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Psychocutaneous disorders in childhood and adolescence
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Psychocutaneous disorders in childhood and adolescence
issues than they did 30 years ago. It has been consistently reported in centres with access to integrated mental health services that a multidisciplinary and holistic approach in these children have improved long term outcomes. There is no universally accepted single classification of psycho cutaneous skin diseases and there is significant overlap between entities. Table 1 outlines the most widely accepted classification by Koo and Lee. Psychiatric disorders such as anxiety or depression in children and young people can manifest as self-induced skin conditions such as Trichotillomania, Acne Excoriee or Dermatitis Artefacta. These factitious disorders may be caused in the conscious or dissociated state and are driven by internal psychological stressors. Overall, these conditions are not associated with secondary gain, but are instead driven by the need to satisfy an unmet psychological need. Munchausen’s by proxy and malingering (extremely rare conditions) are exceptions and represent a population of parents or patients who actively seek medical care and intervention for a pecuniary gain. This article will focus on the three main psychiatric disorders with cutaneous manifestations seen in the paediatric population: Trichotillomania, Skin Picking Disorder (incl. Acne Excoriee) and Dermatitis Artefacta.
Padma Mohandas Jothsana Srinivasan Jane Ravenscroft Anthony Bewley
Abstract The adverse impact of skin diseases on an individual’s physical and emotional well-being is well recognised, particularly in children as it is reflected in their growth and development. Conversely, the psychological and psychosocial issues that a child or young person may face, can manifest as a skin problem. Cutaneous manifestations of an underlying primary psychiatric problem are a poorly recognised entity amongst paediatricians. Limited knowledge and experience in this realm increases diagnostic and management challenges. The discipline of Psychodermatology attempts to address these problems by relating skin disease to intrinsic and extrinsic mental health factors. This review summarises the current literature on Psychocutaneous conditions with expert opinion from the authors own experience. The importance of a holistic approach in a multidisciplinary setting to manage this vulnerable group of children and young people cannot be over-emphasised.
Trichotillomania (TTM) Trichotillomania is a self-induced disorder leading to hair loss due to pulling, rubbing or twisting the hair. It is seen as a bodyfocused repetitive behaviour (BFRB) and is listed in the DSM - 5 (Diagnostic and Statistical Manual of Mental Disorders e Fifth Edition) under the category of Obsessive-Compulsive and Related Disorder. Individuals with TTM suffer from a disorder of impulse control driven by an underlying need to reduce tension or stress by pulling hair. The tension reduction serves as a positive reinforcement perpetuating the behaviour. Sufferers tend to conceal both the action and its effects from others because of stigmatization. TTM has a lifetime prevalence of 1e2% and commonly presents between eight and twelve years of age. The risk of depression and anxiety proportionately increases with age in paediatric TTM. These children experience shame, struggle with low self-esteem, and exhibit repeated efforts to conceal hair loss. Individuals with TTM will often avoid pulling in social situations and prefer to pull while alone or engaged in sedentary activities. Pulling may be associated with one or multiple sites. Although some may pull hairs in a specific area, resulting in easily identifiable bald spots, others may distribute their pulling over a larger area, causing thinning of the hair. The latter is more difficult to identify, and sometimes a widespread pattern of pulling is conducted intentionally to conceal hair loss. Triggers for TTM may be. 1. Sensory, i.e. the hair thickness, length or location may cause the individual to pull. 2. Emotional, such as feeling anxious, bored or tense. 3. Cognitive, for example thoughts about their hair and appearance may precipitate the behaviour.
Keywords artefactual skin disease; childhood; dermatitis artefacta; factitious dermatitis; Munchausen’s by proxy; paediatric; skin picking disorder; trichotillomania
Introduction The mind and the skin are inextricably linked as the skin and nervous system are connected through their common embryonic origin, the ectoderm. Psychiatric and psychological factors play different roles in the pathogenic mechanism of skin diseases and this relationship should be acknowledged. Mental health disorders affect up to one in ten children in the U.K. Studies have shown that more children and young people have mental health
Padma Mohandas MRCP MRCGP MSc is a Specialist Registrar Dermatology in the Department of Paediatric Dermatology, Nottingham University Hospital, Nottingham, UK. Conflicts of Interest: none declared. Jothsana Srinivasan MBBS, MRCP(Paed) is a Consultant Paediatrician in the Department of Paediatric Dermatology, Nottingham University Hospital, Nottingham, UK. Conflicts of Interest: none declared. Jane Ravenscroft MBChB (Hons) MRCP is a Consultant Dermatologist in the Department of Paediatric Dermatology, Nottingham University Hospital, Nottingham, UK. Conflicts of Interest: none declared.
Clinical features
Anthony Bewley BA(Hons) FRCP is a Consultant Dermatologist in the Department of Dermatology Barts Health, London, UK. Conflicts of Interest: none declared.
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Hair pulling usually results in patchy areas of hair loss that are irregularly shaped and contain many broken hairs at different
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lengths (see Figure 1& 2). In some cases, TTM patients also pick at the skin around the hair follicles, resulting in inflammation and erythema. Assessment of the patient includes a thorough history with appropriate skin and mental health evaluation. The ‘Kipling method’, also known as the ‘5Ws and 1H’ (who, what, where, when, why and how), is a systematic problemsolving procedure which utilizes a set of questions, the answers to which give helpful information. Careful examination and documentation of each aspect of the problem is crucial. The application of this method has been advocated for approaching conditions in which clinical information may be masked, such as in cases of physical abuse in children. A patient’s age does influence the mechanism of his/her hairpulling. Two distinct types of hairpulling have been described for trichotillomania: automatic and focused. Automatic pulling occurs outside of one’s own awareness, while focused pulling, in contrast, occurs in awareness and in response to negative emotional states (stress, sadness, anger or anxiety), intense thoughts or urges. Children more often fall in the automatic category, and therefore, they do not recall the actual pulling, but may admit to ‘playing with hair’ or they have been noted to pull their hair in a trance-like, disengaged state. The possibility of ‘sleep-isolated trichotillomania’ should be considered as parents may not be aware of this phenomenon. Direct questioning such as ‘have you ever noticed hair on or around your child’s bed?‘, may lead parents to reveal this observation. Similar questioning about visible hair on clothes or on the floor for example could allude to when hairpulling occurs. Family-related issues such as family breakup, domestic arguments, neglect, death of a loved one, individual issues such as starting a new school, bullying and strained teacherestudent relationships may be causative factors. It is very important to talk to the affected child or young person on their own and explore possible abuse (physical, emotional or sexual) and other comorbidities such as mood issues, anxiety, eating and substance misuse. Dermatological assessment begins with examining the type of hair loss to determine whether it is scarring or nonscarring. Intact hair follicles and presence of follicular openings on dermascopic examination indicates nonscarring hair loss and reassures that the hair will regrow once pulling ceases. Scarring occurs when the follicles are permanently damaged from constant stress and
Classification of Psychocutaenous disorders Koo et al Psychophysiological disorders Psoriasis Atopic dermatitis Acne Exocoriee Hyperhidrosis Urticaria Herpes simplex virus infection Seborrheic dermatitis Aphthosis Rosacea Pruritus Psychiatric disorders with dermatologic symptoms Dermatitis artefacta Delusions of parasitosis Trichotillamania Obsessive-compulsive disorder Phobic states Eating disorders Neurotic excoriations Psychogenic pruritus Dermatological disorders with psychiatric symptoms Alopecia areata Vitiligo Generalised psoriasis Chronic eczema Ichthyisoform syndromes Rhinophyma Neurofibroma Albinism Miscellaneous Cutaneous sensory syndromes Glossodynia Vulvodynia Chronic itching in scalp Psychogenic purpura syndrome Pseudopsychodermatologic disease Suicide in dermatology patients Table 1
Figure 1 Unilateral loss of eyebrow.
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Figure 2 Occipital hair loss, hairs of varying lengths.
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sites of involvement are face and back. The “butterfly sign” is a distinctive feature whereby the inability of the patient to reach the central areas of the back results in peripheral skin trauma resembling butterfly wings. Many patients use their fingernails to pick or squeeze lesions. Very rarely implements such as tweezers and needles may be used. Lesions may range from few millimetres to several centimetres in size. Morphology varies from superficial erosions to deep ulceration associated with post inflammatory hypo or hyper pigmentation. Adolescent females may report premenstrual worsening of symptoms. These patients are a heterogeneous group expressing obsessive compulsive traits. In some, picking may be an expression of a generalised anxiety disorder or depression with the activity frequently occurring at night or when unoccupied. It is vital to obtain psychosocial history in these patients. From a psycho dynamic perspective, there are often histories of difficult childhoods with emotional rejection and harsh parenting. Individuals may lack self-confidence and be overly sensitive to criticism. A percentage also have anger management issues which is displaced into self-destructive picking.
trauma. In this case, the follicle openings are covered in scar tissue and the hair will not resume normal growth. The main differentials for TTM include. Alopecia areata characterised by a non-scarring hair loss, exclamation mark hairs and easily detachable strands (positive pull test), unlike in TTM where the broken hairs are firmly anchored in the scalp. Tinea Capitis is characterised by flaky, patchy hair loss which may be scarring or non-scarring depending on the degree of inflammation. Traction alopecia is usually seen in areas of the scalp where there are constant tensile forces on the scalp. In children, marginal hair loss along the temporal hairline is commonly observed, although other patterns can occur depending on hair style. High-risk hairstyling practices include tights buns, ponytails, braids, application of weaves, braids, or hair extensions. Bear in mind that conditions may co-exist, so a careful history is of the essence.
Treatment and prognosis Serotonin reuptake inhibitors (SSRI’s) demonstrated modest treatment effects in recent meta-analysis. Habit reversal therapy (HRT) and Cognitive Behavioural Therapy (CBT) appear to be the most effective treatment options for children with TTM. Increased focused pulling and older age group carries poor long-term prognosis. Post-pulling behaviour must also be ascertained. Whilst some individuals simply discard pulled hairs, others bite and ingest all or parts of the hair. Ingesting hairs can result in undigested masses of hair called trichobezoars. Careful assessment and prompt referral to gastroenterologist is warranted in the presence of abdominal symptoms. If left untreated, complications such as bowel obstruction, intestinal bleeding or rarely perforation can occur.
Differential diagnosis The differentials should include both medical and psychiatric conditions. Medical causes - atopic eczema, urticaria, uraemia, cholestatic hepatitis, scabies, lichen planus [look for oral lesions], xerosis and if predominantly photo distributed it is important to exclude photosensitive disorders such as actinic prurigo. Psychiatric conditions - anxiety, depression, OCD, body dysmorphic disorder, borderline personality disorder and dermatitis artefacta. Recreational drug use like cocaine and cannabis, alcohol consumption should also be enquired about.
Skin picking disorder (SPD)/Acne excoriee Investigations
As many as one fifth of the general population admit to skin picking. Clinically significant SPD ranges from 5 to 8% and is characterised by repetitive and compulsive picking of the skin resulting in tissue damage. Patients feel the urge to disturb the skin and find relief in the activity. Attempts to suppress the urge can cause psychological distress. The picking behaviour may begin inadvertently or manifest in a ritualistic fashion followed by feelings of gratification, relief or pleasure. Some individuals may engage in automatic picking, which occurs without full awareness of the patient devoid of any preceding tension. In such circumstances, there tends to be higher level of emotional dysregulation. It is important to recognise this dissociative state, as these patients need stabilisation and suicide risk assessment. The true extent of this disorder is unknown. SPD may be a manifestation of other disorders such as OCD (Obsessive Compulsive Disorder), genetic disorders like Prader Willi syndrome and Body Dysmorphic Disorder (BDD). Although the condition can present at any age, SPD usually manifests in older children with a distinct female preponderance.
Physical causes of pruritus and skin disease should be looked for and excluded in the first instance (see Table 2).
Management Where possible, patients presenting with SPD/Acne excoriee should be managed in a dedicated psycho dermatology clinic, with the input of dermatologist, psychiatrist, psychologist and dermatology nurse specialist. Assessment of psychosocial morbidities such psychological trauma and stressful life events are important, as these factors have shown to have a direct impact
Suggested investigations for skin picking disorder C
C C C
Clinical features Lesions may arise from pre-existing skin problems like acne or urticated papules or they may be created deenovo. The common
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Blood tests [Full Blood Count/Thyroid Function Test/Liver Function Test/Renal Function Test/Iron/Ferritin/Glucose], HIV serology and protein electrophoresis as clinically indicated. Skin swabs for microscopy and culture. Skin biopsies with immunofluorescence if needed. Other tests such as Chest X eray/CT scans depending on the situation for suspected malignancies.
Table 2
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b. Pharmacological Therapy Obsessive compulsive symptoms as seen in skin picking disorders are associated with Serotonin mediated neural pathways. Antidepressants that selectively block serotonin uptake [SSRI’s] can be of benefit in this group. Commonly used SSRI’s include Citalopram, Sertraline and Fluoxetine. In the paediatric population we would recommend the input of a child psychiatrist to initiate and monitor response.
on skin barrier function and immune response. There is numerous disease specific [SPS-Skin picking Scale, Y-BOCS-Yale Brown Obsessive Compulsive Scale] and general quality of life scales such as the CDLQI [Childrens Dermatology Life Quality Index] and HAD [Hospital Anxiety and Depression] that assess stress and the impact on the skin. They are useful as an objective measure of evaluating health related quality of life, suffering from skin problems. Our experience of evaluation in a joint psycho-dermatology clinic is that psychiatric assessment can be conducted progressively over time. The patient’s issues are viewed holistically from the outset, with rapport building between the patient, dermatologist and psychiatrist as sessions unfold. 1. Communication As with all psycho dermatological conditions patients should be dealt in a non -confrontational manner. Fostering a positive relationship by empathising with their condition is important. It may also be helpful to explain that although the actual reason for their symptoms is not clearly understood, there are strategies that can be employed which can change the way the skin and brain process the signals it receives. 2. Treatment of Skin Picking Disorder a. Topical: Treatment is based on symptom severity. For example, if pruritus is an issue, preparations of Menthol containing emollients may be useful [e.g. in Menthol in Aqueous Cream] or 5% Doxepin cream. Cool compresses can be helpful to remove crusting and to soothe the skin. Emollients [patient preference to be considered] with or without antiseptics can also be suggested to improve hydration, and thereby reducing sensation of itch. Adopting a positive approach in dealing with skin issues helps enormously as patients invariably become upset if the cutaneous component of their condition is overlooked. Topical/Intralesional steroids/tape to address the inflammatory component of existing lesions can be used as adjunct for chronic or non-healing lesions. b. Systemic Therapy [i] Physical Phototherapy [TL01] whole body or localised, can be used with good results especially in cases where widespread itching is a feature (e.g.: poorly controlled atopic eczema). Immunomodulatory and anti-inflammatory effects of phototherapy lead to itch reduction and improvement of the underlying dermatitis. [ii] Pharmacotherapeutics Oral Tetracyclines [Lymecycline or Doxycycline in the older children] have been tried with benefit in view of their antiinflammatory and antibiotic effects. Treatment courses tend to last for weeks or months depending on the response. Conventional sedative antihistamines such as Hydroxyzine or Chlorpheniramine maleate [Piriton] can help with itching. 3. Psychological and Psychiatric Interventions a. Non-Pharmacological Therapy Counselling can be beneficial in patients where psychosocial stressors have precipitated or perpetuated their skin problem [e.g. bullying at school, breakdown, bereavement]. Cognitive behavioural therapy [CBT] can be very effective for patients with OCD, and who are willing to engage with their psychologist.
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Prognosis Prognosis is influenced by predisposing factors, such as a premorbid anxious personality, other personality disorder or childhood traumas [physical or emotional abuse]. Precipitants such as stressful life events [e.g. bereavement]. Perpetuating factors e.g. poverty and social isolation. The average duration of illness is reported to be around 5e8 years with relapses and remissions that parallel stressful situations.
e Acne excorie Acne excoriee is a self-inflicted skin condition which is thought to be a subset of SPD where the picking or scratching is directed at real or imagined acne lesions. The condition differs from other artefactual dermatoses in that the patient usually admits the selfinflicted nature of the condition. Social embarrassment prevents patients from seeking help. When managing this group of patients, the mechanism of picking is usually not stressed upon, as it is the underlying psychosocial issue that is of importance. Given the high co-morbidity of skin picking with other psychiatric disorders, clinicians should enquire about the cutaneous and psychiatric symptoms when either is found to be present. Acne excoriee is most often seen in young women hence the description “des jeunes filles”.
Clinical features Individuals with acne excoriee usually have some form of acne existing on the face, chest or back. Lesions can range from superficial excoriations [Figure 3] to deep gouges. Scarring post inflammatory hyper and hypo pigmentation are common. As in other SPD’s women may report pre-menstrual flare of their lesions and picking habits. Many patients have underlying anxiety and or depression as co-morbidities. Other psychiatric diagnoses to
Figure 3 Excoriated papules on forehead of a young girl.
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Children can present with a myriad of skin lesions ranging from very superficial (and sometimes obvious) skin pigment changes, to lesions that mimic organic skin disease so closely that they may deceive the clinician for years (Figure 5). Establishing the diagnosis is often a challenge but clues from the consultation can help towards making an accurate diagnosis. Table 3 outlines the salient features in the history and examination that may prompt a diagnosis of DA. The indifferent child, also coined as “la belle indifference” is seen in children with conversion disorders (otherwise known as functional neurological symptom disorder). Patients and their relatives may consume huge amount of time and medical resources to seek the cause and resolution of the ‘problem.’
consider are Post Traumatic Stress Disorder [PTSD], Obsessive Compulsive Disorder [OCD] and Body Dysmorphic Disorder [BDD].
Management 1. Treatment of Skin Disease (a) Topical Treatments: Skin treatment modalities include topical antibiotics [Duac/Zineryt], topical retinoids in singular or combination therapy. (b) Systemic Therapy; For mild to moderate papulo pustular acne, oral antibiotics can be useful. Anti-androgen treatment, anti-androgen contraceptives such as Dianette can be considered for pre-menstrual flares in young adults. Low doses of isotretinoin [less than 0.5 mg/kg body weight] over a period of 12e18 months may be beneficial in selected cases [with concomitant psychological/psychiatric input]. 2. Psychological and Psychiatric Interventions: A multidisciplinary approach led by psychiatrist with nonpharmacological and pharmacological interventions as described above in skin picking disorder is warranted.
Dermatitis artefacta (DA) DA is a primary psychiatric disorder, with skin manifestations. The lesions observed are self-induced. DA/ASD (Artefactual Skin Disease) are given a formal DSM-V mental health diagnosis of a Factitious Disorder 300.19. It is a poorly understood condition that can present to different disciplines before a diagnosis is made. Patients are usually referred to the dermatologists (as opposed to mental health services) as they (the patient and family) are often unable to acknowledge the psychosocial basis for their physical disease. Studies suggest that the incidence of DA is approximately 1 in 20000 children. However, this figure is contentious as many cases are under reported or misdiagnosed. DA largely occurs in older children and adolescents with a female preponderance. The entity of DA differs from other factitious disorders such as TTM and Acne Excoriee as in the former the child does not offer any suggestion that the condition is self-induced.
Clinical presentation
Figure 5 Likely aerosol induced blistering.
Many different methods may be used to induce skin damage including application of substances onto or into the skin, sucking (Figure 4), scratching and rubbing.
Clues to the diagnosis of DA C C C C C C C C C C C
Table 3
Figure 4 Suction purpura.
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Lack of detail about how the lesions appear “the hollow history” Indifferent child Extreme parental concern and attention “Sudden” appearance Irregular geometric shapes Lesions on accessible sites Sibling with organic disease or disability taking parents attention Family member with similar disease e.g. gout Possible preceding mild skin disease which gained attention Removal with alchohol wipe. Other somatising symptoms e.g. abdominal pain, functional epileptic fits
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diagnostic clue. Especially, especially if new lesions start appearing elsewhere. Converting a dermatological presentation to a psychological one is fraught with difficulty and may alienate the parents. The popular view, that skin disease is can be triggered by stress, can be employed in this context. Parents may agree to see a counsellor, psychologist or other therapist if told that “skin disease may be triggered by stress”, “people sometimes damage their skin subconsciously if they are stressed”, and “skin disease causes a degree of stress which needs expert help”. Sometimes the child’s difficulty can be identified and addressed directly. Other approaches include anxiety reduction strategies, social skills training, development of a support network at school, and cognitive behaviour therapy. Occasionally psychoactive medication, such as antidepressant, is required. Team work, involving both physician and psychologist, assures the family that the physical symptom is still being dealt with.
Relatives are usually extremely concerned and convinced that the patient is genuinely ill and often take offence at the suggestion that there may be a mental health component to the presentation. The child may simulate skin findings which mimic actual pathology (also known as dermatitis simulata). Here the patient may present acutely with symptoms evolving over a few days which mimic other conditions e.g. gout. These patients do not significantly damage their skin. Lesions are classically seen over accessible areas available to the handedness of the patient. Make up can be used to paint on a rash or simulate a birthmark. This is most common in children. These discolorations can be removed by aqueous or alcohol swabs and analysed if need be. The clinician may be able to uncover that the child has a family member or knows of a person with a similar illness. Any investigation into the organic nature of the illness is unlikely to yield any positive results. If there is a delay in diagnosis as there was in the child in Figure 5, the behaviour becomes entrenched and more challenging to unravel. The girl depicted presented to one of the authors with a ten-year history of blistering eruption over her torso and limbs. She had been investigated extensively and came with a diagnosis of systemic lupus. Previous treatments included immunosuppressants and opioids for her joint pains. She had a Cushingoid appearance secondary to systemic corticosteroids used for treatment. Once a diagnosis of DA was made, it became clear that the immunosuppressants and steroids were not in the patient’s best interest. She was treated by the local dermatologists together with counselling from local psychologists and improved albeit very slowly. The important step in her management was making the diagnosis of DA and deconstructing the use of immunosuppressants. Diagnosing DA can sometimes be a challenge as the skin signs can mimic a variety of possible dermatological diagnosis both clinically and pathologically. Atypical presentations of skin lesions should always give rise to the possibility of DA in the right clinical context. DA is the somatic presentation of significant psychological distress of which the patient themselves may not be aware. Simulating an illness in some instances allows for inappropriate regression and avoidance of adult responsibilities. Over investigating must be avoided as this may inadvertently not only exacerbate skin symptoms, but parents are also more likely to firmly believe that there is an organic skin condition to be treated by physical methods. Organic pathology should therefore be ruled out before a diagnosis of DA is made.
Prognosis Unlike in the adult population, DA in children has a relatively good prognosis. Providing, providing that the psychiatric diagnosis is accepted, and the family accept mental health service intervention. The outcomes of DA depend on the nature of the problem troubling the child, their levels of resilience, and the degree of parental insight and support. DA may represent a shortterm response to a current predicament (caring for younger sibling), a behaviour pattern in a child lacking emotional resilience (persistent unaddressed bullying at school) or a cry for help in an intolerable situation (childhood abuse).
Munchausen’s by proxy This condition, first identified by paediatrician Roy Meadow, is a disturbing form of child abuse and can rarely present in a dermatology setting. In this scenario the parents/carers simulate skin changes (usually for pecuniary gain) in the child. It is a very complicated phenomenon where there can be conflict of interests between the physician, child, and parent. Signs suggestive of this fabricated illness are a child that appears indifferent or exhibits flatness of affect in response to unpleasant procedures. If Munchausen’s by proxy is suspected, then it is empirical that appropriate safeguarding procedures are followed including an urgent referral to social care and police.
Management
Conclusion
We advocate treating the skin symptoms as well as addressing the underlying psychosocial elements in conjunction. A degree of uncertainty often arises when there is no clear precipitating factor in the history, however it is worth communicating to the family that keeping an open mind is essential. Skin directed therapy in the form of bland emollients or short term topical antibiotics for secondarily affected skin may afford the patient some consolation that something is being done to help them. We do not advocate bandaging or occluding the problematic skin unless there is ulceration or skin trauma that is deep. Having said that, rapid healing of previously poor healing ulcers refractory to therapy may prove to be a
The skin and the mind are inextricably linked. Self-induced skin changes, sometimes in association with other unexplained medical symptoms, are common in childhood and often associated with psychological distress. The literature suggests that without early intervention, children who somatise are more likely to develop factitious disorders in adulthood, with the potential for serious self-harm. It is imperative that clinicians dealing with the paediatric population are aware of such behaviour and can sign post patients and their carers to the appropriate service for management. A holistic and multidisciplinary approach is essential to manage these complex children with psycho cutaneous disorders.
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Funding sources None declared.
and serotonin reuptake inhibitors. J Psychiatr Res 2014 Nov; 58: 76e83. https://doi.org/10.1016/j.jpsychires.2014.07.015. Mohandas P, Ravenscroft JC, Bewley A. Dermatitis artefacta in childhood and adolescence: a spectrum of disease. G Ital Dermatol Venereol 2018 Aug; 153. Epub 2018. Murphy YE, Flessner CA. Family functioning in paediatric obsessive compulsive and related disorders. Br J Clin Psychol 2015 Nov; 54: 414e34. https://doi.org/10.1111/bjc.12088. Xu L, Liu KX, Senna MM. A practical approach to the diagnosis and management of hair loss in children and adolescents. Front Med (Lausanne) 2017 Jul 24; 4: 112.
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FURTHER READING Amber B Dunbar, Michelle Magid, Jason S, Reichenberg G. Habit reversal training for body-focused repetitive behaviours: a practical guide for the dermatologist. Ital Dermatol Venereol 2018 August; 153. Bewley Anthony, Taylor Ruth E, Reichenberg Jason S, Michelle Magid. Practical Psychodermatology. Wiley-Blackwell, May 2014; 134e42. McGuire JF, Ung D, Selles RR, et al. Treating trichotillomania: a metaanalysis of treatment effects and moderators for behaviour therapy
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Psychocutaneous disorders in childhood and adolescence
issues than they did 30 years ago. It has been consistently reported in centres with access to integrated mental health services that a multidisciplinary and holistic approach in these children have improved long term outcomes. There is no universally accepted single classification of psycho cutaneous skin diseases and there is significant overlap between entities. Table 1 outlines the most widely accepted classification by Koo and Lee. Psychiatric disorders such as anxiety or depression in children and young people can manifest as self-induced skin conditions such as Trichotillomania, Acne Excoriee or Dermatitis Artefacta. These factitious disorders may be caused in the conscious or dissociated state and are driven by internal psychological stressors. Overall, these conditions are not associated with secondary gain, but are instead driven by the need to satisfy an unmet psychological need. Munchausen’s by proxy and malingering (extremely rare conditions) are exceptions and represent a population of parents or patients who actively seek medical care and intervention for a pecuniary gain. This article will focus on the three main psychiatric disorders with cutaneous manifestations seen in the paediatric population: Trichotillomania, Skin Picking Disorder (incl. Acne Excoriee) and Dermatitis Artefacta.
Padma Mohandas Jothsana Srinivasan Jane Ravenscroft Anthony Bewley
Abstract The adverse impact of skin diseases on an individual’s physical and emotional well-being is well recognised, particularly in children as it is reflected in their growth and development. Conversely, the psychological and psychosocial issues that a child or young person may face, can manifest as a skin problem. Cutaneous manifestations of an underlying primary psychiatric problem are a poorly recognised entity amongst paediatricians. Limited knowledge and experience in this realm increases diagnostic and management challenges. The discipline of Psychodermatology attempts to address these problems by relating skin disease to intrinsic and extrinsic mental health factors. This review summarises the current literature on Psychocutaneous conditions with expert opinion from the authors own experience. The importance of a holistic approach in a multidisciplinary setting to manage this vulnerable group of children and young people cannot be over-emphasised.
Trichotillomania (TTM) Trichotillomania is a self-induced disorder leading to hair loss due to pulling, rubbing or twisting the hair. It is seen as a bodyfocused repetitive behaviour (BFRB) and is listed in the DSM - 5 (Diagnostic and Statistical Manual of Mental Disorders e Fifth Edition) under the category of Obsessive-Compulsive and Related Disorder. Individuals with TTM suffer from a disorder of impulse control driven by an underlying need to reduce tension or stress by pulling hair. The tension reduction serves as a positive reinforcement perpetuating the behaviour. Sufferers tend to conceal both the action and its effects from others because of stigmatization. TTM has a lifetime prevalence of 1e2% and commonly presents between eight and twelve years of age. The risk of depression and anxiety proportionately increases with age in paediatric TTM. These children experience shame, struggle with low self-esteem, and exhibit repeated efforts to conceal hair loss. Individuals with TTM will often avoid pulling in social situations and prefer to pull while alone or engaged in sedentary activities. Pulling may be associated with one or multiple sites. Although some may pull hairs in a specific area, resulting in easily identifiable bald spots, others may distribute their pulling over a larger area, causing thinning of the hair. The latter is more difficult to identify, and sometimes a widespread pattern of pulling is conducted intentionally to conceal hair loss. Triggers for TTM may be. 1. Sensory, i.e. the hair thickness, length or location may cause the individual to pull. 2. Emotional, such as feeling anxious, bored or tense. 3. Cognitive, for example thoughts about their hair and appearance may precipitate the behaviour.
Keywords artefactual skin disease; childhood; dermatitis artefacta; factitious dermatitis; Munchausen’s by proxy; paediatric; skin picking disorder; trichotillomania
Introduction The mind and the skin are inextricably linked as the skin and nervous system are connected through their common embryonic origin, the ectoderm. Psychiatric and psychological factors play different roles in the pathogenic mechanism of skin diseases and this relationship should be acknowledged. Mental health disorders affect up to one in ten children in the U.K. Studies have shown that more children and young people have mental health
Padma Mohandas MRCP MRCGP MSc is a Specialist Registrar Dermatology in the Department of Paediatric Dermatology, Nottingham University Hospital, Nottingham, UK. Conflicts of Interest: none declared. Jothsana Srinivasan MBBS, MRCP(Paed) is a Consultant Paediatrician in the Department of Paediatric Dermatology, Nottingham University Hospital, Nottingham, UK. Conflicts of Interest: none declared. Jane Ravenscroft MBChB (Hons) MRCP is a Consultant Dermatologist in the Department of Paediatric Dermatology, Nottingham University Hospital, Nottingham, UK. Conflicts of Interest: none declared.
Clinical features
Anthony Bewley BA(Hons) FRCP is a Consultant Dermatologist in the Department of Dermatology Barts Health, London, UK. Conflicts of Interest: none declared.
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Hair pulling usually results in patchy areas of hair loss that are irregularly shaped and contain many broken hairs at different
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lengths (see Figure 1& 2). In some cases, TTM patients also pick at the skin around the hair follicles, resulting in inflammation and erythema. Assessment of the patient includes a thorough history with appropriate skin and mental health evaluation. The ‘Kipling method’, also known as the ‘5Ws and 1H’ (who, what, where, when, why and how), is a systematic problemsolving procedure which utilizes a set of questions, the answers to which give helpful information. Careful examination and documentation of each aspect of the problem is crucial. The application of this method has been advocated for approaching conditions in which clinical information may be masked, such as in cases of physical abuse in children. A patient’s age does influence the mechanism of his/her hairpulling. Two distinct types of hairpulling have been described for trichotillomania: automatic and focused. Automatic pulling occurs outside of one’s own awareness, while focused pulling, in contrast, occurs in awareness and in response to negative emotional states (stress, sadness, anger or anxiety), intense thoughts or urges. Children more often fall in the automatic category, and therefore, they do not recall the actual pulling, but may admit to ‘playing with hair’ or they have been noted to pull their hair in a trance-like, disengaged state. The possibility of ‘sleep-isolated trichotillomania’ should be considered as parents may not be aware of this phenomenon. Direct questioning such as ‘have you ever noticed hair on or around your child’s bed?‘, may lead parents to reveal this observation. Similar questioning about visible hair on clothes or on the floor for example could allude to when hairpulling occurs. Family-related issues such as family breakup, domestic arguments, neglect, death of a loved one, individual issues such as starting a new school, bullying and strained teacherestudent relationships may be causative factors. It is very important to talk to the affected child or young person on their own and explore possible abuse (physical, emotional or sexual) and other comorbidities such as mood issues, anxiety, eating and substance misuse. Dermatological assessment begins with examining the type of hair loss to determine whether it is scarring or nonscarring. Intact hair follicles and presence of follicular openings on dermascopic examination indicates nonscarring hair loss and reassures that the hair will regrow once pulling ceases. Scarring occurs when the follicles are permanently damaged from constant stress and
Classification of Psychocutaenous disorders Koo et al Psychophysiological disorders Psoriasis Atopic dermatitis Acne Exocoriee Hyperhidrosis Urticaria Herpes simplex virus infection Seborrheic dermatitis Aphthosis Rosacea Pruritus Psychiatric disorders with dermatologic symptoms Dermatitis artefacta Delusions of parasitosis Trichotillamania Obsessive-compulsive disorder Phobic states Eating disorders Neurotic excoriations Psychogenic pruritus Dermatological disorders with psychiatric symptoms Alopecia areata Vitiligo Generalised psoriasis Chronic eczema Ichthyisoform syndromes Rhinophyma Neurofibroma Albinism Miscellaneous Cutaneous sensory syndromes Glossodynia Vulvodynia Chronic itching in scalp Psychogenic purpura syndrome Pseudopsychodermatologic disease Suicide in dermatology patients Table 1
Figure 1 Unilateral loss of eyebrow.
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Figure 2 Occipital hair loss, hairs of varying lengths.
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sites of involvement are face and back. The “butterfly sign” is a distinctive feature whereby the inability of the patient to reach the central areas of the back results in peripheral skin trauma resembling butterfly wings. Many patients use their fingernails to pick or squeeze lesions. Very rarely implements such as tweezers and needles may be used. Lesions may range from few millimetres to several centimetres in size. Morphology varies from superficial erosions to deep ulceration associated with post inflammatory hypo or hyper pigmentation. Adolescent females may report premenstrual worsening of symptoms. These patients are a heterogeneous group expressing obsessive compulsive traits. In some, picking may be an expression of a generalised anxiety disorder or depression with the activity frequently occurring at night or when unoccupied. It is vital to obtain psychosocial history in these patients. From a psycho dynamic perspective, there are often histories of difficult childhoods with emotional rejection and harsh parenting. Individuals may lack self-confidence and be overly sensitive to criticism. A percentage also have anger management issues which is displaced into self-destructive picking.
trauma. In this case, the follicle openings are covered in scar tissue and the hair will not resume normal growth. The main differentials for TTM include. Alopecia areata characterised by a non-scarring hair loss, exclamation mark hairs and easily detachable strands (positive pull test), unlike in TTM where the broken hairs are firmly anchored in the scalp. Tinea Capitis is characterised by flaky, patchy hair loss which may be scarring or non-scarring depending on the degree of inflammation. Traction alopecia is usually seen in areas of the scalp where there are constant tensile forces on the scalp. In children, marginal hair loss along the temporal hairline is commonly observed, although other patterns can occur depending on hair style. High-risk hairstyling practices include tights buns, ponytails, braids, application of weaves, braids, or hair extensions. Bear in mind that conditions may co-exist, so a careful history is of the essence.
Treatment and prognosis Serotonin reuptake inhibitors (SSRI’s) demonstrated modest treatment effects in recent meta-analysis. Habit reversal therapy (HRT) and Cognitive Behavioural Therapy (CBT) appear to be the most effective treatment options for children with TTM. Increased focused pulling and older age group carries poor long-term prognosis. Post-pulling behaviour must also be ascertained. Whilst some individuals simply discard pulled hairs, others bite and ingest all or parts of the hair. Ingesting hairs can result in undigested masses of hair called trichobezoars. Careful assessment and prompt referral to gastroenterologist is warranted in the presence of abdominal symptoms. If left untreated, complications such as bowel obstruction, intestinal bleeding or rarely perforation can occur.
Differential diagnosis The differentials should include both medical and psychiatric conditions. Medical causes - atopic eczema, urticaria, uraemia, cholestatic hepatitis, scabies, lichen planus [look for oral lesions], xerosis and if predominantly photo distributed it is important to exclude photosensitive disorders such as actinic prurigo. Psychiatric conditions - anxiety, depression, OCD, body dysmorphic disorder, borderline personality disorder and dermatitis artefacta. Recreational drug use like cocaine and cannabis, alcohol consumption should also be enquired about.
Skin picking disorder (SPD)/Acne excoriee Investigations
As many as one fifth of the general population admit to skin picking. Clinically significant SPD ranges from 5 to 8% and is characterised by repetitive and compulsive picking of the skin resulting in tissue damage. Patients feel the urge to disturb the skin and find relief in the activity. Attempts to suppress the urge can cause psychological distress. The picking behaviour may begin inadvertently or manifest in a ritualistic fashion followed by feelings of gratification, relief or pleasure. Some individuals may engage in automatic picking, which occurs without full awareness of the patient devoid of any preceding tension. In such circumstances, there tends to be higher level of emotional dysregulation. It is important to recognise this dissociative state, as these patients need stabilisation and suicide risk assessment. The true extent of this disorder is unknown. SPD may be a manifestation of other disorders such as OCD (Obsessive Compulsive Disorder), genetic disorders like Prader Willi syndrome and Body Dysmorphic Disorder (BDD). Although the condition can present at any age, SPD usually manifests in older children with a distinct female preponderance.
Physical causes of pruritus and skin disease should be looked for and excluded in the first instance (see Table 2).
Management Where possible, patients presenting with SPD/Acne excoriee should be managed in a dedicated psycho dermatology clinic, with the input of dermatologist, psychiatrist, psychologist and dermatology nurse specialist. Assessment of psychosocial morbidities such psychological trauma and stressful life events are important, as these factors have shown to have a direct impact
Suggested investigations for skin picking disorder C
C C C
Clinical features Lesions may arise from pre-existing skin problems like acne or urticated papules or they may be created deenovo. The common
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Blood tests [Full Blood Count/Thyroid Function Test/Liver Function Test/Renal Function Test/Iron/Ferritin/Glucose], HIV serology and protein electrophoresis as clinically indicated. Skin swabs for microscopy and culture. Skin biopsies with immunofluorescence if needed. Other tests such as Chest X eray/CT scans depending on the situation for suspected malignancies.
Table 2
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b. Pharmacological Therapy Obsessive compulsive symptoms as seen in skin picking disorders are associated with Serotonin mediated neural pathways. Antidepressants that selectively block serotonin uptake [SSRI’s] can be of benefit in this group. Commonly used SSRI’s include Citalopram, Sertraline and Fluoxetine. In the paediatric population we would recommend the input of a child psychiatrist to initiate and monitor response.
on skin barrier function and immune response. There is numerous disease specific [SPS-Skin picking Scale, Y-BOCS-Yale Brown Obsessive Compulsive Scale] and general quality of life scales such as the CDLQI [Childrens Dermatology Life Quality Index] and HAD [Hospital Anxiety and Depression] that assess stress and the impact on the skin. They are useful as an objective measure of evaluating health related quality of life, suffering from skin problems. Our experience of evaluation in a joint psycho-dermatology clinic is that psychiatric assessment can be conducted progressively over time. The patient’s issues are viewed holistically from the outset, with rapport building between the patient, dermatologist and psychiatrist as sessions unfold. 1. Communication As with all psycho dermatological conditions patients should be dealt in a non -confrontational manner. Fostering a positive relationship by empathising with their condition is important. It may also be helpful to explain that although the actual reason for their symptoms is not clearly understood, there are strategies that can be employed which can change the way the skin and brain process the signals it receives. 2. Treatment of Skin Picking Disorder a. Topical: Treatment is based on symptom severity. For example, if pruritus is an issue, preparations of Menthol containing emollients may be useful [e.g. in Menthol in Aqueous Cream] or 5% Doxepin cream. Cool compresses can be helpful to remove crusting and to soothe the skin. Emollients [patient preference to be considered] with or without antiseptics can also be suggested to improve hydration, and thereby reducing sensation of itch. Adopting a positive approach in dealing with skin issues helps enormously as patients invariably become upset if the cutaneous component of their condition is overlooked. Topical/Intralesional steroids/tape to address the inflammatory component of existing lesions can be used as adjunct for chronic or non-healing lesions. b. Systemic Therapy [i] Physical Phototherapy [TL01] whole body or localised, can be used with good results especially in cases where widespread itching is a feature (e.g.: poorly controlled atopic eczema). Immunomodulatory and anti-inflammatory effects of phototherapy lead to itch reduction and improvement of the underlying dermatitis. [ii] Pharmacotherapeutics Oral Tetracyclines [Lymecycline or Doxycycline in the older children] have been tried with benefit in view of their antiinflammatory and antibiotic effects. Treatment courses tend to last for weeks or months depending on the response. Conventional sedative antihistamines such as Hydroxyzine or Chlorpheniramine maleate [Piriton] can help with itching. 3. Psychological and Psychiatric Interventions a. Non-Pharmacological Therapy Counselling can be beneficial in patients where psychosocial stressors have precipitated or perpetuated their skin problem [e.g. bullying at school, breakdown, bereavement]. Cognitive behavioural therapy [CBT] can be very effective for patients with OCD, and who are willing to engage with their psychologist.
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Prognosis Prognosis is influenced by predisposing factors, such as a premorbid anxious personality, other personality disorder or childhood traumas [physical or emotional abuse]. Precipitants such as stressful life events [e.g. bereavement]. Perpetuating factors e.g. poverty and social isolation. The average duration of illness is reported to be around 5e8 years with relapses and remissions that parallel stressful situations.
e Acne excorie Acne excoriee is a self-inflicted skin condition which is thought to be a subset of SPD where the picking or scratching is directed at real or imagined acne lesions. The condition differs from other artefactual dermatoses in that the patient usually admits the selfinflicted nature of the condition. Social embarrassment prevents patients from seeking help. When managing this group of patients, the mechanism of picking is usually not stressed upon, as it is the underlying psychosocial issue that is of importance. Given the high co-morbidity of skin picking with other psychiatric disorders, clinicians should enquire about the cutaneous and psychiatric symptoms when either is found to be present. Acne excoriee is most often seen in young women hence the description “des jeunes filles”.
Clinical features Individuals with acne excoriee usually have some form of acne existing on the face, chest or back. Lesions can range from superficial excoriations [Figure 3] to deep gouges. Scarring post inflammatory hyper and hypo pigmentation are common. As in other SPD’s women may report pre-menstrual flare of their lesions and picking habits. Many patients have underlying anxiety and or depression as co-morbidities. Other psychiatric diagnoses to
Figure 3 Excoriated papules on forehead of a young girl.
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Children can present with a myriad of skin lesions ranging from very superficial (and sometimes obvious) skin pigment changes, to lesions that mimic organic skin disease so closely that they may deceive the clinician for years (Figure 5). Establishing the diagnosis is often a challenge but clues from the consultation can help towards making an accurate diagnosis. Table 3 outlines the salient features in the history and examination that may prompt a diagnosis of DA. The indifferent child, also coined as “la belle indifference” is seen in children with conversion disorders (otherwise known as functional neurological symptom disorder). Patients and their relatives may consume huge amount of time and medical resources to seek the cause and resolution of the ‘problem.’
consider are Post Traumatic Stress Disorder [PTSD], Obsessive Compulsive Disorder [OCD] and Body Dysmorphic Disorder [BDD].
Management 1. Treatment of Skin Disease (a) Topical Treatments: Skin treatment modalities include topical antibiotics [Duac/Zineryt], topical retinoids in singular or combination therapy. (b) Systemic Therapy; For mild to moderate papulo pustular acne, oral antibiotics can be useful. Anti-androgen treatment, anti-androgen contraceptives such as Dianette can be considered for pre-menstrual flares in young adults. Low doses of isotretinoin [less than 0.5 mg/kg body weight] over a period of 12e18 months may be beneficial in selected cases [with concomitant psychological/psychiatric input]. 2. Psychological and Psychiatric Interventions: A multidisciplinary approach led by psychiatrist with nonpharmacological and pharmacological interventions as described above in skin picking disorder is warranted.
Dermatitis artefacta (DA) DA is a primary psychiatric disorder, with skin manifestations. The lesions observed are self-induced. DA/ASD (Artefactual Skin Disease) are given a formal DSM-V mental health diagnosis of a Factitious Disorder 300.19. It is a poorly understood condition that can present to different disciplines before a diagnosis is made. Patients are usually referred to the dermatologists (as opposed to mental health services) as they (the patient and family) are often unable to acknowledge the psychosocial basis for their physical disease. Studies suggest that the incidence of DA is approximately 1 in 20000 children. However, this figure is contentious as many cases are under reported or misdiagnosed. DA largely occurs in older children and adolescents with a female preponderance. The entity of DA differs from other factitious disorders such as TTM and Acne Excoriee as in the former the child does not offer any suggestion that the condition is self-induced.
Clinical presentation
Figure 5 Likely aerosol induced blistering.
Many different methods may be used to induce skin damage including application of substances onto or into the skin, sucking (Figure 4), scratching and rubbing.
Clues to the diagnosis of DA C C C C C C C C C C C
Table 3
Figure 4 Suction purpura.
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Lack of detail about how the lesions appear “the hollow history” Indifferent child Extreme parental concern and attention “Sudden” appearance Irregular geometric shapes Lesions on accessible sites Sibling with organic disease or disability taking parents attention Family member with similar disease e.g. gout Possible preceding mild skin disease which gained attention Removal with alchohol wipe. Other somatising symptoms e.g. abdominal pain, functional epileptic fits
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diagnostic clue. Especially, especially if new lesions start appearing elsewhere. Converting a dermatological presentation to a psychological one is fraught with difficulty and may alienate the parents. The popular view, that skin disease is can be triggered by stress, can be employed in this context. Parents may agree to see a counsellor, psychologist or other therapist if told that “skin disease may be triggered by stress”, “people sometimes damage their skin subconsciously if they are stressed”, and “skin disease causes a degree of stress which needs expert help”. Sometimes the child’s difficulty can be identified and addressed directly. Other approaches include anxiety reduction strategies, social skills training, development of a support network at school, and cognitive behaviour therapy. Occasionally psychoactive medication, such as antidepressant, is required. Team work, involving both physician and psychologist, assures the family that the physical symptom is still being dealt with.
Relatives are usually extremely concerned and convinced that the patient is genuinely ill and often take offence at the suggestion that there may be a mental health component to the presentation. The child may simulate skin findings which mimic actual pathology (also known as dermatitis simulata). Here the patient may present acutely with symptoms evolving over a few days which mimic other conditions e.g. gout. These patients do not significantly damage their skin. Lesions are classically seen over accessible areas available to the handedness of the patient. Make up can be used to paint on a rash or simulate a birthmark. This is most common in children. These discolorations can be removed by aqueous or alcohol swabs and analysed if need be. The clinician may be able to uncover that the child has a family member or knows of a person with a similar illness. Any investigation into the organic nature of the illness is unlikely to yield any positive results. If there is a delay in diagnosis as there was in the child in Figure 5, the behaviour becomes entrenched and more challenging to unravel. The girl depicted presented to one of the authors with a ten-year history of blistering eruption over her torso and limbs. She had been investigated extensively and came with a diagnosis of systemic lupus. Previous treatments included immunosuppressants and opioids for her joint pains. She had a Cushingoid appearance secondary to systemic corticosteroids used for treatment. Once a diagnosis of DA was made, it became clear that the immunosuppressants and steroids were not in the patient’s best interest. She was treated by the local dermatologists together with counselling from local psychologists and improved albeit very slowly. The important step in her management was making the diagnosis of DA and deconstructing the use of immunosuppressants. Diagnosing DA can sometimes be a challenge as the skin signs can mimic a variety of possible dermatological diagnosis both clinically and pathologically. Atypical presentations of skin lesions should always give rise to the possibility of DA in the right clinical context. DA is the somatic presentation of significant psychological distress of which the patient themselves may not be aware. Simulating an illness in some instances allows for inappropriate regression and avoidance of adult responsibilities. Over investigating must be avoided as this may inadvertently not only exacerbate skin symptoms, but parents are also more likely to firmly believe that there is an organic skin condition to be treated by physical methods. Organic pathology should therefore be ruled out before a diagnosis of DA is made.
Prognosis Unlike in the adult population, DA in children has a relatively good prognosis. Providing, providing that the psychiatric diagnosis is accepted, and the family accept mental health service intervention. The outcomes of DA depend on the nature of the problem troubling the child, their levels of resilience, and the degree of parental insight and support. DA may represent a shortterm response to a current predicament (caring for younger sibling), a behaviour pattern in a child lacking emotional resilience (persistent unaddressed bullying at school) or a cry for help in an intolerable situation (childhood abuse).
Munchausen’s by proxy This condition, first identified by paediatrician Roy Meadow, is a disturbing form of child abuse and can rarely present in a dermatology setting. In this scenario the parents/carers simulate skin changes (usually for pecuniary gain) in the child. It is a very complicated phenomenon where there can be conflict of interests between the physician, child, and parent. Signs suggestive of this fabricated illness are a child that appears indifferent or exhibits flatness of affect in response to unpleasant procedures. If Munchausen’s by proxy is suspected, then it is empirical that appropriate safeguarding procedures are followed including an urgent referral to social care and police.
Management
Conclusion
We advocate treating the skin symptoms as well as addressing the underlying psychosocial elements in conjunction. A degree of uncertainty often arises when there is no clear precipitating factor in the history, however it is worth communicating to the family that keeping an open mind is essential. Skin directed therapy in the form of bland emollients or short term topical antibiotics for secondarily affected skin may afford the patient some consolation that something is being done to help them. We do not advocate bandaging or occluding the problematic skin unless there is ulceration or skin trauma that is deep. Having said that, rapid healing of previously poor healing ulcers refractory to therapy may prove to be a
The skin and the mind are inextricably linked. Self-induced skin changes, sometimes in association with other unexplained medical symptoms, are common in childhood and often associated with psychological distress. The literature suggests that without early intervention, children who somatise are more likely to develop factitious disorders in adulthood, with the potential for serious self-harm. It is imperative that clinicians dealing with the paediatric population are aware of such behaviour and can sign post patients and their carers to the appropriate service for management. A holistic and multidisciplinary approach is essential to manage these complex children with psycho cutaneous disorders.
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Funding sources None declared.
and serotonin reuptake inhibitors. J Psychiatr Res 2014 Nov; 58: 76e83. https://doi.org/10.1016/j.jpsychires.2014.07.015. Mohandas P, Ravenscroft JC, Bewley A. Dermatitis artefacta in childhood and adolescence: a spectrum of disease. G Ital Dermatol Venereol 2018 Aug; 153. Epub 2018. Murphy YE, Flessner CA. Family functioning in paediatric obsessive compulsive and related disorders. Br J Clin Psychol 2015 Nov; 54: 414e34. https://doi.org/10.1111/bjc.12088. Xu L, Liu KX, Senna MM. A practical approach to the diagnosis and management of hair loss in children and adolescents. Front Med (Lausanne) 2017 Jul 24; 4: 112.
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FURTHER READING Amber B Dunbar, Michelle Magid, Jason S, Reichenberg G. Habit reversal training for body-focused repetitive behaviours: a practical guide for the dermatologist. Ital Dermatol Venereol 2018 August; 153. Bewley Anthony, Taylor Ruth E, Reichenberg Jason S, Michelle Magid. Practical Psychodermatology. Wiley-Blackwell, May 2014; 134e42. McGuire JF, Ung D, Selles RR, et al. Treating trichotillomania: a metaanalysis of treatment effects and moderators for behaviour therapy
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Please cite this article in press as: Mohandas P, et al., Psychocutaneous disorders in childhood and adolescence, Paediatrics and Child Health (2018), https://doi.org/10.1016/j.paed.2018.10.004