial arm and on the anterior thigh as compared with the posterior thigh. Although it is physically possible to excoriate the medial arm or posterior leg, to do so is so awkward that patients generally do not bother to excoriate these areas. The excoriations themselves appear as erosions, crusting and scabbing. Hypopigmented or hyperpigmented scars may also be evident. When patients with acne have such lesions localized to the face, the disorder is called acne excoriée.

Both medical and psychiatric conditions may be considered among the differential diagnosis of neurotic excoriations. Medical reasons for pruritus that can induce self-excoriation include urticarial, uremia, hepatitis, xerosis, cutaneous dysesthesia and malignancies.[23] Psychiatric conditions that can lead to excoriating behavior include depression, anxiety, OCD, body dysmorphic disorder, borderline personality disorder, delusions of parasitosis, dermatitis artefacta and somatoform disorders, such as hypochondriasis.[2341]

The first-line treatment depends on the precise nature of the underlying psychotic diagnosis involved. The first-line treatment for neurotic excoriations may be SSRIs as they can reduce depressive and compulsive symptoms, if these were the psychiatric diagnosis.[842-44] Anxiolytics such as benzodiazepines can be used for short-term treatment when an acute social stressor or comorbid anxiety is involved. For dermatological management, treatment of pruritus is key. Options include topical antipruritics, including doxepin 5% cream or a menthol or phenol containing lotion with an emollient base. Oral antihistamines such as doxepin or hydroxyzine can improve pruritus.[45] Cool compresses may also be used to provide hydration, accelerate crust removal and sooth the skin. Topical antibiotic agents such as mupirocin 2% ointment or oral antibiotics such as cephalexin may be warranted for infected lesions.

Additional therapeutic options involve non-pharmacologic treatment approaches. These include cognitive therapy, behavior modification, eclectic approach and psychodynamic psychotherapy, which have demonstrated inconsistency in effectiveness.[104044-48] However, before these methods can be considered, the patient should be willing to accept the psychiatric nature of the condition and be able to identify triggers leading to excoriation.

Discussion

Although the underlying cause of dermatitis artefacta, TTM and neurotic excoriations is of a psychiatric nature, patients with these disorders frequently seek help from dermatologists as they may be unable to acknowledge or are not fully aware that they are inducing the physical lesions on their own. Therefore, it is important to understand that these disorders can be more effectively managed if the dermatologist is able to familiarize himself or herself with the epidemiology, clinical presentation, differential diagnosis and treatment strategies of these conditions. By establishing a strong therapeutic alliance with the patient, he or she may be more willing to start and maintain pharmacologic and/or non-pharmacologic therapies.