Skin signs of neurological diseases

Author: Dr Sara de Menezes, Basic Physician Trainee, Alfred Health, Melbourne, Australia. DermNet New Zealand Editor in Chief: Hon A/Prof Amanda Oakley, Dermatologist, Hamilton, New Zealand. December 2016.

Introduction

Neurological diseases associated with skin signs include:

• Neurocutaneous disorders
• Neuropsychiatric disorders and addictions
• Disorders related to drug abuse.

Neuropathic itch is also discussed in this topic.

Neurocutaneous disorders

Neurocutaneous disorders are a group of congenital multisystem diseases that result in the growth of tumours in the brain, spinal cord, skin and other organs.

Tuberous sclerosis complex

Tuberous sclerosis complex (TSC) is an autosomal dominant syndrome caused by mutations in the tumour suppressor genes, TSC1 and TSC2. Diagnosis of TSC is based on major and minor clinical criteria. Major features have higher specificity for TSC than minor features. Note that there is no single diagnostic feature, and none are specific for TSC.

Skin manifestations of tuberous sclerosis include:

• Major features:
  • Facial angiofibromas or forehead plaque
  • Non-traumatic ungual or periungual fibromas
  • Three or more hypomelanotic macules
  • Shagreen patch (a connective tissue naevus).
• Minor features:
  • Multiple and randomly distributed dental enamel pits
  • Gingival fibromas
  • Confetti skin lesions.

Other clinical manifestations include retinal nodular hamartomas, and lesions in the kidneys (angiomyolipomas), heart (rhabdomyomas) and brain (subependymal giant cell astrocytomas, cortical tubers). Patients often have learning and behavioural difficulties and seizures.

Cutaneous signs of tuberous sclerosis

Angiofibromas

Ungual fibroma

Ash leaf macule

Neurofibromatosis

Neurofibromatosis is an autosomal dominant condition with three distinct clinical subtypes:

1. Neurofibromatosis type 1 (von Recklinghausen disease; NF1)
2. Neurofibromatosis type 2 (NF2)
3. Schwannomatosis.

Similar to tuberous sclerosis, patients with neurofibromatosis can have learning difficulties.

Cutaneous features of NF1 include:

• Café-au-lait macules (flat, brown marks)
• Neurofibromas of any type, including plexiform neurofibroma
• Axillary or inguinal freckling
• Lisch nodules (brown spots on the iris).

Cutaneous features of NF2 include:

• Café-au-lait macules
• Cutaneous schwannoma or neurilemmoma (purplish plaques)
• Cutaneous neurofibromas (uncommon; indistinguishable from NF1).

Non-cutaneous features of NF1 and NF2 include:

• Bilateral vestibular schwannomas (seen on CT or MRI imaging)
• Meningiomas, ependyomas/gliomas of the central nervous system
• Schwannomas of the spinal cord, cranial and peripheral nerves
• Hearing loss
• Paralysis.

Features of schwannomatosis include:

• Multiple painful schwannomas in peripheral and paraspinal nerve roots
• Vestibular schwannomas do not occur (unlike in NF2)
• A normal lifespan.

Cutaneous signs of neurofibromatosis

Café au lait macule

Neurofibromas

Axillary freckling

Ataxia-telangiectasia

Also known as Louis-Bar syndrome, ataxia-telangiectasia is a rare autosomal recessive disorder that affects the central and peripheral nervous systems. Ataxia (unsteady gait) is often the earliest clinical manifestation of this condition.

Cutaneous telangiectasias (spidery blood vessels) develop after the age of 3 years. They begin in the corners of the eye (ocular canthus) and spread to the membrane covering the eye (bulbar conjunctiva). Telangiectasias may later develop on the cheeks, ears, eyelids, chest, and skin folds of knees and elbows.

Other cutaneous features of ataxia-telangiectasia include:

• Dry skin
• Grey hair
• Scleroderma (atrophy and sclerosis) of the face, arms and hands
• Recurrent impetigo
• Seborrhoeic dermatitis and blepharitis  
• Non-infectious cutaneous granulomas
• Basal cell carcinomas.

Non-cutaneous features of ataxia-telangiectasia include:

• Recurrent bacterial or viral sinus and lung infections
• Immune deficiencies with reduced IgA, IgE and IgG
• Dysarthria (unclear speech) over time
• Deterioration in fine and gross motor skills, with patients, often relying on wheelchairs to mobilise.

Sturge–Weber syndrome

Sturge–Weber syndrome is a rare disorder that involves vascular malformations affecting the face and eye, which correspond with a leptomeningeal angioma, a vascular tumour in the brain. This often causes corresponding neurological and ocular deficits.

Neurological features are progressive and can include seizures, focal neurological deficits and intellectual disability. Visual field defects are also common if the occipital cortex of the brain is involved.

Sturge-Weber syndrome

Sturge-Weber syndrome

Neuropsychiatric and addiction disorders

Psychiatric disorders are central nervous system conditions with a neurobiological basis. They generally involve disturbances of emotion, cognition, motivation and socialisation. Psychiatric disorders can either lead to psychocutaneous (skin) manifestations as a consequence or they may arise as a result of a chronic dermatological condition that impacts on the patient’s mental health.

Psychocutaneous disorders

There are four main types of primary psychocutaneous diseases.

Delusional disorder

A delusional disorder may present as delusions of parasitosis.

• In such cases, there is a fixed, false belief by the patient that they are infested with parasites. This may be the only overt manifestation of psychosis.
• Patients present with ‘matchbox sign’ – that is, they present ‘evidence’ of parasites to the clinician in the form of skin crusts, clothing lint or debris (collected in a matchbox or another small container).
• Excoriations and ulcers are the results of the patient’s attempts to eradicate the ‘parasites’.

Delusions of parasitosis

So-called

Factitious disorder

A factitious disorder may present as dermatitis artefacta.

• In these cases, there is intentional skin injury to allow the patient to fall into the ‘sick role’ and assume illness behaviour.
• Lesions can be in any site but are usually in areas readily accessed by the patient.
• The lesions may have sharp/defined borders and cannot be diagnosed as a known skin disease. They are surrounded by completely normal skin.
• Patients fail to provide a clear history of the evolution of the lesions.
• Dermatitis para-artefacta may be a conscious or semi-conscious manipulation of skin, mainly stemming from impulse control problems (eg, trichotillomania is the repetitive pulling of hair).

Dermatitis artefacta

Cigarette burns

Chemical burns

Petechiae due to coining injury

Somatic symptom disorder

Somatic symptom disorder (previously known as a somatoform disorder) may present as cutaneous dysaesthesia.

• Cutaneous dysaesthesia is also known as atypical chronic pain syndrome.
• There is burning, pain or dysaesthesia (unpleasant sensation) from being touched.
• No physical cause for the symptoms is identified.

Compulsive disorder

A compulsive disorder may present as obsessive–compulsive disorder (OCD).

• OCD is an anxiety-related condition associated with repetitive or routine-based behaviours that help the patient to relieve anxiety (eg, compulsive handwashing, compulsive skin picking).
• Compulsive washing can lead to dry skin and irritant contact dermatitis.
• Lichen simplex is a thickened area of the skin resulting from chronic rubbing.
• OCD may also be associated with trichotillomania or skin picking.

Cutaneous signs of a compulsive disorder

Skin picking

Nail fold picking

Trichotillomania

Disorders related to drug abuse

The use and abuse of drugs may cause cutaneous manifestations and skin disease as a result of local and systemic toxic effects from the drugs involved.

Chronic alcohol abuse and liver disease

• High circulating bilirubin due to liver disease associated with alcohol abuse presents as jaundice (yellow skin).
• The low albumin associated with chronic alcohol abuse and liver failure can cause Muehrcke lines (leukonychia or white lines on nails) and Terry nails (white nails with red tips).
• Alcohol raises oestrogen levels and high oestrogen may result in gynaecomastia (breast enlargement), palmar erythema and telangiectasia.
• The impairment of coagulation factors through heavy alcohol consumption may cause purpura (easy bruising) and bleeding.

Cutaneous signs of alcohol abuse

Jaundice

Terry nail

Palmar erythema

Nicotine and cigarette smoking

• The ‘nicotine sign’ is a yellow/orange discolouration of fingertips and nails from cigarette smoking.
• Fingernail clubbing may indicate chronic lung disease as a result of smoking.
• Smokers also present with signs of premature skin ageing, including wrinkles due to the impairment of elastin and collagen function in the skin.

Cutaneous signs of cigarette smoking

Tobacco staining

Clubbing

Smoker’s lines

Cocaine injected under the skin (‘skin popping’)

• Cocaine use causes skin necrosis, chronic skin ulcers and fibrosis (scarring).
• The skin of cocaine users can also appear atrophic, hypopigmented or hyperpigmented.

Intravenous heroin use

• Heroin users present with ‘track marks’ (linear, cord-like scars following a vascular distribution) from needling.
• Cutaneous nodules, ulcers, panniculitis, skin infections related to intravenous drug use and dermal hardening are all associated with intravenous heroin use.
• ‘Soot tattoo’ — the darkening of the skin from injecting heroin mixed with debris — is also seen in heroin users.

Cutaneous signs of drug abuse

Hyperpigmentation and scarring due to skin infection

Neuropathic itch

Pruritus (itch) can originate from anywhere in the nervous system. Examples of conditions associated with neuropathic itch include:

• Post-herpetic neuralgia — itch or pain that complicates recovery from herpes zoster (shingles)
• Brachioradial pruritus — localised pruritus of the arms as a result of compression of cervical nerve roots (C4–C6)
• Notalgia paraesthetica — localised itch between the shoulder blades as the result of nerve entrapment of the posterior rami of spinal nerves arising at the thoracic vertebrae T2–T6.
• Meralgia paraesthetica – localised itch on the lateral thigh as the result of nerve entrapment of the lateral femoral nerve (L2–L3) under the inguinal ligament.

Neuropathic pruritus

Postherpetic pruritus

Notalgia paraesthetica

Brachioradial pruritus

Types of Neurological Disorders That Affect The Skin

Neurological disturbances are defined as severe diseases resulting from genetic or inheritance factors and prime acquired reasons due to force majeure, incidents, or trauma-concerned circumstances. The severity of such disorders is connected with the complicated nerve ties and the uninvestigated brain functionalities.

Scientists have proven that the initial conjunction between the nerve system and the skin cells is established at the level of embryo development.

The dermatological problems accompany four types of psychological abnormalities: 

• depression,
• jitteriness,
• insanity, and
• delusional parasitosis.

All psychodermatological illnesses need the primary correction to prevent more difficult health problems, leading to a more atrabiliary state of the nerve system. Thus, one of the hazardous ailments related to neurological disorders is tuberous sclerosis. Such a disease is caused by a wide range of behavioral, psychological, mental, neuropsychological, and psychosocial problems, which most doctors neglect. However, the clinical trials emphasize that approximately 85% of the examined cases also have epilepsy which quickly affects the weak neurological system. Due to its genetic nature, the tuberous sclerosis complex is well-known in certain medical circles as hardly probable abnormality subject to treatment procedures.

So, the patient could only eliminate some symptoms of this dangerous disease to eradicate this insidious health problem.

Neurology and the skin: triggers, effects, and healing methods

Neurology requires permanent attention and scheduled medical examinations to avoid the various health problems affecting all human organs (brain, skin, lungs, etc.). The most visible and complex nervous effects on the skin or patients have obsessional states that lead to mini or macro self-injured traumas.

Delusional parasitosis

The main signs discover a controversial belief in being invaded or infected with parasites. To be correct, sufferers have fake perceptions like stinging, crawling, or being bitten. They can not distinguish their cues from real crawling perceptions. Therefore, these neurological disorders qualify as the primary psychiatric diseases.

Dysmorphic disorder

Patients have obsessional complaints about their minor defects in appearance. They usually focus on the nose, lips, hair, chest, or genitals. Such patients draw attention to themselves with increased concern about the sensations of their appearance. They are often socially isolated, as all of their attention is on the face (primarily the nose and lips). In addition to particular symptoms, patients often focus on this obsession. Moreover, they are absorbed in skincare, sitting for a long time in front of a mirror and meticulously assessing their appearance.

Artifactual dermatitis

The nature of the disease refers to self-harm actions against the skin, often using some accidental items. The self-damage reactions have no explanation, and patients refuse their role in the skin injuries or rash occurrence.

Neurotic excoriation

They are usually observed in middle-aged women in the form of a repeated uncontrollable desire to pinch, rub, scratch the skin. Typically, the scalp, face, upper back, outer forearms, lower legs, and hips are affected, but these manifestations can be anywhere. The size of the lesion can vary from a few millimeters to several centimeters, and its occurrence can be diverse: from small superficial erosions to deep rounded or linear ulcerations with a raised edge and finally to hypo- and hyperpigmented scars.

Excoriated acne

The neurological diseases frequently jeopardize young women and are characterized by permanent damage to areas of the skin with acne eruptions, which patients squeeze out or tear off. Acne of very moderate severity is accompanied by solid excoriation. The lesions become more profound, which subsequently ends in scarring of the skin.

Trichotillomania

The pathology is expressed in hair pulling on the scalp, eyebrows, eyelashes, and pubic hair. There is an opinion that trichotillomania should be attributed to obsessive compulsions. According to the diagnostic criteria, the patient feels an involuntary desire to touch, pull, rub their hair, bringing them satisfaction and relief.

Munchausen syndrome

The history of the disease presented by the patients resembles the nature of far-fetched, excessive drama, and implausibility. Typically, these patients are admitted to the clinic with acute pain, bleeding, loss of consciousness, and other symptoms. Such patients even undergo repeated abdominal surgeries. Complaints can be abdominal, hemorrhagic, neurological, and dermatological. In the case of the cutaneous variant, the patients cause and artificially support skin diseases. This pathology is referred to as behavioral and hypochondriacal disorders.

Nodular prurigo

These neurological diseases are referred to as psychodermatological due to biopsy itching, which is practically regarded as self-destruction.

Lichen simplex chronicus

The disease, as a rule, occurs in adults and designates hyperpigmented lichenified rough patches caused by scratching and rubbing and accompanied by itching. Patches are localized on the back of the neck, extensor surfaces of the forearms, ankle joints, wrists, and genitals. The precursors are xerosis and atopy. The round-shaped patches are usually detected in women’s back of the neck and men’s genital areas.

The list of the possible neurological diseases affecting the skin or other organ’s functions is not exhausted. That’s why each particular case is unique and needs special tests and diagnostic procedures adequately executed by professional neurologists, dermatologists, psychologists, and so on. So, the treatment plan will be based on the comprehensive examination deliverables.

However, the core factor for all nervous disorders is stress. In this case, physical exercises, mental therapy, and relaxation activities would be effective instruments to reach the comparative normal living conditions.

Otherwise, the clinical interventions would have poor benefits in the case of the inherited brain-affected disorders. They could not entirely be treated, but the qualified remedy procedures dedicated to removing the core signs and symptoms of the accompanying diseases could enhance the healing probability.

Tuberous sclerosis complex: inheritance, signs, and treatment

The comprehensive clinical picture is shocking. The so-called tuberous sclerosis complex is a multisystem genetic disease associated with a wide range of pathological manifestations which affect the brain, skin, kidneys, eyes, and lungs. Nearly 80% of the respective patients have the accompanying health problems and injured organs listed above due to these genetic illness effects. Moreover, 90% of the interviewed sufferers with the confirmed tuberous sclerosis complex have additional neuropsychological abnormalities.

Even though modern neurology has made significant progress in diagnosing and treating many physical manifestations of this disease, neuropsychiatric disorders remain poorly understood. Skin injuries are a single indicator to detect the severity.

Skin symptoms include:

• an initially pale hypopigmented macula that develops during infancy or early childhood;
• angiofibroma of the face set in late childhood;
• congenital pebbled spots meaning enlarged lesions, corresponding to an orange peel, usually on the back;
• subcutaneous nodules;
• areas colored like cafe au lait;
• subungual fibroids that could develop at any time during childhood or early adulthood.

To receive a correct diagnosis, the patient should undergo special tests investigating the genetic prosperities. In particular, both of the following criteria are required:

• identification of pathogenic mutation of either the TSC1 gene or the TSC2 gene in DNA from healthy tissue; and
• 2 extensive features or 1 prominent segment with ≥ 2 minor ones.

The treatment approach should be based on the medical procedures dedicated to comprehensive or local therapy. This approach has a straightforward explanation. TSC is not entirely subject to the whole healing; however, it could eliminate its symptoms. For instance, skin problems are commonly remedied by dermabrasion tools or using a laser technique.

Nervous system and dermatological pathology

Author:
L. D. Kalyuzhnaya, Doctor of Medical Sciences, Professor, National Medical Academy of Postgraduate Education. P. L. Shupika, Kiev

11/26/2019

The connection of the skin with the nervous system is determined primarily by embryogenesis. After fertilization, the embryo rapidly divides, and on the 1st week it begins to implant in the uterine wall. In the next 3 weeks, the process of gastrulation is carried out (the cells form 3 primary germ layers: endoderm, mesoderm, ectoderm). It is from this embryonic period that an obvious connection between the nervous system and the skin is seen.

Ectodermal cells begin to be responsible for both the epidermis and the neuroectodermal formation. The neuroectoderm first forms the epidermis, then the neural tube. At the 8th week of gestation, the epidermis is stratified, and already from the 15th week keratinization begins, by the 22nd-24th week the epidermis has already formed and consists of 4-5 layers. In early embryonic development, two populations of specialized cells arise – melanocytes and Langerhans cells, which migrate into the epidermis. Melanocyte precursors migrate from the neural tube to the bottom of the mesenchyme of the primitive epidermis. This explains the presence of such a group of hereditary diseases as phakomatoses (neurocutaneous diseases), which include Louis-Bar syndrome, Stürge-Weber syndrome, neurofibromatosis, Bourneville-Pringle disease. But the problem of the connection between skin pathologies and the nervous system is not limited to heredity and features of embryogenesis, since other factors are also involved in this problem: the role of the central and peripheral nervous systems; congenital and acquired pathologies; direct participation of the nervous system in the severity of the course of dermatosis; tendency to exacerbate and relapse; participation in the implementation of itching; neurotic dermatoses and, as already mentioned, neurocutaneous dermatoses.

Consider the psychodermatological group of diseases.

Despite the fact that there are many difficult patients in dermatology – patients with vulgar bubble, skin lymphomas, various genermatosis, psoriatic erythroderma and severe atopic dermatitis (blood pressure) with biopsying itching, one of the most difficult diagnostic and treatment category is patients with self -deportictive dermatosis. And although these conditions are based on primary mental disorders, patients, due to the severity of skin symptoms, turn primarily to a dermatologist. It has been established that in a third of dermatological patients it is necessary to pay attention to their emotional and psychological problems. Most psychodermatological patients, as a rule, refuse to be referred to a psychiatrist and are even outraged by such a formulation of the question. As long as they find many explanations for their indignation and refusal of direction, the situation looks rather strange. The doctor needs to assess the degree of psychological illness of the patient, since it is extremely important for the psychiatrist to establish the true nature of the psychological pathology. For example, patients with psoriasis and eczema are often willing to talk about the effect of stress on the onset of the disease. However, patients with an illusion of parasitosis usually refuse any discussion regarding their psychological status, since they cannot assess their condition. Patients who are oppressed by the symptoms of illusory parasitosis, as a rule, do not accept any discussion of their condition using terminology related to the field of psychology, and do not want to go into this assessment. The patient does not attach importance to the referral to a psychiatrist, is negatively disposed towards the doctors who previously treated him, sometimes writes complaints about them. In this case, the dermatologist has two options. Firstly, still insist on a consultation with a psychiatrist / psychologist, but at the same time be prepared for a long “siege” – the doctor must present the patient and his family with convincing evidence of the diagnosis, various therapeutic approaches and demonstrate the difficulties on the part of dermatological practice. Another approach is to “ignore” the psychological component of the patient’s illness and thus leave the psychological problems untreated. Such an approach should be recognized as suboptimal. For example, a patient with dermatozoic delirium will be left without special therapy and will subsequently switch from one dermatologist to another, ignoring their recommendations and directions.

In dermatology, the term “pathomimia” is predominantly used, which means all skin autodestructive manifestations that reflect nosologically heterogeneous hypochondriacal mental disorders. Psychodermatological diseases can be differentiated into two groups: a psychodermatological condition and the underlying psychopathology of the disease. Psychodermatological patients, for whom a specific treatment is recommended by a dermatologist, most often have obvious mental disorders, most of which fall into four categories:

• alarm condition;
• depression;
• psychosis;
• dermatozoic nonsense.

Dermatozoic delusions (DT) (syn.: external zoopathy; delusions of skin parasites; induced DT). The main signs are: false persistent belief in invasion or infection with parasites; patients have experience of sensations from stinging, crawling or biting; the need to distinguish from the real feeling when crawling. DB falls into the category of primary psychiatric illness. This is a disorder in which patients form a false and fixed belief that they are infected with parasites in the absence of any objective signs of invasion. Frequently, patients with BD experience “pins and needles”, which allegedly confirms the sensation, reminiscent of stinging, biting and crawling insects. The average age of patients with DB is 50 to 60 years. A large number of observations have shown that women over the age of 50 get sick twice as often as their male peers, and before 50 there is no such difference.

Dysmorphic disorders (DR). Among dermatological patients, patients with dysmorphias make up 10-14%, mostly people aged about 33 years. Patients with DR are preoccupied with insignificant or mild defects in appearance. As a rule, the nose, lips, hair, chest or genitals become the subject of their increased attention. Often this anxiety is expressed in an obsessive state or ritual behavior. Dermatologists, primarily those involved in cosmetic procedures, and plastic surgeons are more likely to encounter people with DR associated with minor and imperceptible skin changes. Such patients attract attention with increased concern about their perception of their own external appearance. They are often socially isolated as all their attention is on the face (primarily the nose and lips). In addition to certain symptoms, patients are often focused on this obsession and are absorbed in skin care, sitting for a long time in front of a mirror and meticulously assessing their appearance. The prevalence of this pathology is unknown; according to some data, in the United States, 1% of the population can be attributed to such a cohort of patients. The widespread craze for plastic surgery, the pursuit of momentary “rejuvenation”, which has been rapidly gaining momentum over the past decades, undoubtedly requires deep study from the point of view of psychiatry. One gets the impression that this approach is somewhere in the category of “dysmorphia”. Moreover, the solid funds behind such aggressive intervention in appearance and uncontrolled advertising practically lead to the induction of aging stars and the public, who are not frightened even by obvious examples of unsuccessful, disfiguring plastic surgery and negative consequences for health and life.

Artifical dermatitis (AD) (syn.: actual dermatitis) is more common in women. The essence of the disease is self-damage of the skin, often by foreign bodies. The motivation for AD is unknown. The rashes are located at a distance accessible to the hand. AD is a psychocutaneous disorder in which patients, by self-damaging the skin, thus realize a psychological need that they are not always aware of. At the same time, a person suffering from AD denies his involvement in this process. Some patients cause artificial skin damage in response to acute psychological stress, the vast majority of patients suffer from their own result. Even when the cause of a skin lesion is established, this disorder is difficult to diagnose and treat. Rashes with this type of dermatitis can copy any dermatosis. They are single and multiple, unilateral or bilateral, although they are usually located at arm’s length, they can also be provoked by external additional means. The rash is usually blistering to purplish and can be caused by sharp objects, chemicals, injections of foreign substances. Rashes are of different sizes, bizarre, geometrically irregular outlines, linear or polygonal, which suggests a diagnosis. It should be noted that some patients, due to an incorrect diagnosis by a dermatologist, undergo long-term and unsuccessful treatment, including systemic corticosteroids and cytostatics. Predominantly ill adolescents and young people, mostly female.

Neurotic excoriations (NE). Usually observed in middle-aged women in the form of a recurring uncontrollable desire to pinch, rub, scratch the skin. Usually the scalp, face, upper back, outer surfaces of the forearms, lower legs and thighs are exposed to this effect, but these manifestations can be in any area. The size of the lesion can vary from a few millimeters to several centimeters, and its appearance can be very diverse: from small superficial erosions to deep round or linear ulcerations with a raised edge, and finally to hypo- and hyperpigmented scars. There are frequent cases when patients pull out hair on the head, which resembles cicatricial alopecia. As already mentioned, NE is predominantly affected by women, and of any age, but patients from 30 to 50 years old predominate.

Excoriated acne. More common in young women, it is a subgroup of neurotic excoriations and is characterized by permanent damage to skin areas with acne rashes that patients squeeze out or pluck. Often, acne of very moderate severity is accompanied by strong excoriations. The lesions become deeper, which subsequently ends with scarring of the skin.

Trichotillomania. Predominantly found in children and young girls. Pathology is expressed in pulling out hair on the scalp, eyebrows, eyelashes and pubic hair. There is an opinion that trichotillomania should be attributed to obsessive states. According to the diagnostic criteria, the patient feels an involuntary desire to touch, pull, rub the hair, after which he feels satisfaction and relief. Usually the patient twists the hair around his finger and then pulls it out. The site of injury is single, often very large. In some patients, the pathology is combined with trichophagia (chewing and swallowing hair), which can lead to intestinal obstruction.

Munchausen syndrome. First described in 1951. The history of the disease stated by the patients is in the nature of far-fetchedness, excessive drama and implausibility. Usually these patients come to the clinic with complaints of acute pain, bleeding, loss of consciousness and other symptoms. Often such patients even undergo repeated abdominal operations. Complaints can be abdominal, hemorrhagic, neurological and dermatological. In the cutaneous variant, patients cause and artificially maintain skin diseases. This pathology is referred to as behavioral and hypochondriacal disorders.

Particular attention deserves itching, especially chronic, which accompanies many dermatological diseases. A number of authors emphasize (and rightly so) that the suffering caused by constant excruciating itching is not inferior to severe pain. It is curious that in modern literature such specific, in our opinion, skin pathologies with an obvious clinic, as prurigo nodosum and chronic lichen simplex, are also referred to as psychodermatological diseases. This is explained by the presence of unbearable itching, which in some cases turns into an uncontrollable and uncontrollable realization of an irresistible desire.

In the general population, itching is more common in people with depression – 18% (versus 9% in people without depression). In elderly and senile patients (from 50 to 91 years old), itching is the most common symptom and accounts for 29% of all complaints, and ² / ₃ patients subjectively rated itching as severe. The frequency of chronic itching in the population: 8.4% among 40 thousand in Norway; 13.9% among 200 adults in Germany; among dermatological patients: psoriasis – 87%; BP – 100%; urticaria – 100%; uremic diseases – 10-70%; hepatic diseases – 15-100%.

First of all, it is worth mentioning AD, in which itching of varying intensity is present in the clinic in 100% of cases. The role of neuropeptides in the pathogenesis of AD may not be the main one, but it is obvious that these substances influence the development and course of the disease. After various non-specific trigger factors, as well as after scratching, free nerve endings in the skin release neuropeptides.

Nodular prurigo (NP) . Often occurs in patients with AD and xerosis, characterized by deep nodes with a scaly-crust located in the center. The process is localized mainly on the extensor surfaces of the limbs. UP occurs in all age groups of patients, but mostly in middle-aged women, and most often on the extensor surfaces of the limbs, while the face, hands and feet are extremely rarely affected. Itching in UP causes severe scratching and lichenification, but the reason for their development has not been explained. In modern literature, this disease is referred to as psychodermatological due to the presence of biopsy itching, which is practically regarded as self-destruction.

Lichen simplex chronic (syn.: limited neurodermatitis, Vidal’s lichen). The disease usually occurs in adults and is characterized by hyperpigmented, lichenified, rough plaques caused by scratching and rubbing and accompanied by itching. Most often, plaques are localized on the back of the neck, extensor surfaces of the forearms, in the ankle joint, wrists and genitals. Preceding factors are xerosis and atopy. The plaques are usually round in shape with a preferred localization in women – in the back of the head and back of the neck, in men – in the perineum and on the scrotum.

And finally, speaking about the connection of skin diseases with the nervous system, one cannot fail to note the following: many chronic dermatoses either begin or worsen due to stress. Dermatologists know this fact; in clinical practice, such a dependence is often seen in psoriasis, skin lymphoma, lichen planus and other skin pathologies. All of the above once again reminds of the mandatory interdisciplinary solution of many dermatological diseases.

Medical newspaper “Health of Ukraine 21 stories” No. 20 (465), June 2019R.

• Number:
• Medical newspaper “Health of Ukraine 21 stories” No. 20 (465), date 2019

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Stress and skin diseases — St. Petersburg State Budgetary Institution of Health “Dermatovenerological Dispensary No. 4”

The skin is highly sensitive to psychogenic and situational influences.

Psychogenic pruritus, localized or generalized hyperhidrosis (sweating) and others tend to regress after stress relief.

There is a group of dermatosis manifestation and subsequent recurrence of which is mediated by mental trauma.

The skin more often than other body systems becomes an “accomplice” to mental illness ( neurotic excoriations, trichotillomania, zoopathic delusions, dysmorphophobia, cheilophagy, onychophagia , etc. )

Along with vulnerability to stress, expressed in the form of dermatoses, there are also inverse ratios.

Chronic dermatological diseases, torpid to therapy, accompanied by severe itching and rashes, with localization in “intimate places”, as well as in open areas of the skin, can themselves be a severe stress and provoke psychogenic disorders.

Zoopathic (dermatozoic) delusions . Patients are convinced that they are infected with scabies or other parasites. They “see”, “feel”, “touch” insects. This state at the present level of knowledge is the subject of discussion. Many researchers consider this a manifestation of an organic lesion of the central nervous system. Others view this condition as part of schizophrenia, its debut.

These patients require microscopic and other examinations of materials containing “particles” of insects or parasites.

Epithelium, villi, pellets are filled into special containers (“matchbox symptom”) and presented to the laboratory as larvae, eggs or waste products of parasites.

A negative answer is considered only as a reason to expand the circle of institutions for the provision of “material evidence”.

Pest control, handling disinfection requirements, own methods of control, including “extracting insects from the body” can become self-injurious actions: cauterization, use of scissors, needles, razor blades. These injuries are located on easily accessible areas of the body – the face, upper and lower limbs, the upper third of the back.

Such patients pay special attention to linen – chemical treatment, washing, boiling, ironing several times a day, changing clothes.

Neurotic (psychogenic) excoriations-actions accompanied by self-harm, preceded by feelings of discomfort, itching of the skin.

The desire for repeated combing, the removal of a non-existent rash leads to the formation of fresh excoriations against the background of previously unchanged skin, followed by the formation of scars. Scratching is often preceded by visual inspection or touching the skin.