Darkness visible: psychocutaneous disease.

A dejected, overweight young woman with excoriations on her face and arms sits in my examination room. Her intake form says “pimples and itching.” Every few months I see similar patients, almost all women. They’ve been to their primary care providers, seen therapists, and often consulted other dermatologists. It is unclear what they were told and I’m not sure I can offer much help. This woman and her doppelgangers are excoriators and some darkness in their early or present lives has usually set the stage for this type of self-destructive behavior. Compulsive picking is akin to other self-destructive behaviors (like cutting), and it is difficult to manage. Dermatologists and psychiatrists see patients with psychocutaneous disease (PCD) on a regular basis. The broad area is introduced cogently in the article by Jafferany et al. In spite of this and other fine articles on the subject, I cannot think of many patients I have helped or who have been helped by my dermatologic colleagues or psychiatrists. This may be because we are inadequately trained, or because some of us may not be all that interested in these patients. It is easier and more lucrative to spray keratoses with liquid nitrogen, remove skin cancers, or inject Botox. For my psychiatric colleagues, medicating a patient with bipolar illness or depression is a comfort zone. Patients with PCD are difficult-to-treat timesinks and sometimes impossible to reach. The article by Jafferany et al and a recent similar article in the dermatologic literature shed light on this vast dark terra incognito. In dermatology, our journals and continuing medical education (CME) courses focus instead on diseases like psoriasis and enhancements that are funded by industry or the universities. Hyperhidrosis, in some cases a PCD, is on the radar screen but only because expensive fixes like botulinum toxin and transthoracic sympathectomy are therapeutic options. Walter and Dorinda Shelley coined the term “Orphan Patient” in 1988. The concept holds true for many patients with PCD. While CME courses will help some of us, there will still be many of these patients waiting to be “adopted” by caring physicians (ie, dermatologists, psychiatrists, primary care physicians). There are a handful of dermatology-psychiatry liaison clinics which address the needs of these patients, but they reach a small number of such patients. I suspect that the buck will stop with those rare physicians who are willing to adopt these patients and join them on their journeys. These caregivers will need to dispense the “time, sympathy and understanding” of a caring physician to work with these patients in an attempt to cure, relieve, and comfort. To this end, the CME lectures and courses envisioned by Jafferany et al will be of help. It is unclear how many practitioners will be at these courses, and how they will be funded. CME, after all, is heavily underwritten by the Pharmaceutical Research and Manufacturers of America (PhRMA) and other special interest groups. A free, easily accessible online resource on PCD could be created that would serve as a resource for both patients and physicians. Such a Web site could be constructed with the help of some excellent, but not easy to access resources, and it would be a superlative project for a humanistic dermatology or psychiatry resident. Osler wrote: “Carry a small note-book which will fit into your waistcoat pocket, and never ask a new patient a question without note-book and pencil in hand. ..... Begin early to make a three-fold category-clear cases, doubtful cases and mistakes.” Many PCD patients are “doubtful” cases, and they will demand curiosity, study, time and insight. There is no cookbook recipe for success. When a sad-looking young woman with excoriations of face and arms next presents at your office, accessing an online reference on PCD while she is still in the examination room will help one make fewer diagnosis or management mistakes. A therapeutic plan could then be developed that would better serve the patient and caregiver.