Skip to main content
SpringerLink
Log in

Unmet Needs in Psychodermatology: A Narrative Review

  • Review Article
  • Published:
CNS Drugs Aims and scope Submit manuscript

Abstract

Psychodermatology, the multidisciplinary field that explores the intricate interplay between the mind and the skin, has gained increasing recognition over the past decade. However, several knowledge gaps and unmet needs persist in the field. The objective of this narrative review was to investigate the unmet needs in the field of psychodermatology as they pertain to medical training, treatment, research, and care access. PubMed was searched from inception through December 2023 to identify articles related to psychodermatology. Findings revealed several unmet needs within the field of psychodermatology. First, there is a need for further investigation into the pathophysiology that links psychological stress to cutaneous disease including the development of novel therapies targeting key neuropeptides. Second, the existing literature focuses primarily on the pharmacologic treatment of body dysmorphic disorder and body-focused repetitive behaviors, as well as delusional parasitosis, for which the first-line agents are selective serotonin reuptake inhibitors and atypical antipsychotics, respectively. However, additional research into the efficacy and safety of the remaining psychotropic medications and the treatment of other common psychocutaneous diseases is required. Finally, there exists a significant gap in knowledge amongst clinicians tasked with treating psychocutaneous diseases. Dermatologists report low rates of training in psychodermatology and discomfort with prescribing psychotropic medications. In conclusion, increasing resources for dermatologist education on psychotropic agent use, development of new drugs targeting stress-induced skin conditions, and research on the psychocutaneous applications of current medications may greatly improve the quality and access of psychodermatology care.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Similar content being viewed by others

References

  1. Ferreira BR, Vulink N, Mostaghimi L, et al. Classification of psychodermatological disorders: proposal of a new international classification. J Eur Acad Dermatol Venereol. 2023 (epub 2023/12/12).

  2. Picardi A, Abeni D, Melchi CF, et al. Psychiatric morbidity in dermatological outpatients: an issue to be recognized. Br J Dermatol. 2000;143(5):983–91.

    CAS  PubMed  Google Scholar 

  3. Hughes JE, Barraclough BM, Hamblin LG, et al. Psychiatric symptoms in dermatology patients. Br J Psychiatry. 1983;143:51–4.

    CAS  PubMed  Google Scholar 

  4. Wang J, Wu X, Lai W, et al. Prevalence of depression and depressive symptoms among outpatients: a systematic review and meta-analysis. BMJ Open. 2017;7(8): e017173.

    PubMed Central  PubMed  Google Scholar 

  5. Balieva F, Abebe DS, Dalgard FJ, et al. Risk of developing psychiatric disease among adult patients with skin disease: a 9-year national register follow-up study in Norway. Skin Health Dis. 2023;3(6): e294.

    PubMed Central  PubMed  Google Scholar 

  6. Gaston L, Lassonde M, Bernier-Buzzanga J, et al. Psoriasis and stress: a prospective study. J Am Acad Dermatol. 1987;17(1):82–6.

    CAS  PubMed  Google Scholar 

  7. Hedman-Lagerlöf E, Fust J, Axelsson E, et al. Internet-delivered cognitive behavior therapy for atopic dermatitis: a randomized clinical trial. JAMA Dermatol. 2021;157(7):796–804.

    PubMed  Google Scholar 

  8. Stewart TJ, Schut C, Whitfeld M, et al. Cross-sectional study of psychological stress and skin symptoms in Australian university students. Australas J Dermatol. 2018;59(1):e82–4.

    PubMed  Google Scholar 

  9. Bin Saif GA, Alotaibi HM, Alzolibani AA, et al. Association of psychological stress with skin symptoms among medical students. Saudi Med J. 2018;39(1):59–66.

    PubMed  Google Scholar 

  10. Troy AS, Willroth EC, Shallcross AJ, et al. Psychological resilience: an affect-regulation framework. Annu Rev Psychol. 2023;74:547–76.

    PubMed  Google Scholar 

  11. Kim JE, Cho BK, Cho DH, et al. Expression of hypothalamic-pituitary-adrenal axis in common skin diseases: evidence of its association with stress-related disease activity. Acta Derm Venereol. 2013;93(4):387–93.

    PubMed  Google Scholar 

  12. Hall JM, Cruser D, Podawiltz A, et al. Psychological stress and the cutaneous immune response: roles of the HPA axis and the sympathetic nervous system in atopic dermatitis and psoriasis. Dermatol Res Pract. 2012;2012: 403908.

    PubMed Central  PubMed  Google Scholar 

  13. Slominski AT, Slominski RM, Raman C, et al. Neuroendocrine signaling in the skin with a special focus on the epidermal neuropeptides. Am J Physiol Cell Physiol. 2022;323(6):C1757–76.

    CAS  PubMed Central  PubMed  Google Scholar 

  14. Keller JJ. Cutaneous neuropeptides: the missing link between psychological stress and chronic inflammatory skin disease? Arch Dermatol Res. 2023;315(7):1875–81.

    CAS  PubMed  Google Scholar 

  15. Oetjen LK, Mack MR, Feng J, et al. Sensory neurons co-opt classical immune signaling pathways to mediate chronic itch. Cell. 2017;171(1):217-28.e13.

    CAS  PubMed Central  PubMed  Google Scholar 

  16. Raychaudhuri SP, Sanyal M, Weltman H, et al. K252a, a high-affinity nerve growth factor receptor blocker, improves psoriasis: an in vivo study using the severe combined immunodeficient mouse-human skin model. J Invest Dermatol. 2004;122(3):812–9.

    CAS  PubMed  Google Scholar 

  17. Peters EM, Liezmann C, Spatz K, et al. Nerve growth factor partially recovers inflamed skin from stress-induced worsening in allergic inflammation. J Invest Dermatol. 2011;131(3):735–43.

    CAS  PubMed  Google Scholar 

  18. Pondeljak N, Lugović-Mihić L. Stress-induced interaction of skin immune cells, hormones, and neurotransmitters. Clin Ther. 2020;42(5):757–70.

    CAS  PubMed  Google Scholar 

  19. Jafferany M. Psychodermatology: a guide to understanding common psychocutaneous disorders. Prim Care Companion J Clin Psychiatry. 2007;9(3):203–13.

    PubMed Central  PubMed  Google Scholar 

  20. Samuels DV, Rosenthal R, Lin R, et al. Acne vulgaris and risk of depression and anxiety: a meta-analytic review. J Am Acad Dermatol. 2020;83(2):532–41.

    PubMed  Google Scholar 

  21. Cheng BT, Silverberg JI. Depression and psychological distress in US adults with atopic dermatitis. Ann Allergy Asthma Immunol. 2019;123(2):179–85.

    PubMed  Google Scholar 

  22. Jalenques I, Bourlot F, Martinez E, et al. Prevalence and odds of anxiety disorders and anxiety symptoms in children and adults with psoriasis: Systematic review and meta-analysis. Acta Derm Venereol. 2022;102: adv00769.

    PubMed  Google Scholar 

  23. Ezzedine K, Eleftheriadou V, Jones H, et al. Psychosocial effects of vitiligo: a systematic literature review. Am J Clin Dermatol. 2021;22(6):757–74.

    PubMed Central  PubMed  Google Scholar 

  24. Kouris A, Platsidaki E, Christodoulou C, et al. Quality of life and psychosocial implications in patients with hidradenitis suppurativa. Dermatology. 2016;232(6):687–91.

    PubMed  Google Scholar 

  25. McDonald K, Shelley A, Jafferany M. The PHQ-2 in dermatology-standardized screening for depression and suicidal ideation. JAMA Dermatol. 2018;154(2):139–41.

    PubMed  Google Scholar 

  26. Pereira IN, Chattopadhyay R, Fitzpatrick S, et al. Evidence-based review: screening body dysmorphic disorder in aesthetic clinical settings. J Cosmet Dermatol. 2023;22(7):1951–66.

    PubMed  Google Scholar 

  27. Tan C, Jiang J, Deng X, et al. Effect of cognitive behavioral therapy on anxiety and depression in patients with psoriasis: a protocol for systematic review and meta-analysis. Medicine (Baltimore). 2021;100(46): e27720.

    CAS  PubMed  Google Scholar 

  28. Mashayekhi Goyonlo V, Sardabi MS, Tavalaei AM, et al. Cognitive behavioral therapy as an adjuvant therapy in acne excoriée: a randomized controlled clinical trial. J Dermatolog Treat. 2022;33(2):782–8.

    PubMed  Google Scholar 

  29. Skurya J, Jafferany M, Everett GJ. Habit reversal therapy in the management of body focused repetitive behavior disorders. Dermatol Ther. 2020;33(6): e13811.

    PubMed  Google Scholar 

  30. Norén P, Hagströmer L, Alimohammadi M, et al. The positive effects of habit reversal treatment of scratching in children with atopic dermatitis: a randomized controlled study. Br J Dermatol. 2018;178(3):665–73.

    PubMed  Google Scholar 

  31. Piaserico S, Marinello E, Dessi A, et al. Efficacy of biofeedback and cognitive-behavioural therapy in psoriatic patients: a single-blind, randomized and controlled study with added narrow-band ultraviolet B therapy. Acta Derm Venereol. 2016;96(217):91–5.

    PubMed  Google Scholar 

  32. Neerackal RJ, Abdul Latheef EN, Sukumarakurup S, et al. Relaxation therapy in the management of psoriasis. Dermatol Ther. 2020;33(6): e14030.

    CAS  PubMed  Google Scholar 

  33. Gallo R, Chiorri C, Gasparini G, et al. Can mindfulness-based interventions improve the quality of life of patients with moderate/severe alopecia areata? A prospective pilot study. J Am Acad Dermatol. 2017;76(4):757–9.

    PubMed  Google Scholar 

  34. Willemsen R, Haentjens P, Roseeuw D, et al. Hypnosis in refractory alopecia areata significantly improves depression, anxiety, and life quality but not hair regrowth. J Am Acad Dermatol. 2010;62(3):517–8.

    PubMed  Google Scholar 

  35. Phillips KA, Albertini RS, Rasmussen SA. A randomized placebo-controlled trial of fluoxetine in body dysmorphic disorder. Arch Gen Psychiatry. 2002;59(4):381–8.

    CAS  PubMed  Google Scholar 

  36. Phillips KA. An open-label study of escitalopram in body dysmorphic disorder. Int Clin Psychopharmacol. 2006;21(3):177–9.

    PubMed Central  PubMed  Google Scholar 

  37. Phillips KA, Keshaviah A, Dougherty DD, et al. Pharmacotherapy relapse prevention in body dysmorphic disorder: a double-blind, placebo-controlled trial. Am J Psychiatry. 2016;173(9):887–95.

    PubMed Central  PubMed  Google Scholar 

  38. Phillips KA, Najjar F. An open-label study of citalopram in body dysmorphic disorder. J Clin Psychiatry. 2003;64(6):715–20.

    CAS  PubMed  Google Scholar 

  39. Phillips KA, McElroy SL, Dwight MM, et al. Delusionality and response to open-label fluvoxamine in body dysmorphic disorder. J Clin Psychiatry. 2001;62(2):87–91.

    CAS  PubMed Central  PubMed  Google Scholar 

  40. Phillips KA, Dwight MM, McElroy SL. Efficacy and safety of fluvoxamine in body dysmorphic disorder. J Clin Psychiatry. 1998;59(4):165–71.

    CAS  PubMed  Google Scholar 

  41. Perugi G, Giannotti D, Di Vaio S, et al. Fluvoxamine in the treatment of body dysmorphic disorder (dysmorphophobia). Int Clin Psychopharmacol. 1996;11(4):247–54.

    CAS  PubMed  Google Scholar 

  42. Hollander E, Allen A, Kwon J, et al. Clomipramine vs desipramine crossover trial in body dysmorphic disorder: selective efficacy of a serotonin reuptake inhibitor in imagined ugliness. Arch Gen Psychiatry. 1999;56(11):1033–9.

    CAS  PubMed  Google Scholar 

  43. Fang A, Porth R, Phillips KA, et al. Personality as a predictor of treatment response to escitalopram in adults with body dysmorphic disorder. J Psychiatr Pract. 2019;25(5):347–57.

    PubMed Central  PubMed  Google Scholar 

  44. Phillips KA. An open study of buspirone augmentation of serotonin-reuptake inhibitors in body dysmorphic disorder. Psychopharmacol Bull. 1996;32(1):175–80.

    CAS  PubMed  Google Scholar 

  45. Phillips KA. Placebo-controlled study of pimozide augmentation of fluoxetine in body dysmorphic disorder. Am J Psychiatry. 2005;162(2):377–9.

    PubMed Central  PubMed  Google Scholar 

  46. Phillips KA. Olanzapine augmentation of fluoxetine in body dysmorphic disorder. Am J Psychiatry. 2005;162(5):1022–3.

    PubMed Central  PubMed  Google Scholar 

  47. Allen A, Hadley SJ, Kaplan A, et al. An open-label trial of venlafaxine in body dysmorphic disorder. CNS Spectr. 2008;13(2):138–44.

    PubMed  Google Scholar 

  48. Phillips KA, Menard W. A prospective pilot study of levetiracetam for body dysmorphic disorder. CNS Spectr. 2009;14(5):252–60.

    PubMed Central  PubMed  Google Scholar 

  49. Schneier FR, Feusner J, Wheaton MG, et al. Pilot study of single-dose psilocybin for serotonin reuptake inhibitor-resistant body dysmorphic disorder. J Psychiatr Res. 2023;161:364–70.

    PubMed  Google Scholar 

  50. Campbell EH, Elston DM, Hawthorne JD, et al. Diagnosis and management of delusional parasitosis. J Am Acad Dermatol. 2019;80(5):1428–34.

    PubMed  Google Scholar 

  51. Martins AC, Mendes CP, Nico MM. Delusional infestation: a case series from a university dermatology center in São Paulo, Brazil. Int J Dermatol. 2016;55(8):864–8.

    CAS  PubMed  Google Scholar 

  52. Hamann K, Avnstorp C. Delusions of infestation treated by pimozide: a double-blind crossover clinical study. Acta Derm Venereol. 1982;62(1):55–8.

    CAS  PubMed  Google Scholar 

  53. Laidler N. Delusions of parasitosis: a brief review of the literature and pathway for diagnosis and treatment. Dermatol Online J. 2018;24(1).

  54. Freudenmann RW, Lepping P. Second-generation antipsychotics in primary and secondary delusional parasitosis: outcome and efficacy. J Clin Psychopharmacol. 2008;28(5):500–8.

    CAS  PubMed  Google Scholar 

  55. Lu JD, Gotesman RD, Varghese S, et al. Treatments for primary delusional infestation: systematic review. JMIR Dermatol. 2022;5(1): e34323.

    PubMed Central  PubMed  Google Scholar 

  56. Wong S, Bewley A. Patients with delusional infestation (delusional parasitosis) often require prolonged treatment as recurrence of symptoms after cessation of treatment is common: an observational study. Br J Dermatol. 2011;165(4):893–6.

    CAS  PubMed  Google Scholar 

  57. van Minnen A, Hoogduin KA, Keijsers GP, et al. Treatment of trichotillomania with behavioral therapy or fluoxetine: a randomized, waiting-list controlled study. Arch Gen Psychiatry. 2003;60(5):517–22.

    PubMed  Google Scholar 

  58. Ninan PT, Rothbaum BO, Marsteller FA, et al. A placebo-controlled trial of cognitive-behavioral therapy and clomipramine in trichotillomania. J Clin Psychiatry. 2000;61(1):47–50.

    CAS  PubMed  Google Scholar 

  59. Soomro GM, Altman D, Rajagopal S, et al. Selective serotonin re-uptake inhibitors (SSRIs) versus placebo for obsessive compulsive disorder (OCD). Cochrane Database Syst Rev. 2008;2008(1): CD001765.

    PubMed Central  PubMed  Google Scholar 

  60. Schumer MC, Bartley CA, Bloch MH. Systematic review of pharmacological and behavioral treatments for skin picking disorder. J Clin Psychopharmacol. 2016;36(2):147–52.

    CAS  PubMed Central  PubMed  Google Scholar 

  61. Van Ameringen M, Mancini C, Patterson B, et al. A randomized, double-blind, placebo-controlled trial of olanzapine in the treatment of trichotillomania. J Clin Psychiatry. 2010;71(10):1336–43.

    PubMed  Google Scholar 

  62. Stewart RS, Nejtek VA. An open-label, flexible-dose study of olanzapine in the treatment of trichotillomania. J Clin Psychiatry. 2003;64(1):49–52.

    CAS  PubMed  Google Scholar 

  63. White MP, Koran LM. Open-label trial of aripiprazole in the treatment of trichotillomania. J Clin Psychopharmacol. 2011;31(4):503–6.

    CAS  PubMed  Google Scholar 

  64. Grant JE, Odlaug BL, Chamberlain SR, et al. A double-blind, placebo-controlled trial of lamotrigine for pathological skin picking: treatment efficacy and neurocognitive predictors of response. J Clin Psychopharmacol. 2010;30(4):396–403.

    CAS  PubMed Central  PubMed  Google Scholar 

  65. Grant JE, Odlaug BL, Kim SW. Lamotrigine treatment of pathologic skin picking: an open-label study. J Clin Psychiatry. 2007;68(9):1384–91.

    CAS  PubMed  Google Scholar 

  66. Grant JE, Chamberlain SR, Redden SA, et al. N-acetylcysteine in the treatment of excoriation disorder: a randomized clinical trial. JAMA Psychiat. 2016;73(5):490–6.

    Google Scholar 

  67. Grant JE, Chesivoir E, Valle S, et al. Double-blind placebo-controlled study of memantine in trichotillomania and skin-picking disorder. Am J Psychiatry. 2023;180(5):348–56.

    PubMed  Google Scholar 

  68. Gee SN, Zakhary L, Keuthen N, et al. A survey assessment of the recognition and treatment of psychocutaneous disorders in the outpatient dermatology setting: how prepared are we? J Am Acad Dermatol. 2013;68(1):47–52.

    PubMed  Google Scholar 

  69. Christensen RE, Jafferany M. Global awareness, knowledge, and practice patterns of psychocutaneous medicine: a primary care perspective. Prim Care Companion CNS Disord. 2022;24(4):41972.

    Google Scholar 

  70. Senulytė A, Vasiliauskaitė G, Rudzikaitė-Fergizė G, et al. Psychodermatology in Lithuania. A survey on knowledge, awareness, and practice patterns in Lithuanian dermatovenereologists. Arch Dermatol Res. 2023;315(8):2351–7.

    PubMed  Google Scholar 

  71. Ait Oussous S, Jafferany M, Chakiri R. Psychodermatology knowledge, awareness and patterns of practice among Moroccan dermatologists: a national survey study. Clin Exp Dermatol. 2023;48(10):1152–4.

    PubMed  Google Scholar 

  72. Poot F, Sampogna F, Onnis L. Basic knowledge in psychodermatology. J Eur Acad Dermatol Venereol. 2007;21(2):227–34.

    CAS  PubMed  Google Scholar 

  73. Ryan MP, Wagner RF. Psychodermatology fellowship: is it time? Dermatol Online J. 2021;27(2).

  74. Patel A, Jafferany M. Multidisciplinary and holistic models of care for patients with dermatologic disease and psychosocial comorbidity: a systematic review. JAMA Dermatol. 2020;156(6):686–94.

    PubMed  Google Scholar 

  75. Misery L, Schut C, Balieva F, et al. White paper on psychodermatology in Europe: a position paper from the EADV Psychodermatology Task Force and the European Society for Dermatology and Psychiatry (ESDaP). J Eur Acad Dermatol Venereol. 2023;37(12):2419–27.

    PubMed  Google Scholar 

  76. Seale L, Gaulding JV, Porto D, et al. Implementation of a psychodermatology clinic at a major health system in Detroit. Int J Womens Dermatol. 2018;4(4):227–9.

    CAS  PubMed Central  PubMed  Google Scholar 

  77. Silvan M. An integrated approach to the treatment of psychodermatology patients. Dermatol Psychosom. 2001;2(2):86–92.

    Google Scholar 

  78. Shenoi SD, Prabhu S, Nirmal B, et al. Our experience in a psychodermatology liaison clinic at manipal, India. Indian J Dermatol. 2013;58(1):53–5.

    PubMed Central  PubMed  Google Scholar 

  79. Orion E, Feldman B, Ronni W, et al. A psychodermatology clinic: the concept, the format, and our observations from Israel. Am J Clin Dermatol. 2012;13(2):97–101.

    PubMed  Google Scholar 

  80. Gould WM, Gragg TM. A dermatology-psychiatry liaison clinic. J Am Acad Dermatol. 1983;9(1):73–7.

    CAS  PubMed  Google Scholar 

  81. Van Beugen S, Schut C, Kupfer J, et al. Perceived stigmatization among dermatological outpatients compared with controls: an observational multicentre study in 17 European countries. Acta Derm Venereol. 2023;103: adv6485.

    PubMed  Google Scholar 

  82. Thornicroft G, Sunkel C, Alikhon Aliev A, et al. The Lancet Commission on ending stigma and discrimination in mental health. Lancet. 2022;400(10361):1438–80.

    PubMed  Google Scholar 

Download references

Author information

Authors and Affiliations

  1. Department of Psychiatry and Behavioral Sciences, Central Michigan University College of Medicine/CMU Medical Education Partners, Saginaw, MI, 48603, USA

    Rachel E. Christensen & Mohammad Jafferany

  2. Department of Dermatology, Northwestern Feinberg School of Medicine, Chicago, IL, 60611, United States

    Rachel E. Christensen

Authors
  1. Rachel E. Christensen
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Mohammad Jafferany
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Mohammad Jafferany.

Ethics declarations

Funding

The authors did not receive support from any organization for the submitted work.

Conflict of interest

The authors have no relevant financial or non-financial interests to disclose.

Ethics approval

Ethics approval was not required for this narrative review.

Consent to participate

Not applicable.

Consent for publication

Not applicable.

Availability of data and material

This review article synthesizes and analyzes information from publicly available, previously published data. All data referenced in this review are derived from existing literature, which is appropriately cited. No new data were generated or collected specifically for this review.

Code availability

Not applicable.

Author contributions

All authors contributed to the study conception and design. Material preparation, literature search, and data analysis were performed by Rachel Christensen. The first draft of the manuscript was written by Rachel Christensen. All authors participated in critical revision of the manuscript. All authors read and approved of the final manuscript, and agree to be accountable for the work.

Rights and permissions

Springer Nature or its licensor (e.g. a society or other partner) holds exclusive rights to this article under a publishing agreement with the author(s) or other rightsholder(s); author self-archiving of the accepted manuscript version of this article is solely governed by the terms of such publishing agreement and applicable law.

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Christensen, R.E., Jafferany, M. Unmet Needs in Psychodermatology: A Narrative Review. CNS Drugs 38, 193–204 (2024). https://doi.org/10.1007/s40263-024-01068-1

Download citation

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s40263-024-01068-1

Search

Navigation