August 2013  << Back  

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Pediatric Psychodermatology: A Clinical Manual of Child and Adolescent Psychocutaneous Disorders

Richard Balon, MD

Wayne State University, Detroit, MI, USA

Edited by Ruqiya Shama Tareen, Donald E. Greydanus, and Mohammad Jafferany. Boston, MA: Walter de Gruyter; 2013; ISBN 978-3-110-273946; pp 550; $140 (hardcover).

The CNS is interconnected with the rest of the body and influences other organs, body systems, and diseases while those organs, systems, and diseases impact the CNS. Various new fields, such as psychoneuroendocrinology, psychoimmunology, and psycho-oncology, have studied the interactions of the CNS with other systems or organs. The relative newcomer among these disciplines is psychodermatology. The relationship between skin, the body’s largest organ, and psyche is assumed in numerous skin diseases, but direct evidence is scarce. The literature is scarcer when it comes to the relationship between the skin and the psyche of children and adolescents and a solid summary text of this topic has not been available. The editors of this large volume fill this void by putting together an international group of 28 authors to bring us all available information about the interrelation of skin, skin diseases, and the CNS of children and adolescents.

The book is divided into 6 parts: I. Interface of dermatology and psychiatry; II. Psychophysiologic disorders; III. Psychiatric disorders with dermatologic manifestation; IV. Dermatologic disorders predisposing to psychiatric disorders; V. Systematic [sic] diseases with psychodermatologic manifestations; and VI. Special issues in management of psychocutaneous disorders. The book also includes an Appendix consisting of 4 “chapters.”

The first part consists of 4 general chapters. Chapter 1, “Perspectives on management of pediatric dermatologic disorders,” is an encyclopedic list of 6 areas: skin infections and infestations, dermatitis, hypersensitivity reactions, miscellaneous skin conditions, dermatologic manifestations of systemic disorders, and disorders of the hair and nail. The description of diseases and their management is brief. The main weakness, as with many other chapters in this book, is the lack of specific illustrations. The Appendix includes pictures of 9 common dermatologic lesions, but are not connected to those numerous diseases listed in this chapter. I am not sure who the intended audience of this chapter is; dermatologists and pediatric dermatologists know many of these diseases or can find them in textbooks and color atlases of pediatric dermatology, while psychiatrists would not be able to use this chapter for either diagnosing or treating these disorders. Chapter 2, “Psychoneuroimmunology and other interactions between skin and psyche,” contains little information about psychoneuroimmunology, which is understandable, as there is little to write about, but then why have a chapter dedicated to this topic? Chapter 3, “A clinician’s approach to psychocutaneous diseases in adolescents: Untying the Gordian knot,” provides a brief guide to interviewing adolescents and even briefer general suggestions on managing an adolescent patient. The last chapter of this section, “Quality of life issues in children and adolescents with dermatological conditions and their wider impact on the family and society,” discusses the impact of skin diseases on the quality of life of children, adolescents, and their families and also includes a solid discussion of quality of life measures in this area.

The 4 chapters of the second part of the book review atopic dermatitis, psoriasis and children, acnes (vulgaris, rosacea, and excoriee), and psychogenic purpura (Gardner-Diamond syndrome). Again, most chapters are too long and focused on providing encyclopedic and minuscule pieces of information (eg, who needs to know that there is an inverse relationship between the number of siblings and atopic dermatitis, and that having ≥3 siblings is protective against atopic dermatitis?). On the other hand, psychological and psychiatric issues are addressed either superficially or not at all—eg, the chapter on psoriasis does not mention lithium, although it may exacerbate preexisting psoriasis and possibly induce de novo psoriasis or cause nail changes. The chapter on acne briefly discusses the complex relationship between depression, suicidality, and isotretinoin (used in treating acne). The authors of the chapter on psychogenic purpura start by saying that it is a very rare syndrome, typically seen in women with psychiatric comorbidity. Why devote a chapter to it in a book addressing pediatric psychodermatology?

The third part includes chapters on body dysmorphic disorder (BDD) in adolescents; delusional infestation in childhood, adolescence, and adulthood; dermatitis artefacta, skin picking, and other self-injurious behaviors; trichotillomania; and psychogenic pruritus with particular emphasis on children and adolescents. Although these chapters deal with topics at the core of this book, they bring information clinicians may not be sure how to use and, on the other hand, some pertinent information is not included. Examples include the note on eye movement desensitization and reprocessing, a treatment technique suggested for treating BDD, without any evidence to support it, or a suggestion on using amisulpiride in delusional infestation without saying that it is not available in the United States. The chapters on skin picking and trichotillomania include pictures; this is good, yet puzzling (why include pictures here and not in other chapters?), and not very useful (the picture of self-cutting is non-contributory). The chapter on psychogenic pruritus seems useful until one reads that the authors prefer to use benzodiazepines for this disease and list escitalopram as an example of benzodiazepine!

The fourth part includes 3 chapters on dermatologic disorders presumably predisposing to psychiatric disorders: disorders of hair loss and skin pigmentation and skin adnexal disorders. These chapters discuss these disorders fairly well, yet provide little evidence that these disorders predispose patients to psychiatric disorders. It is probably more appropriate to say that there are psychological consequences of these disorders (eg, self-esteem issues, depression, or quality of life in disfigurement due to vitiligo).

The 4 chapters of the book discuss systemic diseases with psychodermatologic manifestations: neurocutaneous diseases (eg, neurofibromatosis, tuberous sclerosis); collagen vascular diseases (eg, lupus erythematosus, rheumatoid arthritis); endocrine disorders (eg, diabetes, thyroid diseases); and inborn errors of metabolism (eg, phenylketonuria, Hartnup disease, porphyria). The most clinically useful are on lupus and juvenile rheumatoid arthritis, as these provide more concrete suggestions on managing psychiatric issues in these diseases. The psychiatric aspects of endocrine diseases are more related to the general aspects of these diseases (eg, diabetes) than to their (rare) cutaneous expressions. The same holds for the inborn errors of metabolism chapter.

The last part includes 4 chapters on psychological complications of dermatological treatments; dermatologic manifestations of psychotropic medications, which includes exhaustive tables of all complications, but does not include pictures, which would be beneficial for psychiatrists; nonpharmacological approaches to treat psychocutaneous disorders (again, useful treatments, but why not include a chapter on pharmacological management?); and psychiatric disorders frequently encountered in dermatology practices. The chapter on dermatological manifestations of psychotropic medications includes an important part on serious and life-threatening cutaneous reactions such as erythema multiforme or Stevens-Johnson syndrome. I wish the discussion of Stevens-Johnson syndrome was a bit more discriminative in its listing of medications possibly associated with this condition and discussed in more detail (eg, Stevens-Johnson syndrome associated with lamotrigine). The chapter on psychiatric disorders most frequently encountered in dermatology practices includes quite uneven suggestions on managing these disorders without a sensible suggestion on when to refer them for psychiatric help (dermatologists will not manage eating disorders or borderline personality disorder and the information on management provided in this book is too rudimental for psychiatrists).

The Appendix contains “chapters” about the editors; listing of FDA-approved psychotropic medications for children and adolescents; a glossary of common psychiatric terms; and pictures of common dermatologic lesions (macule, papule, nodule, plaque, etc.). After the Index, the book also includes plate sections with pictures of various conditions. These are useful, but not referenced in the connected text, and some are superfluous, including 3 pictures of a habitual hand washer.

This book is a clear example of a great idea gone wrong, partially due to uneven and perhaps inexperienced editing. Here, while less would be more, the book needs more synthesis and less encyclopedia. It does not contain much child and adolescent information, as there is not much available. A more focused, synthesizing volume with better, clearly defined audience and pictures related to the text—especially for psychiatrists—would be useful. The authors do not focus much on the real connection of skin and psychiatric diseases—the ectoderm. It seems to me that managing disease or disorders of organs originated in ectoderm is more complicated than the rest of the diseases.

Would I keep this book? Yes. Would I buy it? Probably not. Psychodermatology certainly is an important and evolving area; we just need a bit more clinically useful guides.