Clinics in Dermatology (2023) 41, 1–4

Commentary

Psychocutaneous medicine: A
psychopathology-based, problem-focused
approach

Psychocutaneous medicine refers to the interface be- with this traditionally tricky patient population. They discuss
tween psychiatry, psychology, and dermatology—this field topics such as diagnosing primary versus secondary delu-
appeals across disciplines, including internal medicine and sional infestation, how to prepare before entering the exam
pediatrics. It involves the complex interaction of the brain, room, how to write the initial patient note, and when is the
cutaneous nerves, cutaneous immune system, and skin.1 In a ideal time to introduce pharmacotherapy. The contribution
survey by the British Association of Dermatologists, 8% of of Nagesh et al highlights critical clinical aspects of factitial
dermatology patients presented with worsening psychiatric skin disorder (dermatitis artefacta).9 The authors stress the
problems, 3% had a primary psychiatric disorder, 17% need to focus on the psychologic disorders and life stressors
needed psychologic support to help them with the distress that have predisposed the condition rather than the mecha-
secondary to a skin condition, and 14% had a psychologic nism of self-injury. The best outcomes are achieved via a
condition exacerbating their skin disease.2 Eighty-five per- holistic approach in the setting of a multidisciplinary team
cent of dermatology patients indicated that the psychologic addressing cutaneous, psychiatric, and psychologic aspects
aspects of their skin disease are a significant component of of the condition.
their illness. Psychiatric conditions manifest with skin prob- Parsa et al elaborate on skin picking disorder and clas-
lems or conviction of having skin pathology.1 Basic knowl- sify the diagnosis into the following picker categories:
edge of psychodermatology is essential in daily clinical organic/dysesthetic, obsessive-compulsive, functionally au-
practice. tonomous/habit, anxious/depressed, attention deficit hyper-
The Psychocutaneous Medicine issue of Clinics in Der- activity disorder, borderline, narcissistic, body dysmorphic,
matology delves into the clinical aspects of psychocutaneous delusional, guilty, and angry picker.10 Such an organized
disorders with a problem-focused approach and a therapeutic conceptualization of skin picking can guide providers to-
direction. It offers continuity to the Psychosomatic Derma- ward a constructive management approach, increasing the
tology (1984),3 Psychiatric Dermatology (2017),4 , 5 and likelihood of successful therapeutic outcomes. The next
Psychiatric Dermatology: Part II (2018)6 , 7 issues of Clinics contribution, by Madane et al, overviews the current
in Dermatology. All contributions have been authored by understanding of the nature and management of body-
dermatologists and/or mental health providers with expertise focused repetitive behaviors (BFRBs).11 The contributors
in the field. provide clinical pearls for dermatologists in educating
their BFRB patients with compassion and understand-
ing while providing them with resources to reduce their
Primary psychopathology with a focus on the stigma and isolation. Along with recommending a men-
skin tal health specialist, dermatologists should guide patients
to self-monitor their ABC (Antecedents, Behaviors, Con-
The current issue begins with a contribution that details sequences) cycles of BFRBs to understand and interrupt
the approach to the patient with a delusional infestation them.12
(delusions of parasitosis) at the first encounter.8 Brownstone Stamp and Kroumpouzos review eating disorders such as
and Koo highlight the essential management and commu- anorexia nervosa and bulimia nervosa that show many cu-
nication techniques needed for a successful first encounter taneous manifestations—skin signs can be beneficial in the

[Link]
0738-081X/© 2023 Elsevier Inc. All rights reserved.
2 G. Kroumpouzos

early diagnosis.13 Although psychotherapy is paramount, a a stress-reactive skin condition. In his fascinating contribu-
multidisciplinary team approach yields the best outcomes for tion, Tausk elaborates on how stress can grow cancer.19 Pro-
eating disorders. longed or very intense adverse life episodes are perceived by
the brain and translate into physiologic responses that trigger
the secretion of glucocorticosteroids, epinephrine, and nore-
Beauty perception, psychology of aesthetics, pinephrine. Such hormonal changes skew immunity from a
and body dysmorphic disorder Type 1 to a Type 2 response; this impedes the detection and
killing of cancer cells and induces immune cells to facilitate
Additional contributions supervised by Kroumpouzos cancer growth and systemic spread. Tausk dissects the vari-
provide a historical and contemporary review of beauty per- ous mechanisms by which emotions and adversity can lead
ception and elaborate on the psychology of aesthetics.14 , 15 to the development and growth of various tumors, support-
Universally accepted beauty characteristics span different ing the notion that a multimodal biopsychosocial approach
cultures, including facial averageness, symmetry, skin ho- is required when caring for cancer patients.
mogeneity, and sexual dimorphism (sex-typical characteris-
tics). As Dimitrov et al indicate, each person’s perception
of beauty is influenced by their environment and percep- Psychiatric and psychosocial considerations in
tual adaptation, an experience-based process.14 The contrib- common skin diseases
utors discuss typical features of Caucasian, Asian, Black,
and Latino beauty and review the effects of globalization on Chronic skin diseases can substantially impact a patient’s
spreading foreign beauty cultures. physical, psychologic, and social well-being.20 Physicians
Laughter et al provide an overview of the evidence sur- may play a critical role in identifying and managing the psy-
rounding the perception of beauty, cultural aspects of aes- chologic sequelae of the most common chronic skin con-
thetics, and social media’s consequences, especially on body ditions. Christensen and Jafferany seek to delineate all as-
dysmorphic disorder (BDD)’s clinical specifics.15 The au- pects of this hot topic. They review skin conditions such as
thors indicate that social media use may lead to unrealis- acne, atopic dermatitis, psoriasis, vitiligo, alopecia areata,
tic body image ideals, a significant concern with appearance and hidradenitis suppurativa that can put patients at high
and anxiety, and worsen body image dissatisfaction and co- risk for depression, anxiety, and decreased quality of life.20
morbidities of BDD such as depression and eating disorders. The issue continues with a contribution by Mahama and col-
Additionally, excessive social media use can increase pre- leagues focusing on the psychosocial aspects of vitiligo.21
occupation with imagined image defects among BDD pa- The contribution discusses the debate over the “disease-
tients, leading them to pursue minimally invasive cosmetic ification” of vitiligo, its effects on quality of life and mental
and plastic surgery procedures. health, and methods to holistically assist affected individuals
A comprehensive contribution by Turk and colleagues beyond just treatment of the vitiligo itself.
critically appraises diagnostic, screening, and assessment In their challenging presentation, O’Brien and
tools for BDD.16 It is recommended that aesthetic providers Kroumpouzos explore the role of lipids in the patho-
evaluate individuals face-to-face and screen for BDD with genesis of vitiligo and schizophrenia.22 Both conditions
approved scales preoperatively to determine the candidate’s have been associated with stress. Research data indicate
suitability for the procedure.17 Several screening tools were complex interactions between oxidative stress and metabolic
explicitly developed for BDD, whereas others were de- syndrome—with lipid abnormalities being a significant
signed to evaluate body image/dysmorphic concern. Aes- component of the latter—in these diseases. The authors
thetic providers should incorporate into their routines con- suggest that sphingomyelin is possibly involved in the
cise scales that have been developed specifically for BDD pathogenesis of these diseases.
and validated in cosmetic settings, such as the BDD Ques-
tionnaire (BDDQ)–Dermatology Version (BDDQ-DV) and
BDDQ–Aesthetic Surgery (BDDQ-AS). Lastly, the authors Cutaneous sensory disorders
indicate a need to revise many scales with questions relevant
to the behaviors of patients on social media.18 Injury to the peripheral nerve fibers that mediate sensation
predisposes to derangements in communication between the
peripheral and central nervous systems, which manifest clin-
Stress and the skin ically as abnormal, often unpleasant, sensations known as
dysesthesias. Such sensations include pain, burning, crawl-
Stress may initiate or exacerbate many skin diseases, such ing, biting, numbness, piercing, pulling, cold, shock-like,
as psoriasis, atopic dermatitis, or alopecia areata. Addition- pulling, wetness, and heat. In their significant contribution,
ally, the stress associated with having to live with a cos- Holmes and Fried indicate that these sensations can cause
metically disfiguring skin condition can, in turn, exacerbate considerable emotional distress and functional impairment
Psychocutaneous medicine 3

in affected individuals.23 The authors provide a valuable Declaration of Competing Interest

The approach to therapy This work received no funding.

Physicians deal almost every day with patients whose George Kroumpouzos, MD, PhD
problems require attention to psychosomatic issues. Listen- Department of Dermatology, Warren Alpert Medical School
ing to the patient is crucial and helps build rapport—patients at Brown University, Providence, Rhode Island, USA
are exquisitely sensitive to people who are interested in being E-mail address: gk@[Link]
listened to them.24 They can quickly differentiate between
the physician who honestly listens attentively and the physi-
cian who says he does but does not. An empathic, nonjudg- References
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Minimum Standards for Pyschodermatology Services 2012. Available
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It is an honor and a privilege to have this unique opportu- 2017;77:e143–e144.
nity to bring together outstanding contributors with diverse 13. Stamu-O’Brien C, Shivakumar S, Messas T, Kroumpouzos G. Through
backgrounds for this Psychocutaneous Medicine issue of the the looking glass: skin signs that help diagnose eating disorders. Clin
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Clinics. Their contributions to this special issue have been
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vital. I greatly appreciate that they devoted their valuable historical and contemporary review. Clin Dermatol. 2023, doi:10.1016/
time and efforts and shared their extensive knowledge and [Link].2023.02.006.
expertise to make this issue a reading pleasure. I am confi- 15. Laughter M, Anderson J, Maymone MBC, Kroumpouzos G. Psychol-
dent that the goal of providing the readership with a compre- ogy of aesthetics: beauty, social media, and body dysmorphic disorder.
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hensive, practical, and insightful reference on psychocuta-
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neous medicine has been accomplished. Lastly, I would like der: a critical appraisal of diagnostic, screening, and assessment tools.
to express deep gratitude to the Editor-in-chief, Lawrence Clin Dermatol. 2023, doi:10.1016/[Link].2023.03.001.
Charles Parish, for his continuous support throughout this
project.
4 G. Kroumpouzos

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