ONE cannot treat patients suffering from skin disease without becoming acutely aware that many ascribe correctly aggravation of their symptoms to emotional tensions. The exact mechanism by which a condition such as atopic eczema or psoriasis can be influenced by anxiety is unknown but it is reasonable to suppose that skin blood flow and the activity of sweat glands may be altered by stress. In the management of chronic skin disorders therefore an awareness that social and emotional factors are of importance is essential.
Perhaps less often recognised is the effect of skin disorder on the personality of the sufferer. Many adolescents are disturbed by the unsightliness of acne vulgaris and what may appear to be a trivial and commonplace dermatosis can produce very real suffering in the boy or girl who has to face the world with a pimply face. Itching destroys morale equally as much as pain and until the advent of the anti-inflamatory steroids little attention was paid to the effect of chronic itching and sleeplessness on the personality of the sufferer. It is very striking that sufferers from atopic eczema tend to be aggressive, yet this attitude can be changed rapidly by relief of their symptoms by systemic steroids. In addition there are a number of patients who present with symptoms referable to their skin who are suffering from mental disorder.
Some patients become morbidly anxious about what may be a physiological anomaly. The following are examples of this condition; the patient who notices the circumvallate papillae on the tongue or the submucous sebaceous glands on the buccal mucosa (Fordyces spots), which are present in more than 50 per cent of normal individuals. The patient develops a possible cancer phobia and may be difficult to reassure. A particularly difficult problem is the patient with syphilophobia who refuses to be reassured despite numerous negative blood tests. More bizarre cutaneous delusions may be the first evidence of schizophrenia. The belief that the patient is being avoided by his friends because of some trivial blemish or from imagined body odour are common methods of presentation.
Delusion of parasitosis. Parasitophobia
Some people are convinced that the skin is infested with parasites and frequently display a collection of skin scales and rolled up keratin in support of their theory. The patient is usually elderly with an obsessional personality and unfortunately neither dermatological or psychiatric therapy offers much hope.
It is difficult to accept the idea that patients can do inflict lesions on their own skins yet such is the case. Though numerically unimportant, factitious lesions may be so chronic and may have medicolegal implications that some consideration should be given to them.
As a clinical problem dermatitis artefacta should be suspected if superficial ulcerated lesions fail to heal despite prolonged conventional treatment. A clue may be gained from the character of the lesion which may have a bizarre shape (square or rectangular) which does not conform to natural disease. Confirmation of the diagnosis may be obtained by speedy healing of the lesions under occlusive dressings if this is practicable.
The patient should not be questioned directly about the possibility of artefact as the emotional reaction is likely to be violent but the possibility of psychogenic stresses should be investigated.
Young girls frequently produce lesions as a hysterical reaction to draw attention to their problems, whereas in older age groups no adequate reason can be found. The prognosis in these older patients is poor and many continue to produce lesions over 10—15 years. Occasionally artefacts, particularly in men, are produced for financial gain to draw compensation for injuries sustained at work.
Patients who are emotionally labile may inflict deep excoriations on the parts of the skin which they can reach with their finger nails.
The clinical picture of superficial excoriations scattered on the limbs and shoulders, but sparing the centre of the back, and the presence of numerous white healed scars is characteristic. The skin damage is not a result of deliberate intent as in dermatitis artefacta but due to uncontrollable impluses. Occlusion will allow skin lesions to heal and assist in the confirmation of the diagnosis but the prognosis is not good and psychiatric assistance is usually needed.
A variant of neurotic excoriations in the young female adolescent is the picking and squeezing of pustules and comedones of acne vulgaris. Often the scarring of the excoriations far exceeds the severity of the acne. The underlying emotional stresses must be investigated to achieve improvement.
Rubbing, twisting and pulling the hair is a common habit in children which causes a thinning of the scalp hair. Examination reveals that the hair shafts are broken and the alopecia is always incomplete with hairs of varying lengths. Treatment consists in the discovery of why the child is tense and explanation to the parents that the habit will cease in time if no attention is paid to it. Rarely, trichotillosis may also occur in adults when it may be superimposed occasionally on alopecia areata or appear as a self-inflicted mutilation.