Psychocutaneous disorders: a survey study of psychiatrists' awareness and treatment patterns.

OBJECTIVE: To assess the level of training, awareness and attitude about psychocutaneous disorders among psychiatrists. METHODS: A mail-in survey was sent to all members of the Washington State Psychiatric Association and the Washington State Council on Child and Adolescent Psychiatry. Survey respondents were asked about demographic variables, level of training, skills, and degree of comfort in managing psychodermatological disorders, referral patterns, knowledge of patient and family resources on psychodermatology, and interest in continuing medical education on psychocutaneous disorders. RESULTS: A total of 632 surveys were mailed and 223 were returned for analysis. Only 21% of psychiatrists reported a clear understanding of psychodermatology in terms of the interface between skin and the psyche. Twenty-two percent of the respondents reported being very comfortable in diagnosing and treating psychocutaneous disorders. Self-inflicted cutaneous lesions were reported as the most common psychiatric condition associated with a dermatologic component. Medication-related cutaneous rash was the most common diagnosis necessitating referral to dermatologists. About 90% of survey respondents were not aware of any patient or family resources on psychodermatology. Eighty-five percent of psychiatrists expressed interest in attending continuing medical education activities. CONCLUSION: Results of this survey suggest that knowledge about the diagnosis, treatment and/or appropriate referrals of psychocutaneous disorders is lacking. Significant information gaps were also identified about the knowledge of patient or family resources on psychodermatological disorders. Incorporating formal training and didactics on psychodermatology in psychiatry residency programs and regularly occurring CME events are recommended. Psychiatry-dermatology liaison services will prove helpful in the management of these patients.

The knowledge, awareness, and practice patterns of dermatologists toward psychocutaneous disorders: results of a survey study.

BACKGROUND: To assess the level of training in, and awareness and attitude about, psychocutaneous disorders among dermatologists. METHODS: A mail-in survey was sent to all members of Washington State Dermatology Society, who were requested to provide information on demographic variables; level of training, skills, and degree of comfort in managing psychodermatologic disorders; referral patterns, knowledge of patient and family resources on psychodermatology; and interest in continuing medical education on psychocutaneous disorders. RESULTS: Of 237 mailed surveys, 102 were returned for analysis. Only 18% of dermatologists reported a clear understanding of psychodermatology, and 42% of the respondents reported being very comfortable in diagnosing and treating psychocutaneous disorders. Acne, atopic dermatitis and psoriasis were reported as the most common diagnoses associated with psychiatric manifestations. Delusion of parasitosis, neurotic excoriations, and trichotillomania were the most common conditions wherein patients were referred by dermatologists to psychiatrists. About 90% of the survey respondents were not aware of any patient or family resources on psychodermatology. Overall, 39% of the dermatologists expressed interest in attending any kind of continuing medical education activity on psychodermatologic disorders. CONCLUSION: Survey results showed that knowledge about the diagnosis, treatment and/or appropriate referral for psychocutaneous disorders is lacking. Significant information gaps were also identified in the knowledge of patient or family resources on psychocutaneous disorders. We recommend the incorporation of formal training and didactics on psychodermatology in dermatology residency programs and regular CME events. Dermatology-Psychiatry liaison services and psychodermatology clinics will prove helpful in the management of these patients in clinical settings.

Trichodaganomania: the compulsive habit of biting one's own hair.

A 17-year-old male presented with patches of hair loss on both forearms with comorbid depression and anxiety disorders. He had irresistible urges to bite his hair on easily approachable sites and endorsed biting his hair during periods of severe anxiety and boredom, resulting in noticeable patches of hair loss. There was no evidence of trichotillomanic behavior or any other skin pathology resulting in loss of hair at those sites. Microscopy of the bitten end of hairs showed smooth, sharply demarcated, blunted shafts. Trichodaganomania (biting one's own hair) should not be confused with trichotillomania, trichotemnomania, or trichoteiromania. A psychodermatologic evaluation is warranted in the evaluation of these cases.

Winnie the Pooh and psoriasis too: an isomorphic response of guttate psoriasis in a tattoo.

Since Koebner's first observance of the isomorphic response of psoriasis in a tattoo in 1872, a paucity of written reports has appeared in the literature describing this phenomenon, although it appears to be common knowledge among dermatologists. We report a strep-induced guttate psoriasis isomorphic response in a Winnie the Pooh tattoo in a 19-year-old.

Tanning device usage: what are parents thinking?

Tanning device usage is prevalent among adolescents. Few studies have assessed the role of parental influence on children's use of indoor tanning facilities. Our objective was to determine if children's tanning device usage is affected by parental knowledge of risks of indoor tanning or by parental tanning practices. A survey was administered to 160 parents of 328 children at a general pediatrics clinic and 204 parents of 367 children at a pediatric dermatology clinic (parents n=364, children n=695). Over half of all parents and 17% of all teenagers queried had previously used tanning devices. The level of parental knowledge did not predict tanning device usage by their children. However, parental tanning device usage was associated with increased usage by children (p<0.05). Children began using tanning devices on average more than 4 years earlier than their parents. Most parents (69%) never wanted their children to use tanning devices, but only 15% of parents had discussed them with their children. Therefore, health providers can provide an important service by initiating discussions about tanning devices. Additional measures, including legislation requiring parental consent for indoor tanning, are needed to reduce tanning device usage by minors.

Skin cancer prevention in the primary care setting: assessment using a standardized patient.

Our objective was to utilize the standardized patient technique in assessing the ability of primary care physicians to identify and counsel primary prevention for patients at high risk for skin cancer. A secondary goal was to test the feasibility of this technique as a measure of actual physician behaviors in the outpatient setting. We used a convenience sample of 15 primary care physicians. The standardized patient was an 18-year-old woman with skin phototype I. She presented to physicians as needing a general physical examination for a summer lifeguard job at a beach. She stated a family history of skin cancer. Physician performances were rated using a standard checklist completed by the standardized patient following each visit. We found that none of the physicians asked questions specifically related to skin phototype or sun exposure habits such as childhood sunburns. Only 13% asked about mole changes. For counseling, 67% of physicians recommended sunscreen use; only 7% discussed sunscreen types or procedures for effective use. Only 13% counseled other skin protective behaviors. No significant differences by physician gender were found in these areas; however, female physicians counseled more global health behaviors than male physicians (p < or = 0.01). Our pilot data suggest that little skin cancer primary prevention counseling is performed for high-risk patients. The standardized patient technique worked well in obtaining outcome data for physicians' preventive practices.

UV light abuse and high-risk tanning behavior among undergraduate college students.

BACKGROUND: The failure of skin cancer prevention efforts to alter tanning behaviors may be a result of the addictive nature of UV light. OBJECTIVE: This study attempts to determine the prevalence of UV light substance-related disorder (SRD). METHODS: A survey was administered to undergraduate college students. The cut down, annoyed, guilty, eye-opener questionnaire was used to determine existence of SRD. RESULTS: Of 385 respondents, 12% scored positively on the cut down, annoyed, guilty, eye-opener indicating SRD. Women, indoor tanners, students with tanning family and friends, and frequent tanners were significantly more likely than their peers to score positively. LIMITATIONS: The small size is a limitation of this study as results may not be generalizable to larger populations. There also may be self-report bias. CONCLUSIONS: A significant proportion of college students demonstrate evidence of SRD with respect to UV light.

Neonatal lupus.

An otherwise healthy 5-week-old infant with erythematous plaques predominantly on the face and scalp presented to our dermatology clinic. The mother had been diagnosed with lupus erythematosus 2 years earlier but her disease was quiescent. Neonatal lupus is a rare condition associated with transplacental transfer of IgG anti-SSA/Ro and anti-SSB/La antibodies from the mother to the fetus. Active connective tissue disease in the mother does not have to be present and in fact is often absent. Although the cutaneous, hematologic and hepatic manifestations are transient, the potential for permanent heart block makes it necessary for this to be carefully ruled out. As in this case, the dermatologist may be the one to make the diagnosis and should be aware of the clinical presentation, work-up, and management of this important disease.

Skeletal changes in epidermal nevus syndrome: does focal bone disease harbor clues concerning pathogenesis?

Epidermal nevus syndrome (ENS) is a rare, sporadic, congenital disorder of unknown etiology featuring a complex and highly variable phenotype that can include focal or generalized skeletal disease. We describe a young man with ENS manifesting right-sided linear skin lesions, generalized weakness, diffuse osteopenia associated with hypophosphatemic rickets, and distinctive focal bone lesions ipsilateral to the skin findings. Review of the literature concerning ENS-associated skeletal disease suggested such focal bone defects are fibrous dysplasia, but our patient did not have the typical radiographic or histopathologic findings of fibrous dysplasia. Nevertheless, his circulating fibroblast growth factor 23 (FGF-23) level was elevated, likely functioning as a "phosphatonin," yet no activating mutations in GNAS previously reported in fibrous dysplasia or McCune-Albright syndrome were detected in his leukocytes or affected skin. We postulate that the focal skeletal disease, although different than fibrous dysplasia, may be a source of FGF-23 in ENS.

Hemangiomas of infancy: treatment of ulceration in the head and neck.

Ulceration is a common complication of hemangiomas of infancy and presents a therapeutic dilemma for the head and neck-facial plastic surgeon. Multiple therapies are available, further complicating treatment of patients. We review the common characteristics of ulcerated hemangiomas and discuss the treatment modalities available. We present case reports to illustrate management options and a stepwise algorithm for treatment of ulcerated hemangiomas.

Neonate with a fibrosarcoma and consumptive coagulopathy.

We report a case of a neonate with a congenital tumor on the left palm. The patient had a grapefruit-sized tumor and coagulopathy at birth and was presumed to have a hemangioendothelioma with associated Kasabach-Merritt phenomenon. When the tumor failed to respond to systemic steroids, a biopsy specimen was taken, revealing a fibrosarcoma. We describe this case to highlight the importance of including rare tumors, such as fibrosarcomas, in the clinical differential when evaluating a congenital tumor with associated coagulopathy. We discuss subtle differences in clinical presentations that might aid in differentiating vascular tumors from fibrosarcomas.

Tanning facility use: are we exceeding Food and Drug Administration limits?

BACKGROUND: The US Food and Drug Administration (FDA) recommends exposure limits for tanning bed use. Tanning patrons may not be following these recommendations and may be overexposed to damaging ultraviolet radiation (UV). OBJECTIVE: This study was conducted to assess tanning patrons' adherence to FDA-recommended exposure limits and to measure the amount of UVA and UVB radiation emitted by tanning beds. METHODS: A community-based survey was administered during routine state inspections of North Carolina tanning facilities (n = 50). At each facility, patron records were randomly selected (n = 483) for a survey of exposure records, and UVA and UVB outputs were measured for each tanning bed. RESULTS: The recommended limits were exceeded by 95% of patrons, and 33% of patrons began tanning at the maximum doses recommended for maintenance tanning. Average tanning bed output was 192.1 W/m(2) UVA and 0.35 W/m(2) erythemally weighted UVB. CONCLUSIONS: Interventions for tanning bed operators and patrons are needed to increase compliance with federally recommended exposure limits.

Halo scalp ring: a case series and review of the literature.

BACKGROUND: Halo scalp ring is an uncommonly reported alopecia of the scalp that arises perinatally. OBJECTIVES: To describe 5 new cases of halo scalp ring, and to review the literature. SETTING: An outpatient dermatology clinic in an urban area; patients diagnosed in a 2-year period were included in the study. RESULTS: Halo scalp ring is most commonly a temporary, nonscarring alopecia that occurs in patients born to primigravidas. CONCLUSIONS: Halo scalp ring is a distinctive form of alopecia attributed to caput succedaneum. It is underreported and generally has a good prognosis. However, scarring may occur.