Is It a Skin Disorder or Paranoia? Expert at SDPA Discusses Psychodermatology

During his talk at the 2025 Society of Dermatology Physician Assistant (SDPA) annual summer meeting, Theodore Rosen, MD, vice chair of dermatology at Baylor College of Medicine, shared the case of a patient who was convinced tiny spaceships and tiny aliens landed on her head and were going to screw into her.

No reasoning from others changed her mind. To her, the spaceships were there. She injured her head to get rid of them.

“She lost touch with reality,” Rosen said. “She needs mental health professionals. Not me, not you.”

This patient was experiencing delusions of parasitosis, also called Ekbom syndrome. This disorder is characterized by fixed delusions—fixed, despite contrary evidence.

The aforementioned patient thought spaceships were on her head, but other patients may think that parasites or bugs have gotten under their skin. For safe measure, Rosen recommends doing a biopsy. These patients could be prescribed risperidone 1 – 3 mg/day, aripiprazole 2 – 10 mg/d, and pimozide 1 – 5 mg/d.

“It’s not likely to work,” Rosen warned.

What these patients need is a referral to a mental health professional. Rosen’s preferred medication for delusions of parasitosis is pimozide, the second-line treatment; only 50% complete, but those who do all receive benefit. Pimozide should be started at 1 mg/day, and the benefit should be evaluated at 2 – 8 weeks.

The dose can go up to 0.5 – 1.0 mg/day a week, up to a maximum of 5 mg/day. This should be taken in a very low dose because adverse events of a higher dose include visual disturbance, behavioral abnormality, akinesia, akathisia, rigidity, and somnolence.

The first-line treatment for delusions of parasitosis is olanzapine, an atypical antipsychotic. Patients have a greater response rate (75%), but some do not get better. This should be started at 5 mg/day and should be evaluated after 2 – 8 weeks. The dose can increase by 5 mg/day a week until the maximum dose of 20 mg a day. Adverse events of olanzapine include weight gain, somnolence, hyperlipidemia, and hyperglycemia.

Psychotherapy only offers a slight benefit. As Rosen said, “You can’t just talk to someone who lost touch with reality. [You] need medication.”

Another dermatology disease with psychological concerns is trichotillomania. These patients are fixed in reality; they understand that they should not be picking their hair or scalp, and regret it. The best treatment option for this is habit reversal training, which should be done by a mental health professional. For instance, he said that instead of pulling out hair, these patients can learn to think, “turn on the TV.”

For these patients, Rosen recommends N-acetyl cysteine, a simple, cheap, over-the-counter medication. It should be started at 600 mg; it is also available in doses of 900 mg and 1000 mg.

Another disease he talked about was excoriation disorder, where patients have recurring scratching, picking, and digging at the skin. This can be treated like trichotillomania—habit reversal training and N-acetyl cysteine. Another treatment option for excoriation disorder is the SSRI fluvoxamine (50 – 100 mg).

Body dysmorphic disorder, which occurs in 0.7% - 2.4% of US dermatology patients, can be treated with sertraline. This medication should be started at 25 – 50 mg a day. Patients with body dysmorphic disorder may take a high dose of sertraline, such as 300 mg a day. Rosen does not recommend that dermatologists prescribe sertraline.

Another disorder discussed was dermatitis artefacta, an unconscious need to be sick to gain attention. With this disorder, people will self-inflict injuries to their skin, hair, and nails. These patients will often deny causing the lesion and will often have past negative life experiences.

In these patients, Rosen said you can treat the injury if it looks infected. However, for the disorder itself, the patient should be referred to a mental health professional.

Skin diseases may lead to psychiatric disorders, such as anxiety, depression, obsessive-compulsive disorder (OCD), social anxiety, ADHD, conduct disorder, and suicide, among others.

Mental health issues affect a significant portion of patients across dermatologic conditions: 25-41% with acne, 25–30% with rosacea, up to 70% with atopic dermatitis, up to 25% with psoriasis, 30–78% with alopecia, 63–75% with vitiligo, 25–45% with hidradenitis suppurativa, and 23–78% with melanoma (hostility being most common).

Stress worsens dermatologic conditions. To combat stress, patients can focus on lifestyle changes, such as diet, sleep, listening to calming music, or they can seek professional help with therapy or drugs.

Rosen said he will not give drugs for stress—a patient should see a mental health professional. However, he will give a tiny dose of beta-blockers, 25 mg. This will not drop blood pressure or lower heart rate, and can be helpful for patients if they do not have time to see a mental health specialist.

“[It] takes the edge off,” he said.

References

Rosen, T. Psychodermatology: The Skin & the Mind. Presented at SDPA 2025 on Saturday, June 28th in Washington, DC.