A large number of dermatoses occur secondarily, the primary cause being of a psychogenic nature. It is important for the dermatologist to be able to distinguish between these conditions and thus to provide adequate therapy for the patient. When suspecting the presence of dermatosis of a psychogenic nature, it is especially important to take a well-taken personal anamnesis, the family anamnesis for the existence of certain pathological processes of a psychogenic nature in the blood relatives and the pharmacological anamnesis due to the effect of some drugs on mental health.

There is a complex relationship between the skin, the neuroendocrine system and the immune system. The skin is capable of responding to both endogenous and exogenous stimuli. For a better understanding of the pathogenesis, course and treatment planning of psychocutaneous disorders, knowledge of psychoneuroimmunology is required [1].

Stress disrupts the homeostasis of the organism, which in turn has the ability to adapt to these changes, but the chronicity of stressful situations will lead to exhaustion, anxiety and the appearance of a new disease or exacerbation of an already existing dermatosis. There is an ample evidence in literature suggesting that the course of many cutaneous disorders is affected by stress and psychological events [2].

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.

It is a difficult diagnosis to make in adults, it is much more difficult to diagnose in children; hence, these disorders are a frequently misdiagnosed or underdiagnosed entity by dermatologists and pediatricians [3]. It is essential to identify cases of factitious disorders in the pediatric age group to prevent further mental disability and to curb the disease chronicity.

While everyone talks about the most common psychocutaneous problems, there are several others that are more difficult to diagnose and are related to the environment and previous stressful situations that the child has faced.

The most common psychocutaneous dermatoses are Trichotillomania, Dermatillomania, Dermatitis artefacta, Acne excoriate, Neurotic excoriations, Onychophagia.

Psychodermatological diseases can be classified as:

Psychophysiological – exacerbation of the disease occurs as a result of psychological stress: Atopic dermatitis, Psoriasis and Acne vulgaris.

Psychiatric disorders with dermatological manifestations - dermatoses always occur secondarily as a result of psychopathology. This is the most famous group of psychodermatological diseases. Trichotillomania, Neurotic excoriations, Dermatitis artifacta, Chronic lichen simplex, Nodular prurigo. In addition to these dermatoses, pruritus and prolonged cutaneous inflammatory conditions can be observed somewhat less often.

Dermatological diseases with psychological symptoms – psychological symptoms occur as a result of skin changes. Vitiligo, Acne vulgaris, Psoriasis.

Factors that lead to the appearance of psychocutaneous problems in children

Patients suffering from the many disorders that blur the interface between the fields of psychiatry and dermatology are often misdiagnosed and mistreated because of the lack of knowledge and awareness of the underlying disease-causing mechanisms [4].

Two factors that influence the appearance of psychodermatological problems are the existence of a genetic predisposition for emotional instability, and previously experienced trauma. Variations in symptoms largely depend on the degree of trauma, its duration and the consequences it left for the child.

The psychological burden of parental mental illness may not only lead to emotional and behavioral difficulties in children, but also has a more general influence on the children’s social relationships, interests, and academic environment, and thus may affect the children’s overall well-being and life satisfaction [5].

As a reason for the appearance of psychocutaneous manifestations, apart from the genetic predisposition for the existence of a mental illness in the family, previously experienced trauma plays a major role. Very often, these factors are neglected by doctors and these patients are treated very superficially, but every frequent return of the same child leaves room for doubt. Assessment of psychosocial morbidities such psychological trauma and stressful life events are important, as these factors have shown to have a direct impact on skin barrier function and immune response. (6) This heightened level of stress serves as a trigger in the activation of the hypothalamic-pituitary-axis (HPA), mediating immune responses that influence cutaneous disease severity and exacerbation [5].

Prognosis is influenced by predisposing factors, such as a pre-morbid anxious personality, other personality disorder or childhood traumas [physical or emotional abuse] [6].

Skin lesions “call for attention” and highlight an autoaggressive behavior induced by depression, anxiety, and compulsive disorders. Moreover, the patient denies having produced the lesions, and family members, particularly parents, may seek multiple medical consultations before accepting the diagnosis of dermatitis artefacta and the need for psychiatric assessment [7].

Depending on their age, children express the stress they face in a different way. In the absence of a way of expressing the state in which they find themselves, one of the ways of accumulating stress is repetitive behavior aimed at self-harm. Lesions may arise from pre-existing skin problems like acne or urticated papules or they may be created de–novo [6].

In addition to these problems, practice has shown us that in children with psychological problems there is a difficulty in treatment, in them we are faced with the duration of inflammatory skin diseases, the appearance of crusts and self-inflicted wounds in places of previous injuries whose symptoms do not correspond to such an aggressive approach. pruritus without the existence of a somatic etiology, cough in tics that can be equated with an allergic reaction, more common idiopathic inflammatory skin problems.

The average duration of illness is reported to be around 5–8 years with relapses and remissions that parallel stressful situations [6].

Psych dermatology is an expression of the interaction between skin and mind. It is of paramount importance for the clinician to establish an appropriate physician-patient-family relationship in order to diagnose and treat factitial skin diseases [7].

Skin diseases whose basis lies in psychological problems are very often misdiagnosed. Key to the diagnosis is a good relationship with the family and a well-taken history. If a child visits a dermatologist more often with the same or different dermatoses that are prolonged or refractory to therapy, we must always think of the possibility of the existence of another pathology at the basis of the disease. Taking into account the interaction of the skin with the neuroendocrine system, we can say that after gastric problems, skin problems are the second in order that arise as a result of the psychological moment of the child. Dermatologists, pediatricians and psychiatrists are key to diagnosing these conditions. Good multidisciplinary communication can lead to a cure of the condition.

1. Jafferany M, Franca K. Psychodermatology: Basics Concepts. Acta Derm Venereol. 2016; 96: 35-7.
2. Keen HI, Bhat MA, Latif YJ, Insha. Psychodermatoses in Children. Indian Journal of Paediatric Dermatology. 2019; 20: 306-314.
3. Chinmoy R, Maitreyee P, Debasmita B, Bikash Ranjan K. Factitious Disorders in Children: A Diagnostic Labyrinth of Cases. Indian Journal of Paediatric Dermatology. 2019; 20: 134-137.
4. Jafferany M, Patel A. Understanding psychocutaneous disease: psychosocial & psychoneuroimmunologic perspectives. International Journal of Dermatology. 2020; 59: 8-15.
5. Radicke A, Barkmann C, Adema B, Daubmann A, Wegscheider K, et al. Children of Parents with a Mental Illness: Predictors of Health-Related Quality of Life and Determinants of Child-Parent Agreement. Int J Environ Res Public Health. 2021;18: 379.
6. Mohandas P, Srinivasan J, Ravenscroft J, Bewley A. Psychocutaneous disorders in childhood and adolescence. Paediatrics and Child Health, 2018; 28: 533-539.
7. Chiriac A, Brzezinski P, Pinteala T, Chiriac AE, Foia L. Common psychocutaneous disorders in children. Neuropsychiatr Dis Treat. 2015; 11: 333-337.