Wolfgang Harth

Facticious disorders in dermatology.

Facticious Disorders are self inflicted skin lesions and includes the creation of physical or psychiatric symptoms in oneself or other reference persons. In dermatology frequently, there are mechanical injuries by pressures, friction, occlusion, biting, cutting, stabbing, thermal burns or self‐inflicted infections with wound‐healing impairment, abscesses, mutilations or damages by acids and other toxic to the skin. The current classification differentiates between four groups: 1. Dermatitis artefacta syndrome in the narrower sense as unconscious/dissociated self‐injury, 2. Dermatitis paraartefacta syndrome: Disorders of impulse control, often as manipulation of an existing specific dermatosis (often semi‐conscious, admitted – self‐injury), 3. Malingering: consciously simulated injuries and diseases to obtain material gain, 4. special forms, such as the Gardner Diamond Syndrome, Münchhausen Syndrome and Münchhausen‐by‐Proxy Syndrome.

Tacrolimus: A new option in therapy-resistant chronic external otitis

Objective: To evaluate the efficacy of the novel topical immune modulator tacrolimus in chronic uninfectious otherwise therapy‐resistant external otitis (EO).

Successful treatment of pityriasis rubra pilaris (type 1) under combination of infliximab and methotrexate.

Pityriasis rubra pilaris (PRP) is often difficult to treat. A 65‐year‐old women presented with a two week history of widespread erythroderma and scaling with areas of sparing (nappes claires). She also had follicular hyperkeratoses and palmar fissuring. The clinical picture and histology led to the diagnosis of PRP. She failed to respond to initial therapy which included topical and systemic corticosteroids. She was then treated with intravenous methotrexate (MTX) 15–30 mg weekly. Because of the poor response we intensified her regime with infliximab (5 mg/kg). Altogether our patient received infliximab three times together with MTX, which was later given orally. We report for the first time the successful combination of infliximab and MTX for the treatment of PRP.

Complete remission of cutaneous and subcutaneous melanoma metastases of the scalp with imiquimod therapy.

Multiple cutaneous and subcutaneous melanoma metastases represent a therapeutic challenge. A 63‐year‐old man presented with multiple cutaneous and subcutaneous melanoma metastases on his right parieto‐occipital region that appeared ten weeks after surgical excision of the primary tumor. Staging showed no further metastases. Because of the large area of cutaneous metastatic spread, the location and the limited possibility of a complete excision, we decided to begin immunomodulatory therapy with imiquimod applied for eight hours daily five days a week. After six weeks of imiquimod monotherapy, a partial remission of the cutaneous metastases had occurred. After 17 months, the remission of these metastases was complete. Four months later the patient is still free of cutaneous, visceral, cerebral and lymph node metastases.

Psychotrichology: psychosomatic aspects of hair diseases

Hair growth and hair disorders with changes in hair density or quality not only influence an individualís appearance but also often lead to an enormous emotional burden with low self‐confidence, impaired quality of life, and even psychological disorders. Psychosomatic hair diseases cover a wide spectrum of specific psycho‐dermatological disease patterns. This review provides an overview and classification of psychosomatic hair diseases based on primary and secondary disorders.

Delusional parasitosis and the matchbox sign revisited: the international perspective.

© 2010 The Authors. doi: 10.2340/00015555-0909 Journal Compilation

Morgellons in dermatology

Delusional parasitosis (DP) is the most frequent delusional disorder in dermatology. In DP there is a fixed belief of a usually skin‐related invasion or infestation by a number of alleged infectious species (usually parasites and bacteria), whose identity has varied over the decades. Since 2002 worldwide an increasing number of patients have complained of unverifiable fibers and filaments in or on the skin, associated with numerous nonspecific complaints (arthralgias, altered cognitive function and extreme fatigue). This entity has been named “Morgellons disease” by the patients themselves, although medical evidence for its existence is lacking. As an example, we discuss a 55‐year‐old woman who complained of Morgellons disease and was treated as if she had DP. Currently the delusional assumption of infestation with Morgellons should be considered as a new type of DP with some kind of inanimate material. We therefore recommend in case of DP including Morgellons the use of the broader term “delusional infestation”.

The borderline syndrome in psychosomatic dermatology Overview and case report

The borderline syndrome is one of the most severe disturbances of psychosomatic dermatology. Patients with borderline syndrome are situated ‘on the border’ of psychosis, neurosis and personality disorders. The skin as a borderline organ carries a symbolic role. The clinical picture includes artefactual skin diseases due to self‐mutilation by conscious or unconscious cutting, and rubbing, scratching or para‐artefactual manipulations of pre‐existing dermatoses. Leading symptoms of the borderline syndrome are poor impulse control, emotional instability and poor ego strength with low frustration tolerance and unstable personal relationships. We present the case of a 38‐year‐old female patient with borderline syndrome suffering from para‐artefactual skin diseases of the face and a massive hyperhidrosis of the hands and feet. Within 9 months she was treated in four acute psychiatric hospitals and by 12 psychiatrists and psychotherapists. Early and accurate diagnosis and high‐quality, sophisticated long‐term therapy are necessary.

New lifestyle drugs and somatoform disorders in dermatology

An increasing number of healthy individuals make use of ‘lifestyle’ drugs, such as nootropics, psychopharmaca, hormones and eco‐drugs. In this respect, the fact that many people try to improve their outer appearance, solve their ‘cosmetic problems’, influence their rate of hair growth and altogether delay, halt or even reverse the natural ageing process has become a relevant matter for the practising dermatologist. Lifestyle drugs in dermatology are taken in an attempt to increase personal life quality by means of attaining a certain, psychosocially defined beauty ideal. They are not taken to manage a medically identifiable, well‐defined disease. Often, patients suffering from somatoform disorders, such as hypochondriac disorders, body dysmorphic disorders, somatization disorders or persistent somatoform pain disorders, may spontaneously ask physicians, in particular dermatologists and plastic surgeons, to prescribe them lifestyle drugs. Typically, patients repeatedly present with alleged ‘physical symptoms’ that turn out to be subjective complaints without any underlying identifiable medical disease. The use of lifestyle drugs without any proper medical indication may lead to a chronification of the emotional disorders that had ultimately been the cause of the patients’ request for such drugs. Such disorders may need to be treated promptly with psychotherapy and/or appropriate psychopharmacotherapy, and the choice of the treatment requires an accurate differential diagnostic approach.

Psychosomatic disturbances and cosmetic surgery

Medical activity in recent years has experienced a marked expansion of possi‐bilities for aesthetic surgery, usually requested by patients. Especially in derma‐tology, an increasing demand for and use of doctor/medical services by healthy individuals has resulted in a drastic change to cosmetic dermatology. The request for cosmetic surgery is emotionally or psychosocially motivated. Patients with psychological disturbances sometimes push aside possible risks and complications or deny side effects and interactions of the procedures. Subjective impairments of appearance, feelings of inferiority and social pho‐bias may be in the background of somatizing disorders. These emotional disor‐ders, such as body dysmorphic disorder, personality disorder or polysurgical addiction, often remain undiscovered but should be excluded in any patient receiving cosmetic procedures.