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X
- •Preface
- •Acknowledgments
- •Contents
- •Contributors
- •1.5 Pathophysiology
- •1.5.1 The HPA Axis
- •1.5.2 SAM Axis
- •1.7 Treatment
- •References
- •2.2 Management: General Remarks
- •1.5.3 Microbiota-Gut-Brain-Skin Axis
- •1.6 Assessment
- •References
- •3.1 General Clinical Remarks
- •3.4 Diagnostic Criteria
- •3.4.1 Site
- •3.4.2 Morphology
- •3.4.3 Lesions
- •3.4.4 Complementary Tests
- •3.4.5 Clinical Course
- •3.5 Aetiological Agents
- •3.6 Concluding Diagnostic Remarks
- •3.7 Management
- •3.7.1 Assessment
- •3.7.2 Treatment Approach
- •3.7.2.1 Dermatological Treatment
- •3.7.2.2 Psychiatric Treatment
- •3.8 Conclusions
- •References
- •4.1 Diagnostic Clues
- •4.3 Dermatitis Artefacta
- •4.3.1 Aetiopathogenesis
- •4.3.2 Clinical Features
- •4.3.3 Differential Diagnosis
- •4.4 Dermatitis Simulata
- •4.5 Dermatitis Passivata
- •4.6 Dermatological Pathomimicry
- •4.7 Gardner-Diamond Syndrome
- •4.8 Purpura Factitia
- •4.9 Morgellons Syndrome
- •4.10 Münchausen Syndrome
- •4.11 Münchausen Syndrome by Proxy
- •References
- •5.1 Malingering
- •5.1.1 General Remarks
- •5.2 Occupational Dermatitis Artefacta
- •5.4 Witchcraft Syndrome
- •5.5 Secrétan Syndrome
- •5.6 Religious Stigmata
- •5.6.1 General Remarks
- •References
- •6.2 Excoriation Disorders
- •6.3 Trichotillomania (Hair-Pulling Disorder)
- •6.4 Delusional Disorder Somatic Type
- •6.5 Body-Focused Repetitive Behavior Disorder (BFRB)
- •6.6 Body Dysmorphic Disorder (BDD) or Dysmorphophobia
- •6.7 Eating Disorder (ED)
- •6.8 Olfactory Reference Syndrome (ORS)
- •References
- •7.1 Introduction
- •7.1.1 Psychogenic Pruritus
- •7.1.2 Diagnosis
- •7.2 Treatment
- •7.2.1 Prurigo Nodularis
- •7.4.1 Lichen Simplex
- •7.4.2 Acne excoriée
- •7.4.3 Trichotillomania
- •7.5 Risk Factors
- •7.6 Diagnosis
- •7.6.1 Trichotemnomania
- •7.6.2 Trichoteiromania
- •7.6.3 Onychophagia
- •7.6.4 Onychotillomania
- •7.6.5 Factitious Cheilitis
- •7.6.6 Morsicatio Buccarum
- •7.6.7 Pseudo-Knuckle Pads
- •References
- •8.1 Atopic Dermatitis
- •8.2 Psoriasis
- •8.3 Seborrheic Dermatitis
- •8.4 Alopecia Areata
- •8.6 Hyperhidrosis
- •8.9 Aphthosis
- •References
- •9.1 Sick Building Syndrome
- •9.2 Epidemic Hysteria
- •References
- •10.2.2.6 Stabs
- •10.2.2.8 Electrocution
- •10.1 Introduction
- •10.2.1 Forensic Assessment
- •10.2.1.1 Informed Consent
- •10.2.1.2 Case History
- •10.2.1.3 Collecting Pictures
- •10.2.1.4 Clothes Examination
- •10.2.2 Wounds Examination
- •10.2.2.1 Abrasions
- •10.2.2.2 Bruises
- •10.2.2.3 Lacerations
- •10.2.2.4 Cuts
- •10.2.2.5 Chops
- •10.3.2 Defense Wounds
- •10.3.3 Suspected Child Abuse
- •10.3.3.2 Bite Marks
- •10.3.4 Neglect
- •10.4.1 Pathomimesis
- •10.4.2 Malingering
- •10.5 Practical Tips
- •References
- •Index

Psychocutaneous
Diseases
AClinical Dermatological
Approach
Gianni Angelini
Domenico Bonamonte
Anna Belloni Fortina
Iria Neri
Luca Stingeni
Editors
123

Psychocutaneous Diseases

Gianni Angelini • Domenico Bonamonte
Anna BelloniFortina • Iria Neri • Luca Stingeni
Editors
Psychocutaneous Diseases
A Clinical Dermatological Approach

Editors
Gianni Angelini
Professor of Dermatology
University “Aldo Moro”
Bari, Italy
Anna BelloniFortina
Professor of Dermatology and Venereology,
Department of Women’s and Child’s Health
University of Padua
Padova, Italy
Luca Stingeni
Department of Medicine and Surgery
University of Perugia
Perugia, Italy
Domenico Bonamonte
Unit of Dermatology, Department
of Precision and Regenerative Medicine
and Ionian Area
A.O.U.C.Policlinico of Bari– University
“Aldo Moro”
Bari, Italy
Iria Neri
Dermatology Unit
Policlinic S.Orsola-Malpighi
Bologna, Italy
ISBN 978-3-031-70295-2 ISBN 978-3-031-70296-9 (eBook)
https://doi.org/10.1007/978-3-031-70296-9
© The Editor(s) (if applicable) and The Author(s), under exclusive license to Springer Nature Switzerland
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If disposing of this product, please recycle the paper.

Preface
Psychocutaneous disorders represent one of the most challenging problems in clinical medicine. Recent studies have shown that 35–40% of dermatological patients
have psychiatric/psychological comorbidities that impact the outcome of their skin
disease.
The skin and central nervous system arise from the same embryonal tissue, the
ectoderm, which is the reason for the continual two-way interaction between the
skin and the psyche. Adopting a highly simplied model, the diseases that involve
skin and psyche can be grouped as follows: “somatopsychic” disorders (when the
body is primarily involved, and mental disturbances are a consequence of the psychical damage) and “psychosomatic” disorders (when psychological or psychiatric
disorders lie at the origin of the problem, while the somatic disturbances are the
secondary effect).
Undoubtedly, psychocutaneous diseases are in the great majority of cases correlated to mental disorders, and so they are generally included among psychiatric
disorders. This is also because the treatment primarily targets the mental rather than
the dermatological problem. Despite these valid reasons, in this work we have preferred to adopt a classication that highlights the dermatological aspect of the problem, starting from the various skin pictures that can, in turn, be induced by or else
induce psychiatric or psychological disturbances.
The management of patients with psychocutaneous disorders is quite challenging: a joint liaison between psychiatry and dermatology (that has led to the origin of
psychodermatology), however, has proven very helpful to patients.
The purpose of this work, resulting in decades of eld experience and of the joint
efforts of both dermatologists and psychiatrists, is to clarify the terminology of
these disorders and, above all, to analyze their clinical characteristics in detail, the
rst and pivotal sign of suspicion and diagnosis. The topic is completed by the addition of chapters by psychiatric specialists, in order to address pathogenetic problems and therapeutic guidelines, as well as contributions that integrate the approach
with medico-legal expertise. It is hoped that this manual will offer a helpful tool for
v

vi
Preface
dermatologists, psychologists, psychiatrists and forensic doctors, will provide a
handy update on this complex medical area, and in particular, an in-depth analysis
of the clinical aspects of this important eld of psychodermatology.
Bari, Italy GianniAngelini
Bari, Italy DomenicoBonamonte
Padova, Italy AnnaBelloniFortina
Bologna, Italy IriaNeri
Perugia, Italy LucaStingeni

Acknowledgments
This book has been produced, thanks to the valuable contributions of colleagues,
infantile neuropsychiatrists, and forensic doctors, to whom we extend our sincerest
gratitude.
We would like to thank the publishers Springer-Verlag (Berlin) and Edizioni
Minerva Medica (Turin, Italy), editor of the Italian Journal of Dermatology and
Venereology, John Wiley & Sons A/S, editor of the journal Contact Dermatitis, and
Lippincott Williams & Wilkins, editor of the journal Medicine (Baltimore), for
kindly authorizing the reproduction of various gures.
Finally, we are grateful to Springer-Verlag for their assiduous commitment to
producing this volume.
Gianni Angelini, M.D.
Domenico Bonamonte, M.D., Ph.D.
Anna Belloni Fortina, M.D.
Iria Neri, M.D.
Luca Stingeni, M.D.
vii

Contents
1 Psychodermatology: When Psyche and Skin Interact . . . . . . . . . . . . . 1
Lucia Margari, Alessandra Gabellone, Lucia Marzulli,
Emilia Matera, and Maria Giuseppina Petruzzelli
1.1 Denition . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
1.2 History of Psychodermatology . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2
1.3 Fields of Interest of Psychodermatology . . . . . . . . . . . . . . . . . . . . . 3
1.4 Current Subspecialties in Psychodermatology . . . . . . . . . . . . . . . . . 3
1.5 Pathophysiology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4
1.5.1 The HPA Axis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6
1.5.2 SAM Axis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6
1.5.3 Microbiota-Gut-Brain-Skin Axis . . . . . . . . . . . . . . . . . . . . . 8
1.5.4 Immune and Inammatory Dysregulation . . . . . . . . . . . . . . 8
1.6 Assessment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
1.7 Treatment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10
1.8 Conclusion and Future Direction . . . . . . . . . . . . . . . . . . . . . . . . . . . 11
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11
2 Psychocutaneous Diseases . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15
Gianni Angelini, Aurora De Marco, and Domenico Bonamonte
2.1 Classication . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16
2.2 Management: General Remarks . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20
3 Self-Inflicted Skin Disorders: Diagnosis and Management . . . . . . . . 25
Gianni Angelini, Aurora De Marco, and Domenico Bonamonte
3.1 General Clinical Remarks . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25
3.2 Self-Inicted Disorders in Dermatology . . . . . . . . . . . . . . . . . . . . . 28
3.3 Classication and Incidence . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29
3.4 Diagnostic Criteria . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30
3.4.1 Site . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30
3.4.2 Morphology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31
3.4.3 Lesions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31
ix

x
Contents
3.4.4 Complementary Tests . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36
3.4.5 Clinical Course. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 42
3.5 Aetiological Agents . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 44
3.6 Concluding Diagnostic Remarks . . . . . . . . . . . . . . . . . . . . . . . . . . . 45
3.7 Management . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 45
3.7.1 Assessment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 45
3.7.2 Treatment Approach . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 46
3.8 Conclusions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 48
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 48
4 Factitious Skin Disorders Without External Incentives . . . . . . . . . . . 55
Domenico Bonamonte, Aurora De Marco, and Gianni Angelini
4.1 Diagnostic Clues . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 56
4.2 Management and Prognosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 57
4.3 Dermatitis Artefacta . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 57
4.3.1 Aetiopathogenesis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 58
4.3.2 Clinical Features . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 59
4.3.3 Differential Diagnosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 63
4.3.4 Dermatitis Artefacta in Children . . . . . . . . . . . . . . . . . . . . . 64
4.4 Dermatitis Simulata . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 77
4.5 Dermatitis Passivata . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 77
4.6 Dermatological Pathomimicry . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 78
4.7 Gardner-Diamond Syndrome . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 78
4.8 Purpura Factitia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 80
4.9 Morgellons Syndrome . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 81
4.10 Münchausen Syndrome . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 82
4.11 Münchausen Syndrome by Proxy . . . . . . . . . . . . . . . . . . . . . . . . . . 84
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 85
5 Factitious Skin Disorders with External Incentives . . . . . . . . . . . . . . . 93
Domenico Bonamonte, Aurora De Marco, and Gianni Angelini
5.1 Malingering . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 93
5.1.1 General Remarks . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 93
5.1.2 Malingering in Adolescents . . . . . . . . . . . . . . . . . . . . . . . . . 96
5.1.3 Malingering in Soldiers . . . . . . . . . . . . . . . . . . . . . . . . . . . . 97
5.2 Occupational Dermatitis Artefacta . . . . . . . . . . . . . . . . . . . . . . . . . . 98
5.3 Dermatitis Artefacta with Patch Test Artefacts . . . . . . . . . . . . . . . . 105
5.4 Witchcraft Syndrome . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 107
5.5 Secrétan Syndrome . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 110
5.6 Religious Stigmata . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 114
5.6.1 General Remarks . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 114
5.6.2 Religious Stigmata as Malingering Artefacts . . . . . . . . . . . 116
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 119

Contents
6 Psychocutaneous Diseases in Children: A Clinical
Dermatological Approach . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 125
Marco Adriano Chessa, Annalucia Virdi, and Iria Neri
6.1 Factitious Disorder Imposed on Self or Another . . . . . . . . . . . . . . . 126
6.2 Excoriation Disorders . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 128
6.3 Trichotillomania (Hair-Pulling Disorder) . . . . . . . . . . . . . . . . . . . . 129
6.4 Delusional Disorder Somatic Type . . . . . . . . . . . . . . . . . . . . . . . . . 130
6.5 Body-Focused Repetitive Behavior Disorder (BFRB). . . . . . . . . . . 131
6.6 Body Dysmorphic Disorder (BDD) or Dysmorphophobia . . . . . . . 133
6.7 Eating Disorder (ED) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 135
6.8 Olfactory Reference Syndrome (ORS) . . . . . . . . . . . . . . . . . . . . . . 137
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 137
7 Compulsive Skin Disorders . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 141
Anna BelloniFortina and Francesca Caroppo
7.1 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 141
7.1.1 Psychogenic Pruritus . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 142
7.1.2 Diagnosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 143
7.2 Treatment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 144
7.2.1 Prurigo Nodularis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 144
7.3 Diagnosis and Pathophysiology . . . . . . . . . . . . . . . . . . . . . . . . . . . . 145
7.4 Treatment and Management . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 145
7.4.1 Lichen Simplex . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 146
7.4.2 Acne excoriée . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 147
7.4.3 Trichotillomania . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 147
7.5 Risk Factors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 148
7.6 Diagnosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 148
7.6.1 Trichotemnomania . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 149
7.6.2 Trichoteiromania . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 149
7.6.3 Onychophagia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 150
7.6.4 Onychotillomania . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 150
7.6.5 Factitious Cheilitis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 151
7.6.6 Morsicatio Buccarum . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 152
7.6.7 Pseudo-Knuckle Pads . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 152
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 153
xi
8 Cutaneous Diseases Precipitated or Perpetuated by
Emotional Factors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 157
Luca Stingeni, Katharina Hansel, and Elisa Cecchini
8.1 Atopic Dermatitis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 157
8.2 Psoriasis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 159
8.3 Seborrheic Dermatitis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 162
8.4 Alopecia Areata . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 163
8.5 Flushing and Rosacea . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 164
8.6 Hyperhidrosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 165
8.7 Urticaria and Angioedema . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 167
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