Elisabeth H. Tracey, MD

Hidradenitis suppurativa (HS) is a common and debilitating inflammatory disorder of the pilosebaceous unit that presents with recurrent scarring inflammatory nodules and sinus tracts in the intertriginous folds of the body. It is a complex condition that requires multimodal management to address the medical, surgical, and psychosocial needs of affected patients. However, it can be difficult to coordinate all that goes into HS management beyond the standard therapeutic ladder of topical and oral antimicrobials, intralesional corticosteroids, biologics, and surgery. In this article, I will outline 5 important aspects of HS treatment that often are overlooked.

Talk About Pathophysiology

Patients with HS often have limited understanding of their condition. One common misperception is that HS is an infectious disease and that disease activity is associated with poor hygiene.¹ Dispelling this myth may help patients avoid unnecessary hygiene practices, decrease perceived stigma, and enhance your therapeutic alliance.

The current model of HS pathophysiology implicates an aberrant inflammatory response to the cutaneous bacterial microbiome, which leads to follicular occlusion and then rupture of debris and bacteria into the surrounding dermis. Immune cells and inflammatory mediators such as nuclear factor κB and tumor necrosis factor α respond to the disruption. Chronic lesions develop due to tissue repair with scarring and re-epithelialization.^2,3 Although most patients probably are not interested in the esoteric details, I typically make a point of explaining to patients that HS is a chronic inflammatory disease and provide reassurance that it is not a sign of poor hygiene. 

Counsel on Smoking Cessation

Most HS patients use tobacco. As many as 75% of HS patients are active smokers and another 10% to 15% are former smokers. Although there is mixed evidence that disease activity correlates with smoking status, the Hidradenitis Suppurativa Foundation in the United States and Canada concluded in the 2019 North American Clinical Management Guidelines for Hidradenitis Suppurativa that due to the overall health risks of smoking, we should recommend cessation to our patients.⁴

Laser Hair Removal Works

Don’t forget about laser hair removal! Evidence from randomized controlled trials supports the use of the Nd:YAG laser in the treatment of HS. Treat the entire affected anatomic area and use stacked double pulses on active nodules (typical settings: 10-mm spot size; 10-millisecond pulse duration and 35–50 J/cm² in Fitzpatrick skin types I–III; 20-millisecond pulse duration and 25–40 J/cm² in Fitzpatrick skin types IV–VI).⁴ Especially if it is covered by your patient’s insurance, Nd:YAG is a great adjunctive treatment to consider. The guidelines also recommend long-pulsed alexandrite and diode lasers as well as intense pulsed light, all of which result in follicular destruction, though these treatments have less supporting evidence.⁴

Have a Plan for Flares

Intralesional injection of triamcinolone is a mainstay of HS treatment and provides patients with rapid relief of symptoms during a flare.⁵ One case series found that there was a notable decrease in pain, size, and drainage after just 1 day of treatment with intralesional triamcinolone 10 mg/mL (0.2–2.0 mL).⁶

Intralesional steroid injection is a great tool for quieting an active disease flare while simultaneously instating ongoing treatment for preventive management. However, even when disease control is optimized, patients may still experience intermittent flares of disease. For some patients, it may be appropriate to have a plan in place for a return to clinic during the beginning of a flare to obtain intralesional steroids. The ability to come in on short notice may help avoid visits to the emergency department and urgent care where your patients may receive treatments such as short courses of antibiotics or incision and drainage that may deviate from your overall treatment plan.

Consider Childbearing Status

Don’t forget to consider childbearing plans and childbearing potential when treating female patients with HS. Pregnancy is a frequent consideration in HS patients, as HS affects 3 to 4 times more women than men and typically presents after puberty (second or third decades of life). Many of the medications in the HS armamentarium are contraindicated in pregnancy including tetracyclines, retinoids, and hormonal agents. Surgery should be avoided in pregnant patients whenever possible, particularly in the first trimester. Relatively safe options include topical antibiotics such as clindamycin and metronidazole, as well as tumor necrosis factor α inhibitors, which are classified as category B in pregnancy.⁵

Before making treatment decisions in pregnant and breastfeeding patients, consult the US Food and Drug Administration recommendations. Perng et al⁷ reviewed current management strategies for HS in pregnant and breastfeeding women, and their review article in the Journal of the American Academy of Dermatology is an excellent resource.

Final Thoughts

Comprehensive management of HS may include a combination of medication and procedures, lifestyle modification, management of comorbidities, and social support. Formulating a good treatment plan may be a challenge but can drastically improve your patient’s quality of life.

Hidradenitis suppurativa (HS) is a common and debilitating inflammatory disorder of the pilosebaceous unit that presents with recurrent scarring inflammatory nodules and sinus tracts in the intertriginous folds of the body. It is a complex condition that requires multimodal management to address the medical, surgical, and psychosocial needs of affected patients. However, it can be difficult to coordinate all that goes into HS management beyond the standard therapeutic ladder of topical and oral antimicrobials, intralesional corticosteroids, biologics, and surgery. In this article, I will outline 5 important aspects of HS treatment that often are overlooked.

Talk About Pathophysiology

Patients with HS often have limited understanding of their condition. One common misperception is that HS is an infectious disease and that disease activity is associated with poor hygiene.¹ Dispelling this myth may help patients avoid unnecessary hygiene practices, decrease perceived stigma, and enhance your therapeutic alliance.

The current model of HS pathophysiology implicates an aberrant inflammatory response to the cutaneous bacterial microbiome, which leads to follicular occlusion and then rupture of debris and bacteria into the surrounding dermis. Immune cells and inflammatory mediators such as nuclear factor κB and tumor necrosis factor α respond to the disruption. Chronic lesions develop due to tissue repair with scarring and re-epithelialization.^2,3 Although most patients probably are not interested in the esoteric details, I typically make a point of explaining to patients that HS is a chronic inflammatory disease and provide reassurance that it is not a sign of poor hygiene. 

Counsel on Smoking Cessation

Most HS patients use tobacco. As many as 75% of HS patients are active smokers and another 10% to 15% are former smokers. Although there is mixed evidence that disease activity correlates with smoking status, the Hidradenitis Suppurativa Foundation in the United States and Canada concluded in the 2019 North American Clinical Management Guidelines for Hidradenitis Suppurativa that due to the overall health risks of smoking, we should recommend cessation to our patients.⁴

Laser Hair Removal Works

Don’t forget about laser hair removal! Evidence from randomized controlled trials supports the use of the Nd:YAG laser in the treatment of HS. Treat the entire affected anatomic area and use stacked double pulses on active nodules (typical settings: 10-mm spot size; 10-millisecond pulse duration and 35–50 J/cm² in Fitzpatrick skin types I–III; 20-millisecond pulse duration and 25–40 J/cm² in Fitzpatrick skin types IV–VI).⁴ Especially if it is covered by your patient’s insurance, Nd:YAG is a great adjunctive treatment to consider. The guidelines also recommend long-pulsed alexandrite and diode lasers as well as intense pulsed light, all of which result in follicular destruction, though these treatments have less supporting evidence.⁴

Have a Plan for Flares

Intralesional injection of triamcinolone is a mainstay of HS treatment and provides patients with rapid relief of symptoms during a flare.⁵ One case series found that there was a notable decrease in pain, size, and drainage after just 1 day of treatment with intralesional triamcinolone 10 mg/mL (0.2–2.0 mL).⁶

Intralesional steroid injection is a great tool for quieting an active disease flare while simultaneously instating ongoing treatment for preventive management. However, even when disease control is optimized, patients may still experience intermittent flares of disease. For some patients, it may be appropriate to have a plan in place for a return to clinic during the beginning of a flare to obtain intralesional steroids. The ability to come in on short notice may help avoid visits to the emergency department and urgent care where your patients may receive treatments such as short courses of antibiotics or incision and drainage that may deviate from your overall treatment plan.

Consider Childbearing Status

Don’t forget to consider childbearing plans and childbearing potential when treating female patients with HS. Pregnancy is a frequent consideration in HS patients, as HS affects 3 to 4 times more women than men and typically presents after puberty (second or third decades of life). Many of the medications in the HS armamentarium are contraindicated in pregnancy including tetracyclines, retinoids, and hormonal agents. Surgery should be avoided in pregnant patients whenever possible, particularly in the first trimester. Relatively safe options include topical antibiotics such as clindamycin and metronidazole, as well as tumor necrosis factor α inhibitors, which are classified as category B in pregnancy.⁵

Before making treatment decisions in pregnant and breastfeeding patients, consult the US Food and Drug Administration recommendations. Perng et al⁷ reviewed current management strategies for HS in pregnant and breastfeeding women, and their review article in the Journal of the American Academy of Dermatology is an excellent resource.

Final Thoughts

Comprehensive management of HS may include a combination of medication and procedures, lifestyle modification, management of comorbidities, and social support. Formulating a good treatment plan may be a challenge but can drastically improve your patient’s quality of life.

Hidradenitis suppurativa (HS) is a common and debilitating inflammatory disorder of the pilosebaceous unit that presents with recurrent scarring inflammatory nodules and sinus tracts in the intertriginous folds of the body. It is a complex condition that requires multimodal management to address the medical, surgical, and psychosocial needs of affected patients. However, it can be difficult to coordinate all that goes into HS management beyond the standard therapeutic ladder of topical and oral antimicrobials, intralesional corticosteroids, biologics, and surgery. In this article, I will outline 5 important aspects of HS treatment that often are overlooked.

Talk About Pathophysiology

Patients with HS often have limited understanding of their condition. One common misperception is that HS is an infectious disease and that disease activity is associated with poor hygiene.¹ Dispelling this myth may help patients avoid unnecessary hygiene practices, decrease perceived stigma, and enhance your therapeutic alliance.

The current model of HS pathophysiology implicates an aberrant inflammatory response to the cutaneous bacterial microbiome, which leads to follicular occlusion and then rupture of debris and bacteria into the surrounding dermis. Immune cells and inflammatory mediators such as nuclear factor κB and tumor necrosis factor α respond to the disruption. Chronic lesions develop due to tissue repair with scarring and re-epithelialization.^2,3 Although most patients probably are not interested in the esoteric details, I typically make a point of explaining to patients that HS is a chronic inflammatory disease and provide reassurance that it is not a sign of poor hygiene. 

Counsel on Smoking Cessation

Most HS patients use tobacco. As many as 75% of HS patients are active smokers and another 10% to 15% are former smokers. Although there is mixed evidence that disease activity correlates with smoking status, the Hidradenitis Suppurativa Foundation in the United States and Canada concluded in the 2019 North American Clinical Management Guidelines for Hidradenitis Suppurativa that due to the overall health risks of smoking, we should recommend cessation to our patients.⁴

Laser Hair Removal Works

Don’t forget about laser hair removal! Evidence from randomized controlled trials supports the use of the Nd:YAG laser in the treatment of HS. Treat the entire affected anatomic area and use stacked double pulses on active nodules (typical settings: 10-mm spot size; 10-millisecond pulse duration and 35–50 J/cm² in Fitzpatrick skin types I–III; 20-millisecond pulse duration and 25–40 J/cm² in Fitzpatrick skin types IV–VI).⁴ Especially if it is covered by your patient’s insurance, Nd:YAG is a great adjunctive treatment to consider. The guidelines also recommend long-pulsed alexandrite and diode lasers as well as intense pulsed light, all of which result in follicular destruction, though these treatments have less supporting evidence.⁴

Have a Plan for Flares

Intralesional injection of triamcinolone is a mainstay of HS treatment and provides patients with rapid relief of symptoms during a flare.⁵ One case series found that there was a notable decrease in pain, size, and drainage after just 1 day of treatment with intralesional triamcinolone 10 mg/mL (0.2–2.0 mL).⁶

Intralesional steroid injection is a great tool for quieting an active disease flare while simultaneously instating ongoing treatment for preventive management. However, even when disease control is optimized, patients may still experience intermittent flares of disease. For some patients, it may be appropriate to have a plan in place for a return to clinic during the beginning of a flare to obtain intralesional steroids. The ability to come in on short notice may help avoid visits to the emergency department and urgent care where your patients may receive treatments such as short courses of antibiotics or incision and drainage that may deviate from your overall treatment plan.

Consider Childbearing Status

Don’t forget to consider childbearing plans and childbearing potential when treating female patients with HS. Pregnancy is a frequent consideration in HS patients, as HS affects 3 to 4 times more women than men and typically presents after puberty (second or third decades of life). Many of the medications in the HS armamentarium are contraindicated in pregnancy including tetracyclines, retinoids, and hormonal agents. Surgery should be avoided in pregnant patients whenever possible, particularly in the first trimester. Relatively safe options include topical antibiotics such as clindamycin and metronidazole, as well as tumor necrosis factor α inhibitors, which are classified as category B in pregnancy.⁵

Before making treatment decisions in pregnant and breastfeeding patients, consult the US Food and Drug Administration recommendations. Perng et al⁷ reviewed current management strategies for HS in pregnant and breastfeeding women, and their review article in the Journal of the American Academy of Dermatology is an excellent resource.

Final Thoughts

Comprehensive management of HS may include a combination of medication and procedures, lifestyle modification, management of comorbidities, and social support. Formulating a good treatment plan may be a challenge but can drastically improve your patient’s quality of life.

Dermatology patients experience a high burden of mental health disturbance. Psychiatric disease is seen in an estimated 30% to 60% of our patients.¹ It can be secondary to or comorbid with dermatologic disorders, or it can be the primary condition that is driving cutaneous disease. Patients with secondary or comorbid psychiatric disorders often are amenable to referral to a mental health provider or are already participating in some form of mental health treatment; however, patients with primary psychiatric disease who present to dermatology generally do not accept these referrals.² Therefore, if these patients are to receive care anywhere in the health care system, it often must be in the department of dermatology.

What primary psychiatric conditions do we see in dermatology?

Common primary psychiatric conditions seen in dermatology include delusional infestation, obsessive-compulsive disorder and related disorders, and dermatitis artefacta.

Delusional Infestation
Also known as delusions of parasitosis or delusional parasitosis, delusional infestation presents as a fixed false belief that there is an organism or other foreign entity that is present in the skin and is the cause of cutaneous disruption. It often is an isolated delusion but can have a notable psychosocial impact. The term delusional infestation is sometimes preferred, as it is inclusive of delusions focused on any type of organism, not just parasites. It also encompasses delusions of infestation with nonliving matter such as fibers, also known as Morgellons disease.³

Obsessive-Compulsive Disorder and Related Disorders
This broad category includes several conditions encountered in dermatology. Body dysmorphic disorder (BDD), olfactory reference syndrome (ORS), excoriation disorder, and trichotillomania are some of the most common variants. In patients with BDD, skin and hair are the 2 most common preoccupations. It has been estimated that 12% of dermatology patients experience BDD. Unsurprisingly, it is more common in patients presenting to cosmetic dermatology, but general dermatology patients also are affected at a rate of 7%.² Patients with ORS falsely believe they have body odor and/or halitosis. Excoriation disorder manifests as repetitive skin picking, either of normal skin or of lesions such as pimples and scabs. Trichotillomania presents as repeated hair pulling, and trichophagia (eating the pulled hair) also may be present.

Dermatitis Artefacta
Almost 1 in 4 patients who seek dermatologic evaluation for primarily psychiatric disorders have dermatitis artefacta, the presence of deliberately self-inflicted skin lesions.² Patients with dermatitis artefacta have unconscious motives for their behavior and should be distinguished from malingering patients who have a conscious goal of secondary gain.

What treatments are available?

Antidepressants
Selective serotonin reuptake inhibitors are one of the first-line treatments for BDD and may be useful in ORS. In excoriation disorder and trichotillomania, selective serotonin reuptake inhibitors are the most commonly prescribed pharmacotherapy, but they have limited efficacy.²

Antipsychotics
The recommended treatment of delusional infestation is antipsychotic pharmacotherapy. Treatment with risperidone and olanzapine has been reported to achieve full or partial remission in more than two-thirds of cases.⁴ Aripiprazole, a newer antipsychotic, has fewer side effects and has been successful in several case reports.^5-7

Cognitive Behavioral Therapy
Psychotherapy, most often in the form of cognitive behavioral therapy, has been reported as effective treatment of several psychocutaneous diseases. Cognitive behavioral therapy is considered first-line treatment of body-focused repetitive behavior disorders such as excoriation disorder and trichotillomania.² It addresses maladaptive thought patterns to modify behavior.

Who treats patients with neurodermatoses?

If a patient presents to dermatology with a rash found to be related to an underlying thyroid disorder, the treatment plan likely would include referral to an endocrinologist. Similarly, patients with primary psychiatric conditions presenting to dermatology should ideally be referred to psychiatrists or psychotherapists, the providers most thoroughly trained and best equipped to treat them. The challenge in psychodermatology is that patients often are resistant to the assessment that the primary pathology is psychiatric. Patients may deny that they are “crazy” and see numerous providers in search of a dermatologist who “believes” them.⁸

Referral to mental health professionals almost always is refused by patients with primarily psychiatric neurodermatoses, which presents dermatologists with a dilemma. As the authors of the “Psychotropic Agents” chapter of Comprehensive Dermatologic Drug Therapy put it: “A dermatologist has two choices. The first is to try to ‘look the other way’ and pacify the patient by providing relatively benign, but minimally effective treatments. The other option is to try to directly address the psychological/psychiatric problems.” The chapter then provides a thorough guide for the use of psychotropic medications in the dermatology population, advocating for option 2: treatment by dermatologists.⁹

Should a dermatologist prescribe psychotropic drugs?

In Dermatology, the principle reference textbook in many dermatology training programs, it is stated that “[a]lthough less comprehensive than treatment delivered in collaboration with a psychiatrist, in the authors’ opinion, management of these issues by a dermatologist is better than no treatment at all.”¹⁰ Recent reviews in the dermatologic literature of psychiatric diseases and drugs in dermatology agree that dermatologists should feel comfortable with prescribing pharmacologic treatment.^2,8,11 Performance of psychotherapy by dermatologists, on the other hand, is not recommended based on time constraints and lack of training.

Despite the apparent agreement in the texts and literature that pharmacotherapy of psychiatric neurodermatoses is within our scope of practice in dermatology, most dermatologists do not prescribe psychotropic agents. Dermatology residencies generally do not provide thorough training in psychopharmacotherapy.⁹ Unsurprisingly, a survey of 40 dermatologists at one academic institution found that only 11% felt comfortable prescribing an antidepressant and a mere 3% were comfortable prescribing an antipsychotic.¹²

Final Thoughts

The challenges involved in managing patients with primary psychiatric disease in dermatology are great and many patients are undertreated despite the availability of effective, evidence-based treatment options. We need to continue to work toward providing better access to these treatments in a way that maximizes the chance that our patients will accept our care.

Dermatology patients experience a high burden of mental health disturbance. Psychiatric disease is seen in an estimated 30% to 60% of our patients.¹ It can be secondary to or comorbid with dermatologic disorders, or it can be the primary condition that is driving cutaneous disease. Patients with secondary or comorbid psychiatric disorders often are amenable to referral to a mental health provider or are already participating in some form of mental health treatment; however, patients with primary psychiatric disease who present to dermatology generally do not accept these referrals.² Therefore, if these patients are to receive care anywhere in the health care system, it often must be in the department of dermatology.

What primary psychiatric conditions do we see in dermatology?

Common primary psychiatric conditions seen in dermatology include delusional infestation, obsessive-compulsive disorder and related disorders, and dermatitis artefacta.

Delusional Infestation
Also known as delusions of parasitosis or delusional parasitosis, delusional infestation presents as a fixed false belief that there is an organism or other foreign entity that is present in the skin and is the cause of cutaneous disruption. It often is an isolated delusion but can have a notable psychosocial impact. The term delusional infestation is sometimes preferred, as it is inclusive of delusions focused on any type of organism, not just parasites. It also encompasses delusions of infestation with nonliving matter such as fibers, also known as Morgellons disease.³

Obsessive-Compulsive Disorder and Related Disorders
This broad category includes several conditions encountered in dermatology. Body dysmorphic disorder (BDD), olfactory reference syndrome (ORS), excoriation disorder, and trichotillomania are some of the most common variants. In patients with BDD, skin and hair are the 2 most common preoccupations. It has been estimated that 12% of dermatology patients experience BDD. Unsurprisingly, it is more common in patients presenting to cosmetic dermatology, but general dermatology patients also are affected at a rate of 7%.² Patients with ORS falsely believe they have body odor and/or halitosis. Excoriation disorder manifests as repetitive skin picking, either of normal skin or of lesions such as pimples and scabs. Trichotillomania presents as repeated hair pulling, and trichophagia (eating the pulled hair) also may be present.

Dermatitis Artefacta
Almost 1 in 4 patients who seek dermatologic evaluation for primarily psychiatric disorders have dermatitis artefacta, the presence of deliberately self-inflicted skin lesions.² Patients with dermatitis artefacta have unconscious motives for their behavior and should be distinguished from malingering patients who have a conscious goal of secondary gain.

What treatments are available?

Antidepressants
Selective serotonin reuptake inhibitors are one of the first-line treatments for BDD and may be useful in ORS. In excoriation disorder and trichotillomania, selective serotonin reuptake inhibitors are the most commonly prescribed pharmacotherapy, but they have limited efficacy.²

Antipsychotics
The recommended treatment of delusional infestation is antipsychotic pharmacotherapy. Treatment with risperidone and olanzapine has been reported to achieve full or partial remission in more than two-thirds of cases.⁴ Aripiprazole, a newer antipsychotic, has fewer side effects and has been successful in several case reports.^5-7

Cognitive Behavioral Therapy
Psychotherapy, most often in the form of cognitive behavioral therapy, has been reported as effective treatment of several psychocutaneous diseases. Cognitive behavioral therapy is considered first-line treatment of body-focused repetitive behavior disorders such as excoriation disorder and trichotillomania.² It addresses maladaptive thought patterns to modify behavior.

Who treats patients with neurodermatoses?

If a patient presents to dermatology with a rash found to be related to an underlying thyroid disorder, the treatment plan likely would include referral to an endocrinologist. Similarly, patients with primary psychiatric conditions presenting to dermatology should ideally be referred to psychiatrists or psychotherapists, the providers most thoroughly trained and best equipped to treat them. The challenge in psychodermatology is that patients often are resistant to the assessment that the primary pathology is psychiatric. Patients may deny that they are “crazy” and see numerous providers in search of a dermatologist who “believes” them.⁸

Referral to mental health professionals almost always is refused by patients with primarily psychiatric neurodermatoses, which presents dermatologists with a dilemma. As the authors of the “Psychotropic Agents” chapter of Comprehensive Dermatologic Drug Therapy put it: “A dermatologist has two choices. The first is to try to ‘look the other way’ and pacify the patient by providing relatively benign, but minimally effective treatments. The other option is to try to directly address the psychological/psychiatric problems.” The chapter then provides a thorough guide for the use of psychotropic medications in the dermatology population, advocating for option 2: treatment by dermatologists.⁹

Should a dermatologist prescribe psychotropic drugs?

In Dermatology, the principle reference textbook in many dermatology training programs, it is stated that “[a]lthough less comprehensive than treatment delivered in collaboration with a psychiatrist, in the authors’ opinion, management of these issues by a dermatologist is better than no treatment at all.”¹⁰ Recent reviews in the dermatologic literature of psychiatric diseases and drugs in dermatology agree that dermatologists should feel comfortable with prescribing pharmacologic treatment.^2,8,11 Performance of psychotherapy by dermatologists, on the other hand, is not recommended based on time constraints and lack of training.

Despite the apparent agreement in the texts and literature that pharmacotherapy of psychiatric neurodermatoses is within our scope of practice in dermatology, most dermatologists do not prescribe psychotropic agents. Dermatology residencies generally do not provide thorough training in psychopharmacotherapy.⁹ Unsurprisingly, a survey of 40 dermatologists at one academic institution found that only 11% felt comfortable prescribing an antidepressant and a mere 3% were comfortable prescribing an antipsychotic.¹²

Final Thoughts

The challenges involved in managing patients with primary psychiatric disease in dermatology are great and many patients are undertreated despite the availability of effective, evidence-based treatment options. We need to continue to work toward providing better access to these treatments in a way that maximizes the chance that our patients will accept our care.

Dermatology patients experience a high burden of mental health disturbance. Psychiatric disease is seen in an estimated 30% to 60% of our patients.¹ It can be secondary to or comorbid with dermatologic disorders, or it can be the primary condition that is driving cutaneous disease. Patients with secondary or comorbid psychiatric disorders often are amenable to referral to a mental health provider or are already participating in some form of mental health treatment; however, patients with primary psychiatric disease who present to dermatology generally do not accept these referrals.² Therefore, if these patients are to receive care anywhere in the health care system, it often must be in the department of dermatology.

What primary psychiatric conditions do we see in dermatology?

Common primary psychiatric conditions seen in dermatology include delusional infestation, obsessive-compulsive disorder and related disorders, and dermatitis artefacta.

Delusional Infestation
Also known as delusions of parasitosis or delusional parasitosis, delusional infestation presents as a fixed false belief that there is an organism or other foreign entity that is present in the skin and is the cause of cutaneous disruption. It often is an isolated delusion but can have a notable psychosocial impact. The term delusional infestation is sometimes preferred, as it is inclusive of delusions focused on any type of organism, not just parasites. It also encompasses delusions of infestation with nonliving matter such as fibers, also known as Morgellons disease.³

Obsessive-Compulsive Disorder and Related Disorders
This broad category includes several conditions encountered in dermatology. Body dysmorphic disorder (BDD), olfactory reference syndrome (ORS), excoriation disorder, and trichotillomania are some of the most common variants. In patients with BDD, skin and hair are the 2 most common preoccupations. It has been estimated that 12% of dermatology patients experience BDD. Unsurprisingly, it is more common in patients presenting to cosmetic dermatology, but general dermatology patients also are affected at a rate of 7%.² Patients with ORS falsely believe they have body odor and/or halitosis. Excoriation disorder manifests as repetitive skin picking, either of normal skin or of lesions such as pimples and scabs. Trichotillomania presents as repeated hair pulling, and trichophagia (eating the pulled hair) also may be present.

Dermatitis Artefacta
Almost 1 in 4 patients who seek dermatologic evaluation for primarily psychiatric disorders have dermatitis artefacta, the presence of deliberately self-inflicted skin lesions.² Patients with dermatitis artefacta have unconscious motives for their behavior and should be distinguished from malingering patients who have a conscious goal of secondary gain.

What treatments are available?

Antidepressants
Selective serotonin reuptake inhibitors are one of the first-line treatments for BDD and may be useful in ORS. In excoriation disorder and trichotillomania, selective serotonin reuptake inhibitors are the most commonly prescribed pharmacotherapy, but they have limited efficacy.²

Antipsychotics
The recommended treatment of delusional infestation is antipsychotic pharmacotherapy. Treatment with risperidone and olanzapine has been reported to achieve full or partial remission in more than two-thirds of cases.⁴ Aripiprazole, a newer antipsychotic, has fewer side effects and has been successful in several case reports.^5-7

Cognitive Behavioral Therapy
Psychotherapy, most often in the form of cognitive behavioral therapy, has been reported as effective treatment of several psychocutaneous diseases. Cognitive behavioral therapy is considered first-line treatment of body-focused repetitive behavior disorders such as excoriation disorder and trichotillomania.² It addresses maladaptive thought patterns to modify behavior.

Who treats patients with neurodermatoses?

If a patient presents to dermatology with a rash found to be related to an underlying thyroid disorder, the treatment plan likely would include referral to an endocrinologist. Similarly, patients with primary psychiatric conditions presenting to dermatology should ideally be referred to psychiatrists or psychotherapists, the providers most thoroughly trained and best equipped to treat them. The challenge in psychodermatology is that patients often are resistant to the assessment that the primary pathology is psychiatric. Patients may deny that they are “crazy” and see numerous providers in search of a dermatologist who “believes” them.⁸

Referral to mental health professionals almost always is refused by patients with primarily psychiatric neurodermatoses, which presents dermatologists with a dilemma. As the authors of the “Psychotropic Agents” chapter of Comprehensive Dermatologic Drug Therapy put it: “A dermatologist has two choices. The first is to try to ‘look the other way’ and pacify the patient by providing relatively benign, but minimally effective treatments. The other option is to try to directly address the psychological/psychiatric problems.” The chapter then provides a thorough guide for the use of psychotropic medications in the dermatology population, advocating for option 2: treatment by dermatologists.⁹

Should a dermatologist prescribe psychotropic drugs?

In Dermatology, the principle reference textbook in many dermatology training programs, it is stated that “[a]lthough less comprehensive than treatment delivered in collaboration with a psychiatrist, in the authors’ opinion, management of these issues by a dermatologist is better than no treatment at all.”¹⁰ Recent reviews in the dermatologic literature of psychiatric diseases and drugs in dermatology agree that dermatologists should feel comfortable with prescribing pharmacologic treatment.^2,8,11 Performance of psychotherapy by dermatologists, on the other hand, is not recommended based on time constraints and lack of training.

Despite the apparent agreement in the texts and literature that pharmacotherapy of psychiatric neurodermatoses is within our scope of practice in dermatology, most dermatologists do not prescribe psychotropic agents. Dermatology residencies generally do not provide thorough training in psychopharmacotherapy.⁹ Unsurprisingly, a survey of 40 dermatologists at one academic institution found that only 11% felt comfortable prescribing an antidepressant and a mere 3% were comfortable prescribing an antipsychotic.¹²

Final Thoughts

The challenges involved in managing patients with primary psychiatric disease in dermatology are great and many patients are undertreated despite the availability of effective, evidence-based treatment options. We need to continue to work toward providing better access to these treatments in a way that maximizes the chance that our patients will accept our care.

It is an uncomfortable and unavoidable reality as physicians that for every procedure we learn, there must be a first time we perform it. As with any type of skill, it takes practice to become proficient. The unique challenge in medicine is that the practice involves performing procedures on real patients. We cannot avoid the hands-on nature of the training process; we can, however, approach its ethical challenges mindfully. Herein, I will discuss some of the ethical considerations in providing care as a trainee and identify potential barriers to best practices, particularly as they relate to procedural dermatology.

Tell Patients You Are in Training

In every patient encounter, we must introduce ourselves as a trainee. The principle of right to the truth dictates that we are transparent about our level of training and do not misrepresent ourselves to our patients. A statement released by the American Medical Association (AMA) Council on Ethical and Judicial Affairs asserts that “[p]atients should be informed of the identity and training status of individuals involved in their care.”¹

Although straightforward in theory, this mandate is not always simple in practice. With patients unfamiliar with the health care system, it could be more onerous to clearly communicate training status than simply introducing oneself as a resident. A study conducted in the emergency department at Vanderbilt University Hospital (Nashville, Tennessee) found that many patients and their family members (N=430) did not understand the various roles and responsibilities of physicians in the teaching hospital setting. For example, 30% believed an attending physician requires supervision by a resident, and an additional 17% of those surveyed were not sure.² The AMA requests we “refrain from using terms that may be confusing when describing the training status of the students,”¹ which evidently is audience specific. Thus, as with any type of patient education, a thorough introduction may require assessment of understanding.

Disclosure of Experience Level With a Particular Procedure

There is a clear professional expectation that we disclose to patients that we are in training; however, a universal standard does not exist for disclosure of our exact level of experience in a particular procedure. Do we need to tell patients if it is our first time performing a given procedure? What if it is our tenth? Multiple studies have found that patients want specifics. In one study of bariatric surgery patients (N=108), 93% felt that they should always be informed if it was the first time a trainee was performing a particular procedure.³ A study conducted in the emergency department setting (N=202) also found that the majority of patients thought they should be informed if a resident was performing a procedure for the first time, but the distribution differed by procedure (66% for suturing vs 82% for lumbar puncture).⁴

Despite these findings, this degree of specificity is not always discussed with patients and perhaps does not need to be. LaRosa and Grant-Kels⁵ analyzed a hypothetical scenario in which a dermatology resident is to perform his first excision under attending supervision and concluded that broad disclosure of training status would suffice in the given scenario, as it would not be necessary to state that it was his first time performing an excision. It is unclear if the same conclusion could be drawn for all procedures and levels of experience. Outcome data would help inform the analysis, but the available data are from other specialties including general surgery, gynecology, and urology. Some studies demonstrate an increased risk of adverse outcomes with trainee involvement in procedures such as bariatric surgery and emergency general surgery, but the data are mixed and may not be generalizable to dermatologic procedures.^6-8

The appropriate level of detail to disclose regarding a physician’s experience may need to be assessed on a case-by-case basis, and the principles of informed consent can help. Informed consent requires understanding of the diagnosis, the treatment options including nonintervention, and the risks and benefits of each alternative. In obtaining informed consent, we must disclose “any facts which are necessary to form the basis of an intelligent consent by the patient to the proposed treatment.”⁹ Providers must determine what aspects of a trainee’s experience level are relevant to the risk-benefit analysis in a given set of circumstances. Surely, there is a large degree of subjectivity in this determination as data are limited, but information deemed relevant must be shared. Information that is inconsequential, on the other hand, may be omitted. It could even be argued that more detailed information, especially if it may cause anxiety, would be detrimental to share. For example, we would not list the chemical name of every preservative in every vaccine we recommend for children if there is no evidence of inflicting harm. If the information has not been shown to have clinical impact or affect safety concerns, the anxiety may be undue.

Withholding Information Can Violate Ethical Principles

We must be careful not to withhold details of our experience level with a particular procedure for the wrong reasons. It would be wrong, for example, to withhold information simply to avoid causing anxiety, which could be seen as an invocation of therapeutic privilege, a controversial practice of withholding important information that poses a psychological threat to the patient. A classic example is the physician who defers disclosure of a terminal diagnosis to preserve hope. Although therapeutic privilege theoretically promotes the principle of beneficence, it violates the principles of autonomy and right to truth and therefore generally is regarded as unethically paternalistic in modern medical ethics.⁹

Patients Can Refuse Trainee Participation

It also is unethical to withhold information to obtain consent and avoid refusal of our care. Refusal of trainee participation is not uncommon. In the aforementioned study of bariatric surgery patients, 92.4% supported their procedure being performed at a teaching hospital, but only 56% would consent to a resident assisting staff during the procedure. A mere 33% of those patients would consent to a resident primarily performing with staff assisting.³ Although the proportion of patients who refuse certainly depends on the type of procedure among other factors, it is a reality in any teaching environment. The training paradigm in medicine depends on being able to practice procedures with supervision before we are independent providers. If patients refuse our care, our training suffers. However, the AMA maintains that “[p]atients are free to choose from whom they receive treatment,”¹ and we must respect this aspect of patient autonomy.

Final Thoughts

When it comes to the performance of procedures, there are a few basic principles to keep in mind to provide ethical care to our patients while we are in training. Although we must accept that a crucial part of learning dermatologic procedures is hands on with real patients, we also need to come prepared having learned what we can through reading and practice with cadavers or skin substitutes. Procedures we execute as residents should be performed with adequate supervision, and as we progress through residency, we should be given increased autonomy and graded responsibility to prepare us for independent practice at graduation. Although it is the responsibility of the attending physician to provide appropriate oversight for the resident’s level of training, we should feel empowered to ask for help and have the humility to know when we need it.

It is an uncomfortable and unavoidable reality as physicians that for every procedure we learn, there must be a first time we perform it. As with any type of skill, it takes practice to become proficient. The unique challenge in medicine is that the practice involves performing procedures on real patients. We cannot avoid the hands-on nature of the training process; we can, however, approach its ethical challenges mindfully. Herein, I will discuss some of the ethical considerations in providing care as a trainee and identify potential barriers to best practices, particularly as they relate to procedural dermatology.

Tell Patients You Are in Training

In every patient encounter, we must introduce ourselves as a trainee. The principle of right to the truth dictates that we are transparent about our level of training and do not misrepresent ourselves to our patients. A statement released by the American Medical Association (AMA) Council on Ethical and Judicial Affairs asserts that “[p]atients should be informed of the identity and training status of individuals involved in their care.”¹

Although straightforward in theory, this mandate is not always simple in practice. With patients unfamiliar with the health care system, it could be more onerous to clearly communicate training status than simply introducing oneself as a resident. A study conducted in the emergency department at Vanderbilt University Hospital (Nashville, Tennessee) found that many patients and their family members (N=430) did not understand the various roles and responsibilities of physicians in the teaching hospital setting. For example, 30% believed an attending physician requires supervision by a resident, and an additional 17% of those surveyed were not sure.² The AMA requests we “refrain from using terms that may be confusing when describing the training status of the students,”¹ which evidently is audience specific. Thus, as with any type of patient education, a thorough introduction may require assessment of understanding.

Disclosure of Experience Level With a Particular Procedure

There is a clear professional expectation that we disclose to patients that we are in training; however, a universal standard does not exist for disclosure of our exact level of experience in a particular procedure. Do we need to tell patients if it is our first time performing a given procedure? What if it is our tenth? Multiple studies have found that patients want specifics. In one study of bariatric surgery patients (N=108), 93% felt that they should always be informed if it was the first time a trainee was performing a particular procedure.³ A study conducted in the emergency department setting (N=202) also found that the majority of patients thought they should be informed if a resident was performing a procedure for the first time, but the distribution differed by procedure (66% for suturing vs 82% for lumbar puncture).⁴

Despite these findings, this degree of specificity is not always discussed with patients and perhaps does not need to be. LaRosa and Grant-Kels⁵ analyzed a hypothetical scenario in which a dermatology resident is to perform his first excision under attending supervision and concluded that broad disclosure of training status would suffice in the given scenario, as it would not be necessary to state that it was his first time performing an excision. It is unclear if the same conclusion could be drawn for all procedures and levels of experience. Outcome data would help inform the analysis, but the available data are from other specialties including general surgery, gynecology, and urology. Some studies demonstrate an increased risk of adverse outcomes with trainee involvement in procedures such as bariatric surgery and emergency general surgery, but the data are mixed and may not be generalizable to dermatologic procedures.^6-8

The appropriate level of detail to disclose regarding a physician’s experience may need to be assessed on a case-by-case basis, and the principles of informed consent can help. Informed consent requires understanding of the diagnosis, the treatment options including nonintervention, and the risks and benefits of each alternative. In obtaining informed consent, we must disclose “any facts which are necessary to form the basis of an intelligent consent by the patient to the proposed treatment.”⁹ Providers must determine what aspects of a trainee’s experience level are relevant to the risk-benefit analysis in a given set of circumstances. Surely, there is a large degree of subjectivity in this determination as data are limited, but information deemed relevant must be shared. Information that is inconsequential, on the other hand, may be omitted. It could even be argued that more detailed information, especially if it may cause anxiety, would be detrimental to share. For example, we would not list the chemical name of every preservative in every vaccine we recommend for children if there is no evidence of inflicting harm. If the information has not been shown to have clinical impact or affect safety concerns, the anxiety may be undue.

Withholding Information Can Violate Ethical Principles

We must be careful not to withhold details of our experience level with a particular procedure for the wrong reasons. It would be wrong, for example, to withhold information simply to avoid causing anxiety, which could be seen as an invocation of therapeutic privilege, a controversial practice of withholding important information that poses a psychological threat to the patient. A classic example is the physician who defers disclosure of a terminal diagnosis to preserve hope. Although therapeutic privilege theoretically promotes the principle of beneficence, it violates the principles of autonomy and right to truth and therefore generally is regarded as unethically paternalistic in modern medical ethics.⁹

Patients Can Refuse Trainee Participation

It also is unethical to withhold information to obtain consent and avoid refusal of our care. Refusal of trainee participation is not uncommon. In the aforementioned study of bariatric surgery patients, 92.4% supported their procedure being performed at a teaching hospital, but only 56% would consent to a resident assisting staff during the procedure. A mere 33% of those patients would consent to a resident primarily performing with staff assisting.³ Although the proportion of patients who refuse certainly depends on the type of procedure among other factors, it is a reality in any teaching environment. The training paradigm in medicine depends on being able to practice procedures with supervision before we are independent providers. If patients refuse our care, our training suffers. However, the AMA maintains that “[p]atients are free to choose from whom they receive treatment,”¹ and we must respect this aspect of patient autonomy.

Final Thoughts

When it comes to the performance of procedures, there are a few basic principles to keep in mind to provide ethical care to our patients while we are in training. Although we must accept that a crucial part of learning dermatologic procedures is hands on with real patients, we also need to come prepared having learned what we can through reading and practice with cadavers or skin substitutes. Procedures we execute as residents should be performed with adequate supervision, and as we progress through residency, we should be given increased autonomy and graded responsibility to prepare us for independent practice at graduation. Although it is the responsibility of the attending physician to provide appropriate oversight for the resident’s level of training, we should feel empowered to ask for help and have the humility to know when we need it.

It is an uncomfortable and unavoidable reality as physicians that for every procedure we learn, there must be a first time we perform it. As with any type of skill, it takes practice to become proficient. The unique challenge in medicine is that the practice involves performing procedures on real patients. We cannot avoid the hands-on nature of the training process; we can, however, approach its ethical challenges mindfully. Herein, I will discuss some of the ethical considerations in providing care as a trainee and identify potential barriers to best practices, particularly as they relate to procedural dermatology.

Tell Patients You Are in Training

In every patient encounter, we must introduce ourselves as a trainee. The principle of right to the truth dictates that we are transparent about our level of training and do not misrepresent ourselves to our patients. A statement released by the American Medical Association (AMA) Council on Ethical and Judicial Affairs asserts that “[p]atients should be informed of the identity and training status of individuals involved in their care.”¹

Although straightforward in theory, this mandate is not always simple in practice. With patients unfamiliar with the health care system, it could be more onerous to clearly communicate training status than simply introducing oneself as a resident. A study conducted in the emergency department at Vanderbilt University Hospital (Nashville, Tennessee) found that many patients and their family members (N=430) did not understand the various roles and responsibilities of physicians in the teaching hospital setting. For example, 30% believed an attending physician requires supervision by a resident, and an additional 17% of those surveyed were not sure.² The AMA requests we “refrain from using terms that may be confusing when describing the training status of the students,”¹ which evidently is audience specific. Thus, as with any type of patient education, a thorough introduction may require assessment of understanding.

Disclosure of Experience Level With a Particular Procedure

There is a clear professional expectation that we disclose to patients that we are in training; however, a universal standard does not exist for disclosure of our exact level of experience in a particular procedure. Do we need to tell patients if it is our first time performing a given procedure? What if it is our tenth? Multiple studies have found that patients want specifics. In one study of bariatric surgery patients (N=108), 93% felt that they should always be informed if it was the first time a trainee was performing a particular procedure.³ A study conducted in the emergency department setting (N=202) also found that the majority of patients thought they should be informed if a resident was performing a procedure for the first time, but the distribution differed by procedure (66% for suturing vs 82% for lumbar puncture).⁴

Despite these findings, this degree of specificity is not always discussed with patients and perhaps does not need to be. LaRosa and Grant-Kels⁵ analyzed a hypothetical scenario in which a dermatology resident is to perform his first excision under attending supervision and concluded that broad disclosure of training status would suffice in the given scenario, as it would not be necessary to state that it was his first time performing an excision. It is unclear if the same conclusion could be drawn for all procedures and levels of experience. Outcome data would help inform the analysis, but the available data are from other specialties including general surgery, gynecology, and urology. Some studies demonstrate an increased risk of adverse outcomes with trainee involvement in procedures such as bariatric surgery and emergency general surgery, but the data are mixed and may not be generalizable to dermatologic procedures.^6-8

The appropriate level of detail to disclose regarding a physician’s experience may need to be assessed on a case-by-case basis, and the principles of informed consent can help. Informed consent requires understanding of the diagnosis, the treatment options including nonintervention, and the risks and benefits of each alternative. In obtaining informed consent, we must disclose “any facts which are necessary to form the basis of an intelligent consent by the patient to the proposed treatment.”⁹ Providers must determine what aspects of a trainee’s experience level are relevant to the risk-benefit analysis in a given set of circumstances. Surely, there is a large degree of subjectivity in this determination as data are limited, but information deemed relevant must be shared. Information that is inconsequential, on the other hand, may be omitted. It could even be argued that more detailed information, especially if it may cause anxiety, would be detrimental to share. For example, we would not list the chemical name of every preservative in every vaccine we recommend for children if there is no evidence of inflicting harm. If the information has not been shown to have clinical impact or affect safety concerns, the anxiety may be undue.

Withholding Information Can Violate Ethical Principles

We must be careful not to withhold details of our experience level with a particular procedure for the wrong reasons. It would be wrong, for example, to withhold information simply to avoid causing anxiety, which could be seen as an invocation of therapeutic privilege, a controversial practice of withholding important information that poses a psychological threat to the patient. A classic example is the physician who defers disclosure of a terminal diagnosis to preserve hope. Although therapeutic privilege theoretically promotes the principle of beneficence, it violates the principles of autonomy and right to truth and therefore generally is regarded as unethically paternalistic in modern medical ethics.⁹

Patients Can Refuse Trainee Participation

It also is unethical to withhold information to obtain consent and avoid refusal of our care. Refusal of trainee participation is not uncommon. In the aforementioned study of bariatric surgery patients, 92.4% supported their procedure being performed at a teaching hospital, but only 56% would consent to a resident assisting staff during the procedure. A mere 33% of those patients would consent to a resident primarily performing with staff assisting.³ Although the proportion of patients who refuse certainly depends on the type of procedure among other factors, it is a reality in any teaching environment. The training paradigm in medicine depends on being able to practice procedures with supervision before we are independent providers. If patients refuse our care, our training suffers. However, the AMA maintains that “[p]atients are free to choose from whom they receive treatment,”¹ and we must respect this aspect of patient autonomy.

Final Thoughts

When it comes to the performance of procedures, there are a few basic principles to keep in mind to provide ethical care to our patients while we are in training. Although we must accept that a crucial part of learning dermatologic procedures is hands on with real patients, we also need to come prepared having learned what we can through reading and practice with cadavers or skin substitutes. Procedures we execute as residents should be performed with adequate supervision, and as we progress through residency, we should be given increased autonomy and graded responsibility to prepare us for independent practice at graduation. Although it is the responsibility of the attending physician to provide appropriate oversight for the resident’s level of training, we should feel empowered to ask for help and have the humility to know when we need it.