Written By: Dennis A Porto MD, @daporteaux

Mental health is an oft-overlooked contributing factor to many skin conditions. Skin conditions (like uncontrolled psoriasis, for example) can of course contribute to things like depression. However, this is a two way street and mental health can also directly contribute to the manifestations of skin disease. A common example is stress causing a cold sore outbreak. However, there are several conditions where the skin disease is a direct reflection of the underlying psychiatric condition of the patient.

1. Acné excoriée des jeunes filles

This common acne subtype is French for “excoriated acne in young girls.” Acné excoriée is most often seen in young women with underlying obsessive-compulsive disorder or depression. They neurotically pick and manipulate their otherwise mild acne, resulting in scabs and shallow erosions. This condition is important, because if left untreated, it can lead to permanent and disfiguring acne scarring. Acne pustules and papules that would have lasted only a few days become excoriated erosions that can last months to heal. These patients often come to the dermatologist for “acne,” but their skin only shows evidence of these excoriated erosions rather than the comedones and pustules typical of acne.

Physicians unfamiliar with this condition may just try to treat the acne more aggressively, but this doesn’t address the underlying cause of the problem and won’t lead to improvement. Instead, treating with an antidepressant can often help the patient stop picking these lesions and lead to their resolution. Nevertheless, this is a difficult condition to treat as patients are often skeptical about starting an antidepressant for what they view as a skin-limited condition.

2. Trichotillomania

Trichotillomania is a rare cause of hair loss that is seen most frequently in children, often young girls. Due to psychological stressors (for example, conflicts at home or school) these young girls subconsciously pull out the hair on their scalp, eyebrows, or eyelashes. These girls may or may not be fully aware that they are pulling their hair. Often times, these children are brought in by their parents who have already been to several dermatologists for unsuccessful treatment of their hair loss. Upon examination, an astute dermatologist will examine the patient with a dermatoscope and identify broken hairs of different length and with a characteristic coiled or frayed appearance. This condition typically improves with time, with proper behavior modification, and as psychological stressors subside.

3. Onychophagia and onychotillomania

These are the medical terms for the common condition where young girls bite and pick their nail plates and cuticles. This is very similar to trichotillomania, and the condition improves with behavior modification and resolution of psychological stressors.

4. Delusions of parasitosis

This is a frustrating condition seen frequently at academic dermatology centers. These patients have a fixed delusion that their skin is infested with parasites when in fact, there are none. They neurotically pick their skin, attempting to “pull out” these “parasites,” causing erosions in their skin that sometimes can get secondarily infected. These patients then point to these self-induced erosions as evidence of their “parasites.” These patients often bring in samples of things they pick from their skin and request that the dermatologist examine them under the microscope (this is called the “matchbox sign”). Under the microscope, these “parasites” are typically found to just be dead skin or cloth from clothing or bandages. These patients can be successfully treated, but it requires a compassionate dermatologist who will spend an extensive amount of time reassuring the patient and providing frequent follow up. Successful treatment of this disease requires the initiation of an anti-psychotic medication. Although this has shown promising efficacy, patients are often resistant to starting this medication as they are convinced that they have parasites.

5. Morgellon’s disease

This is a variant of delusions of parasitosis where patients believe that there are infectious “fibers” that protrude from their skin. They pick at areas where they believe these fibers are at and attempt to pull them from the skin. Like delusions of parasitosis, these patients often bring samples of these “fibers” into dermatology offices for evaluation. Invariably, these “fibers” are dead skin cells or fabric from clothing or bandages.

This condition can be very distressing to patients, as they often spend significant time and money fumigating their homes and cleaning everything with bleach to rid themselves of fibers. Morgellon’s disease is interesting because it is one of the only diseases that is actually transmitted over the internet. Groups like the “Morgellon’s Research Foundation” and the Morgellon’s subreddit serve as echo chambers where those with this condition validate each other’s delusions. The famous singer-songwriter Joni Mitchell suffers from this condition. Like many patients, she unfortunately has refused psychiatric treatment.

Morgellon’s disease can start to consume a patient’s entire life: they spend countless hours picking and cleaning and posting online and they stop doing things that they used to enjoy. It is also disheartening for dermatologists because they know they can help these patients with anti-psychotic medications, but patients often get offended by this suggestion because of the false implication that it “is all in their head.”

It is worth repeating that all of these conditions are real and they need to be taken seriously by dermatologists. The mind is extremely powerful and can have profound effects on our health, including our skin. What causes patients the most frustration is the fact that our mind can be causing skin disease even without us being consciously aware of it. By creating a therapeutic alliance with a compassionate dermatologist, each of these conditions can be overcome.

Written By: Dennis A Porto MD, @daporteaux

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