Management Strategies for Pediatric Psychodermatologic Disorders

Pediatric psychodermatologic disorders are common and require a strong therapeutic patient-physician relationship, according to study findings published in Pediatric Dermatology.

Researchers reviewed evidence-based data for 3 common dermatoses of primary psychiatric conditions in children — dermatitis artefacta, body dysmorphic disorder (BDD), and delusions of parasitosis by proxy (DOP-P). The investigators conducted a literature search in PubMed and Embase in February 2021 and reviewed relevant studies in which the full text was available in English.

Dermatitis artefacta, in which patients self-inflict skin lesions as a result of psychologic stress, occurs primarily in female adolescents. Patients may use sharp instruments, aerosols, hot curling irons, and lighted cigarette butts to cause their wounds owing to sexual abuse, personality disorders, anxiety, depression, and emotional neglect.

“It is recommended the dermatologist establishes an empathetic, nonjudgmental relationship with both the child and the parents, as this is essential for a successful treatment course,” stated the study authors. Psychiatric referral should be promptly discussed with the parents, as timely treatment can prevent further cutaneous sequelae, noted the researchers.

Dermatologic treatment of pediatric patients with dermatitis artefacta should focus on preventing or treating secondary infections and optimizing wound healing, and soaks, emollients, and topical antibiotics can be helpful depending on the cutaneous manifestation of the lesions, according to the investigators. “Ultimately, the recommended therapeutic strategy focuses on identifying and addressing the underlying psychologic causality, instead of solely trying to prevent the act of self-inflicting wounds,” they advised.

BDD is characterized by intrusive, repetitive thoughts about perceived or imagined defects in an individual’s physical appearance, which leads to repetitive behaviors and psychosocial distress. The repetitive behaviors include mirror checking, deliberate positioning of one’s body, excessive grooming habits, or obsessively comparing oneself to others.

“If a patient is suspected of BDD, dermatologists are advised to use open-ended, appearance-specific questions to determine the areas of concern,” recommended the study authors. “Dermatologists should also approach these perceived physical concerns in a sympathetic and sensitive manner.”

BDD is most associated with suicidal ideation and attempted suicide among the 3 disorders in this review. After a diagnosis is made, dermatologists may initiate a discussion by acknowledging the psychologic impact on the patient, it was suggested. Dermatologists also may offer practical skincare regimens to replace unhealthy routines. “The idea of a referral to mental health should be discussed carefully with both the patient and the parent after a therapeutic relationship has been formed,” advised the investigators. “Cognitive-behavioral therapy with deliberate exposure and response prevention is recommended first-line therapy for pediatric patients.”

Delusions of parasitosis, also referred to as Morgellon disease, is a disorder in which patients have a fixed-false belief that they are infested with parasites, which may result in self-inflicted injuries to remove the perceived insects. DOP-P occurs when a patient believes someone close to him or her, typically a family member, is infested with pathogens and most frequently occurs in children of parents with primary delusional disease.

“Assessing any immediate harm to the child is essential when these cases present to the dermatology clinic,” stated the study authors. “When the child is undergoing unneeded, often harmful, home remedies, such as bathing with pesticides or bleach, at the direction of the parent, it may be necessary to involve child protective services.” Successful treatment of the parent with primary disease, most often with antipsychotics, is necessary for effective management of pediatric patients with DOP-P, noted the researchers.

“We encourage dermatologists to continue to seek to be more knowledgeable about the mental state of their pediatric patients,” the study authors concluded.

Reference

Mosca M, Martin K, Hong J, Hadeler E, Brownstone N, Koo J. A review of the diagnosis and management of pediatric psychodermatologic conditions: part II. Pediatr Dermatol. 2022;39(1):12-16. doi:10.1111/pde.14885