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 Table of Contents  
REVIEW ARTICLE
Year : 2019  |  Volume : 20  |  Issue : 4  |  Page : 306-314

Psychodermatoses in children


Department of Dermatology, STD & Leprosy, Government Medical College, Srinagar, Jammu and Kashmir, India

Date of Web Publication30-Sep-2019

Correspondence Address:
Dr Iffat Hassan
Department of Dermatology, Government Medical College, Karan Nagar, Srinagar - 190 010, Jammu and Kashmir
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijpd.IJPD_135_18

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  Abstract 


The relationship between the skin and the psyche is undeniable. Hence, it becomes mandatory for the dermatologists to be alert for psychological conditions affecting the skin. Since cutaneous diseases are well known to cause a significant impact on a patient's quality of life, the relationship works the other way as well. Stress has been found to contribute to the severity of various dermatoses such as psoriasis, atopic dermatitis, and acne. Awareness of psychodermatological disorders among dermatologists will lead to a more holistic treatment approach and better prognosis in this unique group of patients. This article summarizes various aspects of psychodermatology and focuses on psychodermatological disorders as well as highlights the interaction between psyche and skin.

Keywords: Psychodermatology, psychology, skin


How to cite this article:
Hassan I, Keen MA, Bhat YJ, Latif I. Psychodermatoses in children. Indian J Paediatr Dermatol 2019;20:306-14

How to cite this URL:
Hassan I, Keen MA, Bhat YJ, Latif I. Psychodermatoses in children. Indian J Paediatr Dermatol [serial online] 2019 [cited 2019 Nov 13];20:306-14. Available from: http://www.ijpd.in/text.asp?2019/20/4/306/268391




  Introduction Top


Psychodermatology, an interaction between the mind and skin, is a relatively new discipline in psychosomatic medicine. There is a complex interplay between the skin and the neuroendocrine and immune systems. Skin responds to both endogenous and exogenous stimuli; it senses and integrates environmental cues and transmits intrinsic conditions to the outside world. The exact prevalence of psychological factors that affect skin disease is not known; however, it has been estimated to be 25%–33% in various studies.[1] There is an ample evidence in literature suggesting that the course of many cutaneous disorders is affected by stress and psychological events.[2],[3] A holistic treatment approach is needed while managing these patients.[4] It involves addressing with a special approach assisting their psychological need, pharmacotherapy for their psychiatric morbidity, and skin disease.[4] Hence, there is a dire need for integration with professionals in psychology and psychiatry to attend specific cases of these specialties. This cooperation between dermatology, psychiatry, and psychology becomes essential in cases with a predominant psychological event as the starting point of the dermatoses or in cases in which the dermatoses has damaging and unbalancing effect on the psyche. Therefore, psychodermatology is a field of integrated action of three specialties without which it will not be possible to give the appropriate care to the patient.


  Classification Top


Psychodermatology encompasses all the personal and social consequences of dermatoses and the mental and emotional mechanisms involved in their origin, maintenance, or aggravation. Psychodermatoses are the skin changes that:

  1. Are caused by psychiatric problems
  2. Cause psychiatric or psychological disorders due to its clinical manifestation
  3. Influence the psychological state and is maintained or aggravated by it.


Psychodermatologic disorders can be broadly classified under three main categories as follows:[5] psychophysiologic disorders, primary psychiatric disorders (PPsDs), and secondary psychiatric disorders.


  Psychophysiologic Disorders Top


These are the disorders in which the course of a given skin disease is affected by the psychological state of a patient; are often precipitated or exacerbated by emotional stress and/or anxiety in a significant number of cases; and include psoriasis,[6] acne,[7] alopecia areata,[8] rosacea,[9] urticaria,[10] atopic dermatitis,[11] and vitiligo vulgaris.[12] It is imperative for a dermatologist to ascertain various types of psychosocial and occupational stresses in these cases so as to prevent the vicious cycle of stress–disease exacerbation, and thereby the deterioration of the primary dermatological disease.

Although these patients have a good insight into their respective primary dermatological disease, most of them are not able to fully understand the role of psychological factors on their disease. In these patients, besides the treatment of their primary dermatological disease, nonpharmacological as well as pharmacologic therapy such as with benzodiazepines and selective serotonin reuptake inhibitors (SSRIs) are helpful. Nonresponding cases must be referred to a psychiatrist.


  Primary Psychiatric Disorders Top


In primary psychiatric disorders, primary pathology is in psyche, skin complaints being self-induced and secondary. The primary role of a dermatologist is initial suspicion of the disease, establishment of diagnosis, and providing appropriate treatment. The main groups of primary psychiatric disorders are listed in [Table 1]. In some cases, diagnosis is easy, but few PPsDs show a close resemblance to cutaneous disorders. Hence, in order to arrive at a proper diagnosis, a high degree of suspicion is required on the part of the dermatologist. Usually, these patients may have an underlying psychological functional problem such as delusion, obsessive-compulsive disorder (OCD), anxiety, depression, impulse control disorder, and personality disorder, which needs to be addressed besides being given a supportive skin therapy.
Table 1: Primary psychiatric disorders

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  Disorder of Dermatological Beliefs Top


Delusion of parasitosis

Delusion of parasitosis (DOP) (parasitophobia and Ekbom's syndrome) is an unusual psychiatric syndrome in which the patient has a delusion that his or her own body is infested with parasites, seen above 40 years of age, usually in women.[13] These patients usually consult a dermatologist, thereby rejecting the possibility of a mental disease.[14] No amount of explanation or investigations on the part of the dermatologist will convince them that the insects are not present.[15] Characteristic profile is a middle-aged/elderly females presenting in anxious, ruminative, and overwhelmed state after having visited several doctors without satisfaction. The patients narrate about visual and tactile hallucinations of the parasites crawling, burrowing, and biting all over their body. Excoriations are usual, and sometimes, extensively produced in an attempt to extricate the organism.

Prescription of topical insecticides or topical caustics to such patients should be prohibited because it would strengthen the delusional conviction, making psychiatric intervention difficult at later stages. Because of the psychiatric nature of the disorder, patients with DOP should be treated by two professionals – a dermatologist as well as a psychiatrist. In general, however, these patients refuse to consult a mental health professional because they do not recognize that the underlying cause of their symptoms is of a psychiatric nature. Therefore, dermatologists need to know how to effectively treat DOP patients without the assistance of a mental health professional or else a large proportion of these patients will never be effectively treated.[16]

At the outset, actual infestation must be ruled out . The differential diagnosis includes psychiatric disorders such as schizophrenia, psychotic depression, psychosis episode in a maniac patient, formication without delusion, organic causes such as withdrawal from cocaine, amphetamines or alcohol, Vitamin B12 deficiency, multiple sclerosis, syphilis, and cerebrovascular disease. Nonpharmacologic interventions have limited use for DOP patients because the underlying disorder is psychosis. The drug of choice for DOP is an antipsychotic medication called pimozide.[17] Other alternatives include risperidone, olanzapine, quetiapine, ziprasidone, and aripiprazole.[18]


  Disorder of Body Image Top


Body dysmorphic disorder

Body dysmorphic disorder (BDD), also known as dysmorphophobia, is an underrecognized yet relatively common and severe mental disorder. Patients with BDD believe they look ugly or deformed (thinking, e.g., that they have a large and “repulsive” nose or severely scarred skin), when in reality they look normal. As a result of their appearance concerns, they may stop working and socializing, become housebound, and even commit suicide.[19],[20]

Most patients perform repetitive, compulsive behaviors aimed at examining, improving, or hiding the “defect.”[19],[20] Common behaviors include mirror checking, comparing with others, excessive grooming (e.g., applying makeup and hair styling), camouflaging (e.g., with a hat, clothes, or makeup), frequent cloth changing, reassurance seeking, skin picking, and eating a restricted diet. These behaviors typically occur for many hours a day and are difficult to resist or control.

Most BDD patients seen in psychiatric settings have other mental disorders. Most studies have found that major depression is the most common comorbid disorder.[21] Substance use disorders, social phobia, OCD, and personality disorders (most often, avoidant) also commonly co-occur with BDD.[22]

Management of BDD is extremely difficult, every attempt to explain the trivial nature of skin complaints is futile.[23] Although treatment research is still limited, SRIs and cognitive behavioral therapy (CBT) are currently the treatments of choice.[24],[25]


  Impulse Control Disorders Top


Trichotillomania

Trichotillomania (Greek: Thrix, hair; tillein, pulling out; and mania, madness) is one of the types of traumatic alopecia and is defined as the irresistible urge to pull out the hair, accompanied by a sense of relief after the hair has been plucked. Patients with hair pulling represent an extremely heterogeneous group. In the broad spectrum of psychopathologies (from a transient mild habit, through impulse control disorder, the OCD spectrum, various personality disorders [e.g., borderline personality and histrionic personality], BDD, and mental retardation to psychosis), hair pulling may be present as symptom in these disorders.[26] It is noted predominantly in girls and women and occurs more commonly in children than in adults. Moreover, it occurs more than twice as frequently in females as in males.[27]

The hair-pulling behavior is recognized as senseless and undesirable, but is performed in response to several emotions such as increasing anxiety or unconscious conflicts with resultant tension relief. The scalp is the most common site for hair pulling, followed by the eyebrows, eyelashes, pubic area, trunk, and extremities.[26] Most frequently, hair is plucked from one frontoparietal region, which is on the side of manual dominance [Figure 1]. The temporal and occipital regions are usually spared. Typically, the hairs are short, irregular, broken at various distance, and distorted. On the scalp, an ill-defined patch develops in majority, but the full scalp may be involved in some. The clinical presentation of the lesion is characteristic. The linear or circular patches with irregular borders containing hairs of the varying length, the shortest being those most frequently plucked, result due to plucking of hairs either in a wave-like fashion across the scalp or centrifugally from a single point.[26]
Figure 1: Trichotillomania due to compulsive pulling of hair showing broken hair of different lengths

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Trichotillomania appears to be commonly associated with other problematic behaviors such as nail biting [Figure 2] and [Figure 3], skin picking the acne lesions, nose picking, lip biting, and cheek chewing.[28] Medical complications are uncommon, but sometimes may be serious trichobezoar (gastric or intestinal hairball) is rare but potentially life-threatening. It may cause intestinal obstruction gastric or intestinal bleeding or perforation, acute pancreatitis, or obstruction, jaundice, as well as discomforting symptoms such as abdominal pain nausea, vomiting, constipation, diarrhea flatulence, anorexia, and foul breath.[29]
Figure 2: Onychophagia showing short nail plate length, exposure of distal nail bed, and nailfold damage

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Figure 3: Onychotillomania: Compulsive rubbing together of nails leading to nail plate pigmentation and furrowing

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Various therapeutic modalities which have been considered include supportive psychotherapy, directive and autogenic training, behavioral therapy, hypnotic therapy, and pharmacotherapy.[26],[27] The -line strategy should be a trial of clomipramine. Response to imipramine, isocarboxazid, trazodone, and sertraline and isolated cases that responded to amitriptyline and buspirone are reported.

Efficacy for the combination of selective serotonin reuptake inhibitors (SSRIs) (flavoxetine, paroxetine, sertraline, and citalopram) and neuroleptics (haloperidol, pimozide, and risperidone) is observed in uncontrolled studies. There are reports of successful treatment of trichotillomania with sertraline Hcl 50 mg at bedtime and fluoxetine 10 mg daily. Fluocinolone shampoo 0.01% twice weekly has been found beneficial in some cases.

Neurotic excoriations

In neurotic excoriations, the repetitive self-excoriations are usually initiated by an ich or because of an urge to excoriate a benign irregularity on the skin.[30] It affects approximately 2% of dermatological patients[31] and is most frequently seen in middle-aged females. The lesions are found on the forearm and other accessible areas and are generally crusted and scarred with postinflammatory hypopigmentation or hyperpigmentation.

Patients pick at areas until they can pull the material out of the skin, also referred as “pulling a thread from the skin.” Patients admit to an urge to pick and gouge (unconscious or deliberate) at their skin unlike patients with dermatitis artefacta (DA). Newer lesions are angulated excoriated, crusted erosions, whereas older lesions have depigmented scarred center and hyperpigmented periphery [Figure 4]. Prurigo nodularis is an extreme variant of this entity.
Figure 4: Hyperpigmented scars from neurotic excoriations

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Given the established association between psychogenic excoriation and psychiatric disease, it is not surprising that patients with psychiatric comorbidities presenting with skin lesions are often times incorrectly diagnosed with neurotic excoriation, even before completion of a basic workup to rule out other causes. Despite the strong association and incidence of psychogenic excoriation in patients with a primary psychiatric disorder, it is important for primary care physicians and dermatologists alike to realize that these patients may have true dermatological disease. A complete workup is imperative to rule out other dermatological conditions prior to diagnosing a patient with psychogenic excoriation or any other psychocutaneous disorder. Finally, it is of paramount importance for primary care physicians to consult or refer to specialists when a patient presents with unexplained skin lesions so that adequate testing and appropriate treatment is afforded the patient.

Supportive psychotherapy, CBT, and habit reversal programs along with antidepressants help most of the patients.[32],[33]

Acne excoriee

Acne excoriee results in a variant of neurotic excoriation wherein acne lesions are compulsively squeezed and scratched, resulting in scabs and scars. It is more common in females with a mean age of 30 years.[34],[35] It is a self-inflicted dermatosis, which is admitted by the patients. The patients pick on imagined papules and on physical examination, none of the elementary lesions of acne (comedones) are present. Two types of psychological mechanisms explain the picking – habitual picking and emotional picking.

Lesions morphologically resemble chronic excoriation or neurotic excoriations and are found predominantly distributed around the hairline, forehead, preauricular cheek, and chin areas. If the patient has concomitant acne, aggressive treatment with systemic antibiotic and or systemic retinoids must be considered. Treatment is mainly behavioral as medications (for acne or for the psychological distress) are notoriously ineffective. A more effective treatment is through a psychological/therapy: habit reversal therapy (HrT) and/or relaxation. HrT reduces scratching and can be helpful in patients with habitual picking.


  Factitious Skin Diseases Top


Factitial dermatitis refers to a psychiatric condition in which patients self-induce skin lesions in order to satisfy an unconscious or conscious psychological need to assume the sick role. Patients will not admit to creating the lesions, which are usually more elaborate than simple excoriations. Factitial dermatitis should be differentiated from malingering, in which lesions are created deliberately for secondary gain such as collecting disability or evading prosecution.

The current classification differentiates between four groups:

  1. DA syndrome – as unconscious/dissociated self-injury
  2. Dermatitis paraartefacta syndrome: Disorders of impulse control, often as manipulation of an existing specific dermatoses (often semiconscious and admitted self-injury)
  3. Malingering: Consciously simulated injuries and diseases to obtain material gain
  4. Special forms such as the Gardner–Diamond syndrome, Münchausen syndrome, and Münchhausen by Proxy syndrome.


Dermatitis artefacta

DA is a rare self-induced psychocutaneous disorder where the patient denies his/her role in its causation [Figure 5]. Mechanical and chemical devices are most commonly used to produce such injuries. Laboratory investigations, including histopathological examination, are usually nonspecific and do not give a correct clue to diagnosis.[36] Denial regarding the self-inflicted nature of injury/injuries is a common finding.[37] Therefore, confrontation to explore the underlying psychosocial conflicts should be strongly discouraged;[38] rather, a gentle, nonjudgmental, and empathetic approach often works.
Figure 5: Dermatitis artefacta showing linear crusted plaques in accessible areas

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By definition, external incentives, whether economic, legal, or related to body image, are typically absent.[38] Pathophysiology is still an enigma. Several factors such as delayed developmental milestones, marital dispute, loss of close relatives in the recent past, self-guilt, disturbed parent–child relationship, bipolar personality disorders, and sexual and substance abuse are implicated as the precipitating factors.[39],[40],[41] Adults may be neurotic, depressed, hysterical, or paranoid personality disorder patients. The most common site of involvement is face, followed by dorsum of hands and forearm.[42],[43] The lesions are polymorphic, bizarre, clearly demarcated from the surrounding normal skin and can resemble many inflammatory reactions in the skin. They are crude, angulated and have the tendency for linear configuration. They are produced by every known means of damaging the skin.

The ultimate objective is to assume a sick role to fulfill unconscious psychological need for dependency and to form stable body image and boundaries.[38] In spite of the underlying psychiatric disturbances, the patient appears to be cooperative, unconcerned about his/her painful and puzzling lesions, or somewhat bewildered.[38] On the contrary, anxiety and frustration of the accompanying family members and inquisitiveness about the evolution of the lesions are noteworthy.[38]

Munchausen syndrome should be considered an important psychiatric differential, characterized by flamboyant males who feign multiple symptoms and shifting complains not limited to only the skin, just to draw attention.[39] Malingerers inflict injury on themselves for some secondary gain. Malingering is considered to be a crime as malinger is not mental illness.

Confrontation with the patient can be counterproductive, and the patient may flee from the treatment. Clinician needs to build up a relationship with the patient by frequent visits, symptomatic treatment, and gradually explore the complex personality and behavioral derangement that underlies this condition. Antidepressants in the form of SSRI and behavioral therapy are the mainstay of treatment. Dermatological care with bland emollient, topical antibiotics, and occlusive dressing should not be underestimated as the patients tend to be emotionally attached to their skin.[44],[45]


  Psychogenic Pruritus Top


Psychogenic pruritus can be defined as “an itch disorder where itch is at the center of the symptomatology and where psychological factors play an evident role in the triggering, intensity, aggravation, or persistence of the pruritus.” Although psychogenic factors frequently aggravate itch, the pure psychogenic pruritus is rare. It is very important to have positive diagnostic criteria and to not confound idiopathic and psychogenic pruritus. The DSM5 classification proposes to include it among the “somatic symptom disorders.” Diagnostic criteria for psychogenic pruritus were proposed by Misery et al.[46] and are shown in [Table 2].
Table 2: Diagnostic criteria for psychogenic pruritus[49]

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Pruritic episodes are usually unpredictable with abrupt onset and termination, predominantly occurring at the time of relaxation. Psychogenic pruritus can be generalized or localized. The most common sites of predilection are legs, arms, back, and genitals. Often, there is a history of a major psychological stress preceding the onset of psychogenic pruritus.[1] A significant number of patients have associated anxiety and or depression.[47] Detailed cutaneous and systemic examination and routine baseline investigation should be performed to rule out cutaneous and systemic causes of pruritus before diagnosing psychogenic pruritus.

Salient features of other PPsDs are briefly summarized in [Table 3].
Table 3: Salient features of other primary psychiatric dermatoses

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  Secondary Psychiatric Disorders Top


Although skin conditions are usually not life-threatening because of their visibility they can be “life-ruining.” The prevalence of psychological disorders among patients with skin disease has been found to be about 30%–60% in various studies.[48] Chronic skin diseases, particularly those affecting exposed body parts because of the visibility and resultant disfigurement lead to embarrassment, depression, anxiety, poor self-image, low self-esteem, and suicidal ideation in the patients.[49],[50],[51] Persons with disfigurement frequently feel psychologically and socially devastated. Moreover, persons with skin disorders have trouble getting jobs in which appearance is important.[52] It is also well documented that persons with visible disfigurement face discrimination, especially if the condition is perceived to be contagious.[53] Some patients might be able to cope up with the disease, whereas a few develop secondary psychiatric morbidity.

Dermatologist should introspect into this aspect of chronic disfiguring dermatoses. Usually, patients do not discuss the psychological effects of their disease with the treating physician. If the physician notes that the patient is experiencing significant distress, it is important to explore this issue and decide whether referral to a mental health professional or dermatologic support group might help. If the depression, social phobia or secondary psychopathology is of significant intensity, referral to a psychiatrist may be warranted.


  Medication-Related Cutaneous Adverse Effects Top


Various psychotropics can cause dermatological adverse effects [Table 4]. SSRIs, tricyclic antidepressants (TCAs), mood stabilizers, and antipsychotic medications have been implicated in several cutaneous adverse effects that mimic typical skin disease. A sound knowledge of psychiatric medications and their cutaneous adverse effects is important in the management of psychiatric conditions. In addition, patients should be advised about the adverse effect profiles of all treatment drugs.
Table 4: Potential dermatological adverse effects of psychiatric medications

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Cutaneous adverse effects of antidepressants include toxic epidermal necrolysis, Stevens–Johnson syndrome, leukocytoclastic vasculitis, and erythema on sun-exposed areas. Lithium, which is commonly used in the treatment of bipolar disorder, may cause several dermatological adverse effects.[54] Antidepressants have been used as off-label medications in various psychodermatological disorders. Corticosteroids used in dermatological disorders may cause psychiatric symptoms such as cognitive impairment, mood disorders, depression, delirium, and psychosis.

Psychiatric disturbances as a result of dermatological medications are still not fully understood. Isotretinoin, which is used in severe recalcitrant acne, has been implicated in depression, suicidal ideation, and mood swings. There are conflicting reports about the relationship between isotretinoin and depression and suicide. The exact causal role has not been established, and caution is recommended when treating patients with isotretinoin.


  Treatment Approaches Top


The mainstays of treatment for psychodermatological disorders are an empathetic approach toward the patient; a good physician–patient relationship; and a team approach with psychiatrists, dermatologists, therapists, and social services. Dermatologists should become familiar with basic psychopharmacology and simple nonpharmacological interventions. They also need to have good access to the patient, which depends on considering the situation from the perspective of those who experience the disease. In treatment, they should include pharmacological and nonpharmacological resources and always use stress reduction techniques, the major causative agent of diseases. It is convenient, given the current level of knowledge about the mind-skin connection, that dermatology services have psychiatrists and psychologists for interconsultation acting jointly with dermatologists. The absence of this care to patients reduces the dermatological consultations to attempts to repair the effects without seeking the causes, making patients captive attendants of the services without offering a perspective of solution. The treatment goal is to improve functioning; reduce physical distress; improve sleep disturbances; and manage psychiatric symptoms such as anxiety, depression, social withdrawal/isolation, and low self-esteem.

Both pharmacological and nonpharmacological treatments are used to manage cutaneous disorders. The medications include antidepressants, antianxiety medications, antipsychotics, and topical skin preparations. The choice of a psychopharmacological agent depends on the nature of the underlying psychopathology (anxiety, depression, psychosis, and compulsion). SSRIs and TCAs exert their effects through antihistaminic, anticholinergic, and serotonin-blocking properties.

Antipsychotics may be used to augment medications or as monotherapy, particularly in patients with delusions of parasitosis and more recently, in trichotillomania.[55] Other psychiatric drugs used in the psychodermatological setting include gabapentin (postherpetic neuralgia), pimozide (delusions of parasitosis), topiramate and lamotrigine (skin picking), and naltrexone (pruritus). Recently, N-acetylcysteine and aripiprazole have been used successfully in treating trichotillomania.[55],[56] These drugs have been used as evidence-based medications, and in research trials, although not all are FDA approved as psychodermatological treatments.

Several nonpharmacological treatments that have been used in patients with psychocutaneous disorders include supportive psychotherapy, CBT, hypnosis, relaxation training, biofeedback, stress management, and guided imagery.[57]


  Conclusion Top


Skin diseases are not just a cosmetic issue; they are associated with a myriad of psychological reactions that affect patients' level of functioning and can produce agony for the family. An increased awareness about psychocutaneous disorders and a team approach to treatment lead to improved patient outcomes. Separate psychodermatology clinics, training opportunities for physicians and residents in psychiatry and dermatology residency programs, and family education are some of the important methods to improve better understanding and management of psychocutaneous disorders.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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    Figures

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  In this article
Abstract
Introduction
Classification
Psychophysiologi...
Primary Psychiat...
Disorder of Derm...
Disorder of Body...
Impulse Control ...
Factitious Skin ...
Psychogenic Pruritus
Secondary Psychi...
Medication-Relat...
Treatment Approaches
Conclusion
References
Article Figures
Article Tables

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