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Psychodermatology

Integrated mental health and dermatology for psychocutaneous disorders

Written by: Saygı Hospital Health Guide Editorial Board
Last updated:

This content has been compiled by the Saygı Hospital Health Guide Editorial Board and is periodically reviewed by a specialist physician.

This content is for informational purposes only and does not constitute medical advice. You can book an appointment at our Psikiyatri department. Book Appointment →

What is Psychodermatology?

Psychodermatology recognizes the embryologic origin of skin and brain from neuroectoderm, the rich innervation of skin, and the bidirectional psychoneuroimmunologic interactions between psychological state and inflammatory skin disease. Categories include primary psychiatric disorders with skin manifestations, dermatoses exacerbated by stress, dermatoses causing significant psychological burden, and overlap syndromes. Treatment requires collaborative care between dermatology and psychiatry.

Primary psychiatric conditions with skin manifestations include delusional infestation (delusions of parasitosis, Morgellons-related, often responding to second-generation antipsychotics), excoriation disorder (skin-picking, body-focused repetitive behavior, treated with habit reversal therapy and SSRIs), trichotillomania (hair-pulling), factitious dermatitis (self-induced lesions for primary or secondary gain), and body dysmorphic disorder.

Dermatoses exacerbated by psychological stress include psoriasis, atopic dermatitis, alopecia areata, vitiligo, urticaria, hyperhidrosis, acne, rosacea, and herpes simplex outbreaks. Conditions with significant psychiatric comorbidity include acne (depression, anxiety, suicidal ideation, especially with severe acne and isotretinoin), psoriasis (depression, anxiety, suicidality), hidradenitis suppurativa, vitiligo, and atopic dermatitis. Routine psychiatric screening, integrated care, and addressing both biological and psychological aspects produce best outcomes.

Symptoms

Skin lesions in unusual distribution suggesting self-induced origin
Delusions of infestation (parasites, foreign objects in skin)
Skin-picking behaviors (excoriation disorder)
Hair-pulling (trichotillomania)
Body dysmorphic preoccupation
Stress-induced exacerbation of chronic skin disease
Significant pruritus disproportionate to objective skin findings
Comorbid depression, anxiety, OCD
Suicidal ideation in patients with disfiguring skin disease
Body image distress
Social isolation due to skin appearance
Vocational impairment
Avoidance of intimate relationships
Sleep disturbance from pruritus
Symbolic skin lesions (forearms, easily reachable areas)
Lesions in unusual configurations
Linear excoriations from picking
Hair loss in geometric patterns (trichotillomania)
Hidradenitis suppurativa with shame
Acne with body image distress

Risk Factors

Family history of psychiatric or dermatologic conditions
Female sex (some conditions)
Adolescence and young adulthood
Trauma history
Comorbid mood and anxiety disorders
OCD spectrum disorders
Substance use
Stressful life events
Pre-existing dermatologic disease
Visible skin disease
Disfiguring conditions
Hidradenitis suppurativa
Severe acne (especially with isotretinoin treatment)
Vitiligo
Atopic dermatitis
Psoriasis
Body dysmorphic disorder
Limited social support
Concerning physical examination findings (linear excoriations)
Multiple physician visits seeking dermatologic explanation

When to See a Doctor?

If you experience any of the following symptoms, seek medical attention promptly:

  • Persistent skin condition with disproportionate distress
  • Delusional belief about skin infestation
  • Compulsive skin-picking
  • Hair-pulling
  • Self-induced skin lesions
  • Severe acne with depression
  • Significant body image distress with skin disease
  • Suicidal ideation in patient with skin condition
  • Stress-related exacerbation of chronic skin disease
  • Treatment-resistant skin disease
  • Multiple physician visits without satisfaction
  • Concurrent psychiatric symptoms
  • Social or vocational impairment from skin disease
  • Pre-treatment screening (especially before isotretinoin)

Treatment Methods

01
Comprehensive evaluation by dermatology and psychiatry, ideally in integrated psychocutaneous clinic
02
Detailed history including stress, mood, prior trauma, family history
03
Physical examination with skin focus including hair, nails, mucous membranes
04
Validated screening (PHQ-9, GAD-7, BDD questionnaire, BFRB scales)
05
Suicide risk assessment, especially in severe acne and isotretinoin patients
06
Skin biopsy when indicated to differentiate true dermatologic cause
07
Cognitive behavioral therapy (CBT) — first-line for skin-picking, BDD, BFRBs
08
Habit reversal training (HRT) for excoriation disorder, trichotillomania
09
Acceptance and commitment therapy (ACT)
10
Mindfulness-based interventions
11
Stress management, relaxation training
12
Group therapy
13
Couples and family therapy
14
Peer support groups
15
SSRIs (fluoxetine, sertraline, escitalopram) for OCD spectrum, depression, anxiety
16
Higher SSRI doses for OCD spectrum (sertraline up to 200 mg, fluoxetine up to 80 mg)
17
N-acetylcysteine for trichotillomania and excoriation
18
Naltrexone for skin-picking (limited evidence)
19
Atypical antipsychotics (low-dose risperidone, aripiprazole, olanzapine) for delusional parasitosis
20
Pimozide historically used (cardiac concerns)
21
Hospitalization for self-induced severe lesions, suicide risk
22
Treat underlying dermatologic disease optimally
23
Adequately treat acne (avoid undertreatment that worsens depression)
24
Counsel on isotretinoin and mental health (mood monitoring, baseline assessment)
25
Avoid isotretinoin in active depression unless mood optimized
26
Psychoeducation about psychocutaneous interactions
27
Skin care education and routines
28
Address shame, isolation, identity
29
Coordinated dermatology-psychiatry care
30
Long-term follow-up for chronic conditions
31
Address modifiable factors: stress, sleep, alcohol, smoking

Which Department to Visit?

You can visit our Psikiyatri department for these complaints. Our specialist physicians will create the most suitable treatment plan for you.

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Health Disclaimer: The information on this page is prepared for general informational purposes only. It does not replace medical diagnosis and treatment. Please consult your physician for your complaints. Saygı Hospital does not accept responsibility for actions taken based on the information on this page.