• Characterized by a distressing or impairing preoccupation with a nonexistent or slight defect in appearance.

• On a psychiatric spectrum from obsessional to delusional.

• Mean age of onset is 30–35 years; females = males; present in up to 10–15% of dermatologic patients.

• Patients usually concerned with nose, mouth, hair, breasts, or genitalia.

• Often adopt obsessional (e.g., numerous visits to physician for reassurance), ritualistic (e.g., excessive grooming routines), or delusional (e.g., multiple unnecessary surgeries) behaviors.

• Consider and assess for this diagnosis in patients seeking multiple cosmetic procedures.

• Rx: selective serotonin reuptake inhibitors (SSRIs) for obsessive–compulsive disorder (OCD) variant or antipsychotics for delusional variant.

• A conscious, repetitive, uncontrollable desire to pick, rub, or scratch skin.

• On a psychiatric spectrum most closely related to OCD but may also be an expression of generalized anxiety disorder or depression.

• Most common in middle-age; females > males.

• Favors scalp, face, upper back, extensor forearms, shins, buttocks.

• Lesions usually in all stages of evolution: erosions (prurigo simplex), deep circular or linear ulcerations with hypertrophic borders, hypo- or hyperpigmented scars (Fig. 5.2); admixed well-healed scars point to chronicity.

• DDx: (1) underlying causes of primary pruritus (see Chapter 4); (2) underlying primary cutaneous disorder (e.g., folliculitis).

• Rx: symptomatic treatment of pruritus (topicals, oral antihistamines); tricyclic antidepressants (TCAs) or SSRIs (if underlying depression); SSRIs (if underlying OCD); consultation with a psychiatrist.

• Considered a subset of psychogenic (neurotic) excoriations, characterized by ritualistic picking of acne lesions (Fig. 5.3).

• Often associated with OCD; most common in young females.

• Rx: aggressively treat underlying acne; TCAs or SSRIs (if underlying depression); SSRIs (if underlying OCD); consultation with a psychiatrist.

• Defined as hair loss from a patient’s repetitive self-pulling of hair.

• On a psychiatric spectrum from inattentive habitual hair pulling to impulse disorder to OCD to other underlying psychiatric disorder.

• Most helpful to approach the patient by age of onset, in terms of discussing prognosis and treatment.

– Preschool onset: typically benign course; most children outgrow the habit; Rx involves bringing awareness to parents and patient.

– Pre-adolescent to young adult onset: more chronic, relapsing course; on a spectrum from habit/unawareness to underlying psychopathology; Rx includes bringing awareness, behavioral modification therapy, psychotropic medications as necessary.

– Adult onset: more protracted course; often due to underlying psychopathology; Rx most often entails referral to psychiatrist/psychologist and treatment of underlying psychiatric disorder.

• Peak onset ages 8–12 years; females > males.

• Most commonly scalp hair, but also eyebrows, eyelashes, or pubic hair.

• Classically see hairs of varying lengths distributed within the area of alopecia; uninvolved areas are normal (Fig. 5.4).

• Sometimes associated ritualistic behavior or trichophagy.

• DDx: other causes of non-scarring alopecia (e.g., alopecia areata, tinea capitis).

• A helpful diagnostic test is the ‘clipped hair square,’ in which a small section of hair is clipped close to the scalp with scissors; in trichotillomania the hairs (being too short to pull out) display uniform hair regrowth.

• Rx: behavioral modification is primary treatment; psychosocial support; SSRIs; case reports of N-acetyl cysteine replacement.

• Cutting is a form of nonsuicidal self-injury that has received increased attention by the medical community and media in recent years.

• It is a practice in which the individual makes small cuts on his/her body, most often on the arms and legs, with a sharp instrument such as a razor blade.

• Typically seen in adolescents and young adults (females > males) as a maladaptive response to psychological distress; may also be a symptom of an underlying psychological disorder (e.g., anxiety, depression, borderline personality disorder).

• In contrast to dermatitis artefacta, patients acknowledge that they inflicted the lesions upon themselves.

• Clinically, lesions present as an admixture of linear erosions or well-healed scars, often in an array of parallel lines (likened to ‘railroad ties’); some individuals will cut words into their skin; with time, the cutting will typically escalate to more frequent and numerous lesions.

• Unexplained, recurrent ‘cuts and scratches’ on the forearms and legs of adolescents should arouse suspicion for this behavior.

• Rx: familial and psychological support; treatment of underlying psychopathology.

• Characterized by self-inflicted lesions as a means to satisfy a psychological need that is not consciously understood; self-denial.

• Rare disorder; majority of patients suffer from borderline personality disorder; may have underlying depression and/or anxiety.

• Onset typically in adolescence or young adulthood; females >> males.

• Lesions often appear in easy-to-reach areas and appear in bizarre shapes and configurations; may employ outside instruments (Fig. 5.5).

• DDx: (1) primary dermatologic disorder; (2) monosymptomatic hypochondriacal disorder; (3) malingering (conscious gain); (4) OCD; (5) Münchhausen syndrome by proxy.

• Rx: symptomatic treatment of wounds; psychosocial support; psychotropic medications tailored to underlying psychopathology.

• A monosymptomatic, hypochondriacal psychosis characterized by a fixed and false (delusional) belief that an individual is infested with parasites, despite any objective evidence.

• This delusion is ‘encapsulated’ and other mental functions are usually intact.

• Typical onset is in the mid 50s–60s.

• Patients often bring in bits of skin, lint, and other specimens to prove the existence of the supposed parasites (Fig. 5.6).

• Often experience ‘formication,’ which is a cutaneous sensation of crawling, biting, and/or stinging.

• DDx: (1) legitimate primary dermatologic disorder; (2) true formication without delusion; (3) formication plus delusion, related to substance abuse (e.g., methamphetamines); (4) delusional ideation (i.e., mentally fixated but not completely inflexible).

• A recent investigation by the Centers for Disease Control and Prevention supported the categorization of Morgellons disease as a form of delusions of parasitosis.

• Rx: establish rapport with patient first; pimozide or atypical antipsychotics.

• Characterized by a distressing or impairing preoccupation with a nonexistent or slight defect in appearance.

• On a psychiatric spectrum from obsessional to delusional.

• Mean age of onset is 30–35 years; females = males; present in up to 10–15% of dermatologic patients.

• Patients usually concerned with nose, mouth, hair, breasts, or genitalia.

• Often adopt obsessional (e.g., numerous visits to physician for reassurance), ritualistic (e.g., excessive grooming routines), or delusional (e.g., multiple unnecessary surgeries) behaviors.

• Consider and assess for this diagnosis in patients seeking multiple cosmetic procedures.

• Rx: selective serotonin reuptake inhibitors (SSRIs) for obsessive–compulsive disorder (OCD) variant or antipsychotics for delusional variant.

• A conscious, repetitive, uncontrollable desire to pick, rub, or scratch skin.

• On a psychiatric spectrum most closely related to OCD but may also be an expression of generalized anxiety disorder or depression.

• Most common in middle-age; females > males.

• Favors scalp, face, upper back, extensor forearms, shins, buttocks.

• Lesions usually in all stages of evolution: erosions (prurigo simplex), deep circular or linear ulcerations with hypertrophic borders, hypo- or hyperpigmented scars (Fig. 5.2); admixed well-healed scars point to chronicity.

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