Evan Rieder

Psoriasis, a model of dermatologic psychosomatic disease: psychiatric implications and treatments.

Psoriasis is a common dermatologic disorder with psychiatric comorbidity that often goes undetected and untreated. Psoriasis has higher associations with psychiatric illness than do other dermatologic conditions. We conducted a comprehensive qualitative review of all published medical literature on psoriasis and psychiatric comorbidities since 2005. We found that psoriasis patients suffer psychiatric and psychosocial morbidity that is not commensurate with the extent of cutaneous lesions. Biologic therapies and nonpharmacologic psychosocial interventions show promise in treating comorbid psychiatric illness. The main limitations of this review are the low quality of published studies and the infrequent use of basic science endpoints in reporting treatment outcomes. The literature examining the psychiatric comorbidity of psoriasis is expanding but remains of variable quality. Stronger studies will be necessary to more accurately estimate comorbidities and help identify and comprehensively treat suffering patients.

Psychiatric Consequences of Actual Versus Feared and Perceived Bed Bug Infestations: A Case Series Examining a Current Epidemic

Bed bugs have plagued humans since the beginning of history and have been mentioned in classical Greek writings dating back to the era of Aristotle as well as in medieval European texts. With the introduction of the pesticide dichlorodiphenyltrichloroethane (DDT) in the 1950s, bedbugs were virtually eradicated in the United States. However, with the ban of DDT in 1972, increasing resistance to pesticides over the last 70 years and increased frequency of national and international travel, bed bugs have now become a public health concern in urban areas across the United States. Anecdotes, blogs, bed bug summits, and articles (over 27,000 published in summer 2010) about infestations are ubiquitous. They evidence the increasing anxiety about infestations, have resulted in comparisons to H1N1, and are likely correlated to the surge in associated mental health symptoms including, according to the Centers for Disease Control and Prevention (CDC), anxiety and insomnia. The popular media has even linked bed bugs with paranoia and psychosis, though reports have not been confirmed in the medical literature. Since the mid-1990s, anecdotal and newspaper reports and, later, medical journals have demonstrated a resurgence in bed bugs both in the United States and abroad. Literature has indicated that infestations have been increasingly common in areas in which they had been eradicated, including Australia, Canada, the United Kingdom, and the United States (reviewed in). In 2009, Goddard and deShazo systematically reviewed the medical consequences of bed bug bites and examined the issues of pest control and eradication. While a variety of medical sequelae of bed bug bites have been reported, including cutaneous and rare systemic reactions,

Onychotillomania: An underrecognized disorder.

Onychotillomania is an uncommon and likely underreported condition in which patients repetitively manipulate the different constituents of the nail unit. Onychotillomania is characterized by a range of nonspecific findings, including bizarre morphology of the nail plate and damage to the nail bed and periungual skin. Histopathological changes are also nonspecific, but may be viewed as analogous to lichen simplex chronicus and prurigo nodularis of the skin. Clinical history is essential to making this diagnosis, as effective treatment modalities may focus on behavioral therapies and psychiatric medications.

Frequency of total body skin examinations among US dermatologists

diagnosis made at the in-person visit by a dermatologist. Diagnostic performance was analyzed in terms of sensitivity, specificity, false-positive rate, and falsenegative rate for the decision regarding the referral of patients to an in-person consultation at the skin cancer unit. The diagnostic confidence level (DCL; 1, uncertain diagnosis; 2, likely diagnosis; 3, confident diagnosis), the nonreferral rate, the time spent by the GP and the remote dermatologist, and the image qualitywere also assessed in each study group. The most common lesion examined by teledermatology was seborrheic keratosis (29.2%, n 1⁄4 73), followed by common acquired melanocytic nevus (26.8%, n 1⁄4 67). Basal cell carcinoma was the most common malignant lesion diagnosed (6.4%, n1⁄4 16), followed by squamous cell carcinoma (4%, n 1⁄4 10). Thus, 10.4% (n 1⁄4 26) of patients were referred because of malignant lesions. In the overall series, 60.8% and 76.8% of the CTC and CTC1DTC groups, respectively, were not referred to the skin cancer clinic (P 1⁄4 .001). The subanalysis of patients having pigmented lesions increased this nonreferral percentage to 69.39% and 89.13%, respectively (P 1⁄4 .001). The average time spent by the operating GPs was 7.44 minutes for CTC patients and 8.7 minutes for CTC1DTC patients (P 1⁄4 .01). The time spent by the dermatologist in the evaluation of CTC or CTC1DTC patients was 1.04 minutes and 1.22 minutes, respectively (P1⁄4 .14). The percentage of cases with the highest DCL (DCL1⁄43) was 61.6% in the CTC group and 79.2% in the CTC1DTC group (P 1⁄4 .001). The frequency of low-quality pictures was 3.2% and 1.6% in the CTC and CTC-DTC groups, respectively (P 1⁄4 .41). The results of the diagnostic performance study are listed in Table I. The interim results of this prospective randomized and blinded study provide meaningful favorable data ahead of the definitive results of a large-scale study on the effect of the addition of dermoscopic images to the routine internet-based skin cancer triage.

In response to Ginsberg et al: “A potential role for the dermatologist in the physical transformation of transgender people: A survey of attitudes and practices within the transgender community”

To the Editor: We read with interest the article of Ginsberg et al, ‘‘A potential role for the dermatologist in the physical transformation of transgender people: A survey of attitudes and practices within the transgender community.’’ Ginsberg et al provided an excellent overview of the surgical and cosmetic interventions that dermatologists may provide to patients undergoing a gender transition. Their article also raised important questions regarding medical dermatology for the transgender community, and in particular, the use of isotretinoin. Dermatologists are familiar with the iPLEDGE system, which regulates the use of isotretinoin. The iPLEDGE program patient introductory brochure consistently refers to patient gender in binary terms, but does not account for the fact that for many patients, gender identity and chromosomal sex may be incongruent. With increased visibility of the transgender community and the risk of acneiform eruptions in patients taking hormones to assist in gender transitions, dermatologists have a duty to be more sensitive to the needs of these patients. Not only does the iPLEDGE system potentially alienate transgendered patients with its binary reference to gender, but it also may inadvertently lead to confusion between the transgendered patient and physician. For example, how should a dermatologist treat a patient who was born with the chromosomal sex of a woman, identifies as male gender, and is currently transitioning to male sex? Although the potential for pregnancy is the main concern in determining laboratory monitoring and counseling for isotretinoin, confusion over sex and gender

On Leopards, Cheetahs, and the Cutaneous Stigmata of Onchocerciasis

Onchocerciasis is a tropical disease affecting the eye and the skin and is caused by transmission of the parasitic worm Onchocerca volvulus. Acute cutaneous stigmata of onchocerciasis include subcutaneous nodules and papular dermatitides. In chronic onchocerciasis, skin may become thickened, wrinkled, or hypopigmented to-depigmented. Pigmentary alteration patterns may occur in a spectrum of phenotypes, ranging from spotty depigmented macules to the most advanced stage, which features large patches of depigmented skin with islets of perifollicular sparing. In 1952, Rodhain first described the classic cutaneous stigmata of chronic onchocerciasis as “peau léopardée,” or “leopard skin.” This terminology is now commonly cited in the medical literature, including dermatology textbooks (Figure). The big cats, particularly those found in sub-Saharan Africa, are majestic creatures demonstrating stunning coat patterns that are commonly confused, in particular, the patterns in the leopard and the cheetah. Perhaps the most elusive big cat, the leopard (Panthera pardus) typically has a coat of pale yellow to deep gold. Although there is some variability to its exact pattern, a defining feature of the leopard coat is the black rosette. Rosettes often surround a patch of lighter browncolored hair and are regularly spaced over the animal’s back and lateral torso. The world’s fastest land animal, the cheetah (Acinonyx jubatus), features a similarly pale yellow to tan coat. Contrastingly, the cheetah’s coat demonstrates multiple, regularly spaced, well-demarcated black spots of varied sizes without rosettes. As onchocerciasis progresses, its pigmentation pattern may appear mottled and at times as pseudorosettes from a distance. However, on closer inspection, the actual pattern is one of scattered and coalescing hypopigmented to depigmented macules without classic rosettes. Thus, the skin of chronic onchocerciasis may be more precisely considered as more analogous to that of the cheetah than that of the leopard.

Alopecia Areata and Habit Tic Deformities

Nail involvement is a very common finding in patients with alopecia areata (AA). Most commonly evidenced by nail pitting, nail abnormalities can affect up to 66% of AA patients. We present two cases of the unusual association between habit tic nail deformities and AA.

Nailing the Shared Etiology in the Formation of Curved Hair and Nail Growth

A 55 year old African American woman presented for evaluation of alopecia and was noted to have very long fingernails that she had not cut for 10 years. Physical examination revealed long and curly fingernails with nail plate lengths of approximately 5-30 cm (Figure 1). The dominant right hand nail plates were shorter, as the patient reported occasional breakage from every day maneuvers. This article is protected by copyright. All rights reserved.