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Psychocutaneous Diseases
AClinical Dermatological Approach
Gianni Angelini Domenico Bonamonte Anna Belloni Fortina Iria Neri Luca Stingeni
Editors
123
Psychocutaneous Diseases
Gianni Angelini • Domenico Bonamonte Anna BelloniFortina • Iria Neri • Luca Stingeni
Editors
Psychocutaneous Diseases
A Clinical Dermatological Approach
Editors
Gianni Angelini Professor of Dermatology University “Aldo Moro” Bari, Italy
Anna BelloniFortina 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 AG 2024 This work is subject to copyright. All rights are solely and exclusively licensed by the Publisher, whether the whole or part of the material is concerned, specically the rights of translation, reprinting, reuse of illustrations, recitation, broadcasting, reproduction on microlms or in any other physical way, and transmission or information storage and retrieval, electronic adaptation, computer software, or by similar or dissimilar methodology now known or hereafter developed. The use of general descriptive names, registered names, trademarks, service marks, etc. in this publication does not imply, even in the absence of a specic statement, that such names are exempt from the relevant protective laws and regulations and therefore free for general use. The publisher, the authors and the editors are safe to assume that the advice and information in this book are believed to be true and accurate at the date of publication. Neither the publisher nor the authors or the editors give a warranty, expressed or implied, with respect to the material contained herein or for any errors or omissions that may have been made. The publisher remains neutral with regard to jurisdictional claims in published maps and institutional afliations.
This Springer imprint is published by the registered company Springer Nature Switzerland AG The registered company address is: Gewerbestrasse 11, 6330 Cham, Switzerland
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 simplied 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 classication 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
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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 GianniAngelini Bari, Italy DomenicoBonamonte Padova, Italy AnnaBelloniFortina Bologna, Italy IriaNeri Perugia, Italy LucaStingeni

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 Denition . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 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 Inammatory 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 Classication . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 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-Inicted Disorders in Dermatology . . . . . . . . . . . . . . . . . . . . . 28
3.3 Classication and Incidence . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29
3.4 Diagnostic Criteria . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30
3.4.1 Site . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30
3.4.2 Morphology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31
3.4.3 Lesions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31
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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 BelloniFortina 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
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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