Fitzpatrick's Color Atlas and Synopsis of Clinical Dermatology, Seventh Edition

SECTION 24

Disorders of Psychiatric Etiology

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Classification of Disorders of Psychiatric Etiology

• Dysmorphic syndrome

• Delusions of parasitosis

• Compulsive habits

• Neurotic excoriations

• Trichotillomania

• Factitious syndromes

• Cutaneous signs of injecting drug use

Body Dysmorphic Syndrome (BDS)

ICD-9: 300.7 image ICD-10: F45.2 image

image Patients with dysmorphic syndrome regard their image as distorted in the eyes of the public; this becomes almost an obsession.

image The patient with BDS does not consult a psychiatrist but a dermatologist or plastic surgeon. The typical patient with BDS is a single, female, young adult who is an anxious and unhappy person.

image Common dermatologic complaints are facial (wrinkles, acne, scars, hypertrichosis, dry lips), scalp (incipient baldness, increased hair growth), genital (normal sebaceous glands on the penis, red scrotum, red vulva, vaginal odor), hyperhidrosis, and bromhidrosis.

image Management is a problem. One strategy is for the dermatologist to agree with the patient that there is a problem and thus establish rapport; in a few visits, the complaint can be explored and further discussed.

image If the patient and physician do not agree that the complaint is a vastly exaggerated skin or hair change, then the patient should be referred to a psychiatrist; this latter plan is usually not accepted, in which case the problem may persist indefinitely.

Delusions of Parasitosis ICD-9: 300.29 image ICD-10: F22.0 image

image This rare disorder, which occurs in adults and is present for months or years, is associated with pain or paresthesia and is characterized by the presence of numerous skin lesions, mostly excoriations, which the patient truly believes are the result of a parasitic infestation (Fig. 24-1 A).

image The onset of the initial pruritus or paresthesia may be related to xerosis or, in fact, to a previously treated infestation.

image Patients pick with their fingernails or dig into their skin with needles or tweezers to remove the “parasites” (Fig. 24-1 B).

image It is important to rule out other causes of pruritus. This problem is serious; patients truly suffer and are opposed to seeking psychiatric help. Patients may sell their houses to move away from the offending parasite.

image The patient should see a psychiatrist for at least one visit and for recommendations of drug therapy: pimozide plus an antidepressant. Treatment is difficult and usually unsuccessful.

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Figure 24-1Delusions of parasitosis (A) Usually patients collect small pieces of debris from their skin by scratching with their nails or an instrument and submit them to the doctor for examination for parasites. In this case, pointed tweezers were used and the results are ulcers, crusted lesions, and scars. (B) Occasionally, this can progress to an aggressive behavior such as depicted in this case where the patient posed to demonstrate how she collects the “parasites” from her skin on a piece of paper. In the majority of cases, patients are not dissuaded from their monosymptomatic delusion.

Neurotic Excoriations and Trichotillomania ICD-9: 698.4 image ICD-10: L98.1 image

image Neurotic excoriations are not an uncommon problem, occurring more in females than in males and in the third to fifth decades.

image They may relate the onset to a specific event or to chronic stress; patients deny picking and scratching.

image The clinical lesions are an admixture of several types of lesions, principally excoriations, all produced by habitual picking of the skin with the fingernails; most common on the face (Fig. 24-2), back (Fig. 24-3), and extremities but also at other sites. There may be depigmented atrophic or hyperpigmented macules →7 scars (Fig. 24-3).

image The lesions are located only on sites that the hands can reach, thus often sparing the center of the back.

image The diagnosis can be deceptive, and what prima facie appears to be neurotic excoriations could be a serious cause of pruritus.

image Psychiatric guidance may be necessary if the problem is not solved, as it can be very disfiguring on the face and disruptive to the patient and the family. The course is prolonged, unless life adjustments are made.

image Pimozide has been helpful but must be used with caution and with the advice and guidance of a psychopharmacologist. Also, antidepressant drugs may be used.

image Trichotillomania is a compulsive desire or habit to pluck hair. Can be on the scalp or any other hairy region (e.g., beard). Confluence of areas with very short sparse hairs, small bald areas, and normal area of scalp (Fig. 24-4). More pronounced on the side of dominant hand. Can be combined with neurotic excoriations induced by vigorous plucking with tweezers. Microscopically, anagen hairs, bluntly broken hairs. Treatment as for neurotic excoriations.

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Figure 24-2. Neurotic excoriations Several erythematous and crusted macules and erosions on the lower cheek and upper lip of a 19-year-old female with mild facial acne. No primary lesions are seen. The patient, who is moderately depressed, has mild acneiform lesions, which she compulsively picks with her fingernails.

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Figure 24-3Neurotic excoriations: back Excoriations of the upper, mid-back, and (not shown) on gluteal areas and linear areas of postinflammatory hyperpigmentation, crusting, and scarring in a 66-year-old diabetic female. Lesions have been present for at least 10 years. The ulcerated crusted lesion resolved with cloth tape occlusion. Once the protection was removed, the patient resumed excoriating the sites.

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Figure 24-4Trichotillomania This extensive alopecia has resulted from pulling and plucking hairs by the 17-year-old patient. She appeared balanced but mildly depressed and had considerable conflict with her parents. She admitted pulling hairs after considerable questioning.

Factitious Syndromes (Münchhausen Syndrome)

ICD-9: 301.51 image ICD-10: F 68.1 image

image The term factitious means “artificial,” and in this condition there is a self-induced dermatologic lesion(s); either the patient claims no responsibility or admits deliberately mutilating the skin.

image It occurs in young adults, females > males. The history of the evolution of the lesions is vague (“hollow” history).

image The lesions may be present for weeks to months to years (Fig. 24-5).

image Patient may be normal looking and act normally in every respect, although frequently there is a strange affect and bizarre personality.

image The skin lesions consist of cuts (Fig. 24-5), ulcers, and dense adherent necrotic eschar (Fig. 24-6). The shape of the lesions may be linear (Fig. 24-5), bizarre shapes, geometric patterns, single or multiple. The diagnosis can be difficult, but the nature of the lesions (bizarre shapes) may immediately suggest an artificial etiology.

image It is important to rule out every possible cause—chronic infections, granulomas, and vasculitis—perform a biopsy before assigning the diagnosis of dermatosis artefacta, both for the benefit of the patient and because the physician may be at risk for malpractice if he or she fails to diagnose a true pathologic process.

image There is often serious personality and/or psychosocial stress, or a psychiatric disease.

image The condition demands the utmost tact on the part of the physician, who can avert a serious outcome (i.e., suicide) by attempting to gain enough empathy with the patient to ascertain the cause. This varies with the nature of the psychiatric problem.

image The condition may persist for years in a patient who has selected his or her skin as the target organ of his or her conflicts. Consultation and management with a psychiatrist are mandatory.

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Figure 24-5Factitious syndrome These linear cuts were self-inflicted with a razor blade by a patient with a borderline syndrome. Similar, much deeper cuts were on the forearms.

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Figure 24-6Factitious syndrome These necroses were self-inflicted by the covert application of diluted sulfuric acid and tightly fitting bandages. The patient appeared well adjusted and refused to see a psychiatrist.

Cutaneous Signs of Injecting Drug Use ICD-9: 999.3image

image Injecting drug users often develop cutaneous stigmata as a result of their habit, whether injecting subcutaneously or intravascularly.

image Cutaneous lesions range from foreign body response to injected material, infections, and scars.

Cutaneous Injection Reactions. Cutaneous Injury. Multiple punctures at the sites of cutaneous injection, often linear over veins, linear scars (Fig. 24-7).

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Figure 24-7Injecting drug use: injection tracks over veins on the lower arms Linear tracks with punctures, fibrosis, and crusts were created by daily injections into the superficial veins.

Tattoos. Carbon on needles (after flame sterilization) can result in inadvertent tattooing and pigmented linear scars (Fig. 24-8).

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Figure 24-8Linear tattoos from carbon on needles resulted from intravenous injections.

Foreign Body Granuloma. Subcutaneous injection of adulterants (talc, sugar, starch, baking soda, flour, cotton fibers, glass, etc.) can elicit a foreign body response ± cellulitis ± granuloma ± ulceration (Fig. 24-9).

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Figure 24-9Injecting drug use: cellulitis and foreign body response at injection site The patient injected into the subcutaneous tissue as well as veins of the forearm, resulting in foreign body response and S. aureus cellulitis with associated bacteremia and infectious endocarditis.

Intravascular Injection Reactions. Venous Injury. Intravenous injection can result in thrombosis, thrombophlebitis, septic phlebitis. Chronic edema of the upper extremity is common.

Arterial Injury. Chronic intra-arterial injection can result in injection site pain, cyanosis, erythema, sensory and motor deficits, and vascular compromise (vascular insufficiency/gangrene).

Infections. Transmission of Infectious Agents. Injecting drug use can result in transmission of HIV, hepatitis B virus, and hepatitis C virus with subsequent life-threatening systemic infections.

Injection Site Infections. Local infections include cellulitis (Fig. 24-9), abscess formation, lymphangitis, septic phlebitis/thrombophlebitis. The most common organisms are those from the drug users, e.g., S. aureus and GAS. Less common microbes: enteric organisms, anaerobes, Clostridium botulinum, oral flora, fungi (Candida albicans), and polymicrobial infections.

Systemic Infections. Intravenous injection of microbes can result in infection of vascular endothelium, most commonly heart valve with infectious endocarditis.

Atrophic Punched-Out Scars. Result from subcutaneous injections (i.e., “skin popping”) after an inflammatory (sterile or infected) response to injected material (Fig. 24-7).