A recent systematic review analyzed the role of multidisciplinary clinics for the treatment of patients with psychocutaneous diseases, including delusional infestation. Due to the complex nature of these conditions, a multidisciplinary approach and holistic management is needed, according to the study.
“Psychocutaneous diseases affect an underrecognized patient population facing misdiagnosis and a reduced quality of life due to knowledge gaps and insufficient awareness,” the researchers wrote. They conducted a systematic review of the literature using PubMed and Google Scholar to report key findings on the importance and benefits of providing multidisciplinary care for this patient population, as well as provide structural evidence for more widespread utilization of these clinics.
Of the 923 studies screened, 23 met the inclusion criteria. “Examined data from the included clinics illuminate the increased need and demand for specialized care,” they said. The combined clinics varied in structure, design, and setting, and provided data on 1677 patients from 12 countries with a variety of psychodermatologic conditions, including delusional infestation, trichotillomania, and dermatitis artefacta.
The analysis showed an overall benefit for the implementation of combined-clinic approach to patient management, with 20 studies reporting overall benefits and/or improved patient outcomes. The researchers recommended a well-informed dermatologist identify patients with psychocutaneous disease and treat based on their comfort level or refer if needed. They also recommended psychiatrists, psychologists, dermatologists, and residents all participate in the consultation and management of psychocutaneous diseases, and in some cases, care can be augmented with case management and social services. “This technique ensures key components related to the pathogenesis of patients’ conditions are accounted for while offering appropriate, individualized therapeutic options,” they said.
However, the researchers found clinicians interested in psychodermatology lacked appropriate knowledge and resources for diagnosis and treatment, and patients experienced barriers to accessing care.
“The implementation of combined clinics provides a cost-reducing avenue in the management of dermatologic disease and psychosocial comorbidity by limiting inaccurate diagnoses, ineffective treatments, unnecessary referrals, and ‘doctor shopping,’” the researchers concluded.
Corresponding author Mohammad Jafferany, MD, discussed these findings further in an interview with The Dermatologist. Dr Jafferany, who has combined training in dermatology and psychiatry, is a board-certified psychiatrist in the department of psychiatry at Central Michigan University College of Medicine, East Campus, in Saginaw, MI.
The Dermatologist: Why did you and your team decide to conduct this study?
Dr Jafferany: Psychodermatology is an evolving field of dermatology. We have conducted several studies in different parts of the world to find out the knowledge and awareness of psychodermatology. In all these studies we found lack of awareness among dermatologists whether they are from Europe, South Asia, Middle East, Eastern Europe, Central Asia, or even the United States.
In some places, due to the growing awareness about the field, psychodermatology clinics have been established. Therefore, we decided to study the benefits and usefulness of these clinics in addressing psychodermatologic disorders.
The Dermatologist: What are some of the challenges of treating primary and secondary psychocutaneous disorders?
Dr Jafferany: The most common challenge in treating primary and secondary psychocutaneous disorders are stigma associated with mental illness on part of patients, followed by lack of awareness and knowledge among dermatologists about psychodermatology.
The Dermatologist: You and your team found that some patients visited multiple physicians and also had various diagnoses, which can impact the patient-provider relationship. Why is it important for dermatologists, and psychologists/psychiatrists, to make sure they understand and build trust with these patients?
Dr Jafferany: A therapeutic bond and building trust is of paramount importance in the management of psychocutaneous disorders. Many patients with psychodermatologic disorders, for example body dysmorphic disorder, doctor shop for treatment of their perceived flaws or defect of their body/skin. This creates a lot of resource wasting and unnecessary procedures. This is where trust and therapeutic rapport come into play with patients, who develop confidence in their providers. This help fosters an atmosphere of comfort and credence in the overall management process.
The Dermatologist: Social stigma for mental health conditions, in general, is a significant issue, and your study also highlighted that it can negatively impact treatment and adherence for patients with psychocutaneous disorders. How can dermatologists address the mental component of primary and secondary psychocutaneous disorders without creating any feelings of shame or embarrassment?
Dr Jafferany: As mentioned earlier, social and mental stigma is a large barrier in the management of psychodermatologic disorders. A knowledgeful and insightful dermatologist, with psychodermatology awareness, can discuss with patients about the psychological impact of skin disease and its role in the causation and aggravation of skin disease. An empathetic and nonjudgmental approach with proper psychoeducation wins the confidence of patient, which helps in the long-term management of psychocutaneous disease.
The Dermatologist: In your opinion, how does combining dermatology and psychology/psychiatry visits help mitigate social stigma around mental health?
Dr Jafferany: Combining dermatology and psychiatry clinics and other liaison services such as social services or case management are pivotal in the management of psychocutaneous disorders. The required psychological support, emotion regulation, distress tolerance, and cognitive restructuring has been proven helpful in mitigating social stigma associated with psychocutaneous disease
The Dermatologist: What areas of future research are needed to improve the treatment of primary and secondary psychocutaneous disorders?
Dr Jafferany: In recent years, particularly last decade, a lot of work has been done on psychoneuroimmunoendocrinologic mechanisms associated with stress and psychocutaneous disorders. The role of stress hormones, various cytokines, and chemical mediators have been involved in several psychodermatologic disorders. Future research directed at deeper levels in understanding the role of these hormones, cytokines, and mediators in causation and perpetuation of psychodermatologic disorders is needed.
The Dermatologist: What key takeaways would you like to leave with dermatologists?
Dr Jafferany: A nonjudgmental and empathetic approach towards patients with psychocutaneous disease improves the therapeutic bond and mutual trust between patient and provider, which leads to better prospectus for the management of the disease. A holistic approach involving dermatologist, psychiatrist/psychologist, social services, and case management has proven useful in several psychocutaneous diseases.
Awareness and knowledge about psychodermatology among dermatologists are an additional bonus in the diagnosis and treatment of psychocutaneous disorders. This requires continuing medical education, psychodermatology symposia, and workshops that incorporate psychodermatology in the curricula of dermatology and psychiatry residency programs. In addition, the use of social media in disseminating information about psychocutaneous disorder and formation of support groups, such as for alopecia, psoriasis, and atopic dermatitis, could be helpful in mitigating social stigma associated with these disorders.
Patel A, Jafferany M. Multidisciplinary and holistic models of care for patients with dermatologic disease and psychosocial comorbidity: a systematic review. JAMA Dermatol. 2020;156(6):686-694. doi:10.1001/jamadermatol.2020.0394