Psycho Cutaneous Disorders II PDF

**PSYCHOCUTANEOUS DISORDERS - ll** **MODERATOR: Dr. AKSHAY SAMAGANI** **PRESENTER : Dr. NIKHITHA BILLALAR** Psychodermatology is an increasingly recognized and important branch of dermatology. It encompasses disease that involves the complex interaction between the brain, the cutaneous nerves, th...

**PSYCHOCUTANEOUS DISORDERS - ll** **MODERATOR: Dr. AKSHAY SAMAGANI** **PRESENTER : Dr. NIKHITHA BILLALAR** Psychodermatology is an increasingly recognized and important branch of dermatology. It encompasses disease that involves the complex interaction between the brain, the cutaneous nerves, the cutaneous immune system and the skin. **FACTITIOUS SKIN DISEASE** Clinical deception refers to a spectrum of illness that lies in a continuum depending on the level of intention to deceive at the time of the act, and the motivation for the induced illness. The definition of factitious behaviour is not completely clear since the level of intention may vary, but for the dermatologist the definition by DSM-5 includes: A. Falsification of physical or psychological signs and symptoms, or induction of injury or disese, associated with identified deception. B. The individual presents himself or herself to others as ill, impaired or injured. C. The deceptive behaviour is evident even in the absence of obvious external rewards. D. The behaviour is not better explained by another mental disorder such as a delusional disorder or another psychotic disorder. 1. **DERMATITIS ARTEFACTA** Dermatitis artefacta is a skin disease caused entirely by the actions of the fully aware patient on the skin, hair, scalp, nails or mucosae. These patients hide the responsibility for their actions from their doctors. Epidemiology In adults, female preponderance seen, with the ratio of female to male varying from 20: 1 to 4: 1. prepubertal children have an equal sex ratio, which rises to 3: 1 female predominance by the early teenage years. CLINICAL HISTORY: The \'hollow history\' and shared beliefs: - The story is either a series of fabricated lies or, more commonly, a 'not knowing how the skin lesions happen\'. - The patient often describes the sudden appearance of complete lesions with little or no prodrome. - Lesions appear at an identical stage in development, in crops or groups, more often symmetrically but rarely scattered, apparently at random. - There is usually a lack of disease progression history. - It has been suggested that the patients show a \'belle indifference\' to their predicament as part of a dissociative state and that, in the presence of visible disease, manifest a nonchalance and innocence transmitted through an enigmatic \'Mona Lisa smile\'. Clinical signs: - commonest site of involvement is the face, particularly the cheeks, representing over half the presentations - In children the dorsa of the hands rather than the palms are the next commonest site, then the forearms, most frequently of the non-dominant limb. - There is a particular covert pattern on covered skin where the clothes hide significant mutilation of the breasts, abdominal areas and sometimes the genitalia. - Cutaneous lesions have been produced by every known means of damaging the skin and are therefore polymorphic, bizarre and mimic any of the known inflammatory reactions in the skin The lesions are usually linear, angulated or assume patterns that do not conform to recognized skin disease morphology. - They are often the result of thermal, chemical or instrumental injury - Excoriations may be made with nail files, sanding boards, cheese graters or wire brushes to produce raw, crusty, linear or arciform lesions with characteristic geometrical edges. - Urticarial lesions are initially produced by chemical damage and progress subsequently to blistering, crusting and scarring - \'drip sign' is seen in some cases where corrosive liquids have been uncontrolled and allowed to run over the skin.Bleaches, soaps and household cleaners are most commonly employed by women; industrial acids and automotive fluids by men. Clinical variants: **FACTITIOUS CHEILITIS** - Not common, seen in young girls - Simulation of cheilitis has been produced by applying a crust of paper, glue and colourant. - Reactions of the lips are limited and appear in particular as persistent inflammation with crusting and variable hemorrhage. - The crusts may be very thick with a succession of layers of congealed haemorrhagic exudates resembling a carapace or oyster shell. The haemorrhage can also be impressive with coagulated blood and serum extruding over the lips. This is caused by picking, biting, rubbing and licking. - Differential diagnosis : contact dermatitis, actinic damage **FACTITIOUS NAIL DISEASE** - Traumatic and chemical damage to both the nail and nail fold have been seen in children and adults. - The paediatric cases show chronic paronychia caused by the insertion of nails, pins or splinters. Soldiers avoiding duty have habitually used caustics to damage their fingers. - The characteristic lesions show purpura and haemorrhage around the nail fold but also subungual haemorrhage and pustules. A significant sign is repeated traumatic nail loss occurring singly or multiply on one hand only. **HAIR ARTEFACT.** - A distinctive pattern of hair loss may occur after cutting or shaving. - rough, cropped areas of hair loss or unnatural, patterned shaved alopecia of the scalp or eyebrows. **WITCHCRAFT SYNDROME** - Artefact dermatitis can be provoked on an unknowing and unsuspecting victim by proxy. **CONSTRICTION ARTEFACT** -. Oedema of limbs from constricting bands has been described (Secretan syndrome). It is characteristic that one digit, usually a toe, will be constricted at a time whilst the others are unaffected. **PURPURA ARTEFACT** - Purpura and bruising are seen after suction, friction or blunt trauma. Children produce purpura on the chin by sucking on cups and on limbs by direct mouth suction or with the use of a toy or tool. Shearing stress also produces purpura, tending to present as linear limb lesions. **DERMAL ARTEFACT** - Dermal skin lesions may take the form of panniculitis-type lesions and boggy, fluctuant swellings. Careful examination of an acute lesion may reveal the presence of a needle track where milk, air, faeces, urine, cooking oil, silicone, grease or engine oil has been injected. - Access to needles and syringes may be via medical or paramedical family and friends **POSTSURGICAL ARTEFACT** - There is a group that presents with a non-healing, postsurgical wound. - This may follow a small operation after minor skin trauma, breast biopsy or instrumentation such as a laparoscopy. Wounds \'burst\' after the sutures are removed, become recurrently infected and real organisms such as MRSA appear. Complications and co-morbidities Twenty per cent of patients have a somatization disorder and hypochondriasis. These are co-morbid with anxiety, depression and substance abuse. Complications of dermatitis artefacta include: - Pigmentation disturbances. - Scarring. - Cutaneous infection. - Osteomyelitis. - Fistulae. - Severe infection such as cerebral abscess. Investigations - The diagnosis is usually not very difficult to make and is considered usually quite early on in the patient\'s journey. - it is essential to exclude organic disease. - A skin biopsy may provide essential supportive information but may help to exclude organic disease, but a skin biopsy is not necessary in the majority of cases. - Histology: epidermis damaged by friction or chemicals with a vacuolar dermatitis and lymphocytes around degenerating keratinocytes. Superficial acute and dramatic epidermal necrosis from physical and chemical damage is characteristic of crude damage to the skin. Subepidermal blistering can be produced by thermal and cryodamage. In contrast, the subjacent deeper dermal tissues can appear spared. - Special stains : can reveal silver from silver nitrate caustic damage. - polarized light can identify foreign material **MANAGEMENT** There are three therapeutic aims. 1. Treat the skin appropriately. The skin damage may be extensive, disfiguring and infected, with the potential for scarring and dispigmentation. 2. Time should be taken to identify the nature and extent of the psychological problem. 3. Clinicians need to address why the patient is presenting with dermatitis artefacta. Concommitant affective disease is fairly common and may need to be treated at the same time. **PROGNOSIS** The prognosis is that of the primary psychological disorder. Acute stress reaction can be addressed in a series of short consultations at the time when the dressings are changed. Approximately one-third to one-half of patients continue to develop chronic lesions. Such patients may have a personality disorder (commonly borderline) and need psychiatric assessment. **DERMATITIS SIMULATA** - A skin disease characterised by patients who use an external disguise to simulate disease. - These patients do not significantly damage their skin. Make-up has been used to paint on a rash or simulate a birth-mark. Ex. Red make-up has been used to simulate a port-wine stain on the face. - Most common in children **DERMATOLOGICAL PATHOMIMICRY** - Some patients may intentionally aggravate an existing dermatosis using the explanation of its genesis given by their dermatologist. - It is distinguishable from dermatitits artefacta because the disease looks like an exacerbation of an established skin disease with none of the bizarre physical signs typical of mechanical, chemical or thermal interference. **DERMATITIS PASSIVATA (TERRE FIRME FORME , DERMATITIS HEGLECTA)** - It is caused due to the cessation of normal skin cleansing, producing an accumulation of keratinous crusts. - Common in geriatric or demented patients who suffer from self-neglect - extreme form - Diogenes syndrome. The lesions are the result of self-neglect and comprise cumulative accretions of keratin and dirty debris that forms a thick carapace with time. - Lesions are usually found on the upper central chest, over the back and accumulated as coagulated debris in the groins. - May present with accompanying paranoid, mood disorders or temporofrontal dementia. **MALINGERING** - The American Psychiatric Association DSM-5 definition states that the \'essential feature of malingering is the intentional production of false or grossly exaggerated physical or psychological symptoms, motivated by external incentives such as avoiding military duty, avoiding work, seeking financial compensation, evading criminal prosecution, or obtaining drugs\'. - Malingering may be co-morbid with conversion disorders,personality disorders, and other factitial behaviour. - short term and opportunistic in nature. - Fear, desire and escape are the three main motives for producing false or grossly exaggerated physical or psychological symptoms. Ex.Soldiers feigning disease and disability hope to avoid duty, suspend transfer or be discharged from the service. - Chronic, non-healing, postoperative scars are manipulated with instruments, to maintain sepsis. Hand dermatitis, both irritant and allergic contact, may be perpetuated to seek higher compensation awards. - Treatment depends on the underlying psychiatric illness, if significant psychopathology can be found, but the opportunist response in patients with an underlying personality disorder is poor. **PSEUDOLOGIA FANTASTICA AND MÜNCHAUSEN SYNDROME** - This is a chronic, severe and dramatic subtype of factitious disease. - Characterised by the recurrent nature of the illness, and the frequency and similarity of the repetitive pattern of the complaint in different hospitals (peregrination). - The last element in the syndrome is pseudologia fantastica (pathological lying). This describes the telling of lies about past social history and connections, exploits, wealth and invention of an alias. The patients are usually male, over 30 years of age and travel widely from hospital to hospital. They complain of abdominal pain, haemorrhage or some neurological incapacity. - Skin lesions although rare usually present with, non-healing wounds, widespread blistering or multiple excoriations associated with other somatic complaints. **FABRICATED AND INDUCED ILLNESS ( MÜNCHAUSEN SYNDROME BY PROXY)** - It is seen when the illness in a child is fabricated by the parent, usually the mother, or someone in loco parentis - The history is \'hollow\' with a lack of detail. - Risk factors include single parent, previous abuse, frequent visits to the GP or accident and emergency departments, poverty, overcrowding and young parents. - The victims have a persistent or recurrent illness that cannot be readily explained. The previous diagnoses remain descriptive and not stringent. Symptoms do not respond and laboratory tests are incongruous. The reported symptoms are inconsistent with the presenting health and the symptoms fail to appear in the absence of a certain parent. - The victims are usually infants or toddlers with a mean age at diagnosis of 40 months. - Commonly present with bleeding and bruising, central nervous system depression, apnoea, diarrhoea, vomiting, fever, and rash. - Kicks to the lower body show as irregular, large, deep bruises. - Belt and strap damage appears on the trunk as parallel curved marks. The other skin lesions are usually crude forms of facti-tious dermatitis produced by thermal burns or caustic corrosives on the skin. - Can also be seen in elderly patients. **DELIBERATE SELF-HARM** Self-mutilation of the skin may present with a wide range of lesions, most commonly being cutting, scratching, burning with fire or chemicals, or the insertion of foreign bodies under the skin. Such cases can be associated with suicidal ideation. Deliberate self-harm with suicidal ideation - Self-mutilating behaviour is often grouped with other behaviors, such as self-poisoning, attempted hanging or jumping from heights, as \'parasuicide\' or \'deliberate self-harm\'. - The most frequent lesions are caused by self-cutting, often to the wrists. Burns and ligature marks, and their scars, may also be seen. - The predisposing and precipitating factors for this behaviour are numerous such as that of an underlying psychiatric illness like depression, substance misuse or schizophrenia. - Patients may present with chronic lesions or scarring when this behaviour has become a frequent response to stressors, and such stressors are chronic, such as untreated illness or continuing social problems. Referral for treatment of underlying psychiatric illnesses is indicated where one is present. There is evidence that social intervention is of benefit in improving outcome where these factors are precipitants. **DELIBERATE SELF-HARM WITHOUT SUICIDAL IDEATION** A number of authors have made the case for a distinct syndrome of self-injurious behaviour, or self-mutilation, occurring outside the context of conscious suicidal ideation. Further classification into categories is based on the degree of tissue damage and the rate and pattern of the destructive behaviour: - Major. - Stereotypic. - Superficial/ moderate. Epidemiology Gender Female preponderance noted Age The onset is typically in early life, below the age of 30 years. The mean duration of the syndrome is 12 years. Pathophysiology Predisposing factors: - Genetics have been found a role - other psychiatric conditions such as Personality disorders ( BPD), Eating disorders, depressive and bipolar affective disorders, anxiety disorders, somatoform disorders, OCD, substance misuse disorders and schizophrenia have also been described in association with self-harm. - childhood trauma, including abuse - The patient may experience and describe a strong compulsion to self-harm, similar to compulsion in OCD. - In addition, a marked reduction in pain sensation, or increase in pain tolerance, is described in self-mutilators, although this is not uniform. The act is usually performed in private. Management - Holistic approach with appropriate referral where the disease is associated with another psychiatric diagnosis. - SSRIs have been used, in line with the serotonergic hypofunction hypothesis. Dopamine antagonists and opiate antagonists have also been suggested. Mood stabilizers, B-blockers and analgesics have all been used - Behavioural and psychodynamic techniques are used in group and individual settings. **OTHER PSYCHODERMATOLOGY AND PSYCHOCUTANEOUS DISEASES** **CUTANEOUS DISEASE AND ALCOHOL MISUSE** - Alcohol may have an effect on the skin either directly (toxicity) or indirectly (via mast cells and the peripheral and central nervous system) The effect of alcohol on the liver may also lead to skin disease (porphyria cutanea tarda). - Alcohol dependence and alcohol abuse is a rising problem in the recent times. They rank among the three commonest psychiatric disorders in the community. The prevalence of alcohol abuse and dependence is 4.65% and 3.8%, respectively. - The four-question CAGE questionnaire used as part of a general health enquiry is a consistent indicator of alcohol problems, it is sensitive up to 90%.  **DEPRESSION IN DERMATOLOGICAL PATIENTS** - Depression in patients with dermatological conditions is one of the most overlooked diagnosis by dermatologists. - Depression may affect the skin in several ways: - Skin disease may lead to a loss of self-esteem and so to depression. - Depression may be a co-morbidity of skin disease. - Depression may lead to skin disease. - Medication for depression may lead to skin disease (e.g. lithium and psoriasis). There are three main types of mood disorder: - Major depressive disorder. - Dysthymia. - Bipolar disorder. **SUICIDE IN DERMATOLOGICAL PATIENTS** - Suicide refers to a range of self-destructive behaviours ranging from non-lethal acts, which have been called suicidal gestures, attempted suicide, parasuicide and more recently self-injury, to a lethal action in which a patient dies, defined as a completed suicide. - disfiguring chronic dermatoses have been shown to put patients at risk, like psoriasis. - They can be associated with other psychiatric illness also Assessment of risk when a depressed patient has confided their distress, it is essential that they should be asked about suicidal thoughts. Dermatologists should be aware of the risk factors for suicide: - Prior suicide attempts. - Suicide plans. - Ruminations about suicide. - Depression or anxiety disorder. - Psychotic symptoms. - Unstable mood states, for example as in emotionally unstable personality disorder or in bipolar illness. - Hopelessness. - Substance misuse. - Social isolation. - Physical illness, especially those that are chronic, painful and debilitiating. - Recent substantial loss, for example bereavement, job loss, relationship loss or recent health deterioration. - Impaired insight or impulsivity. **ISOTRETINOIN AND MOOD CHANGES** - oral isotretinoin has been linked to the development of depression and suicidality. - Reported psychological effects include aggression, personality changes, poor concentration, tearfulness, depression, ruminations of guilt and psychosis. These neuropsychological adverse effects have been suggested as a general model for retinoid side effects. - A recent study reported a rise in the risk of attempted suicide in patients both on treatment and after treatment with isotretinoin (incidence ratio 1.57, 95% confidence interval 0.86-2.63). However, the risk of attempted suicide had been increasing before the treatment was started, so it could not be established whether the increased risk during and after treatment was because of the isotretinoin. - There still remains enough doubt about the validity of a relationship between isotretinoin and mood changes - regularly assessing patients for suicide before, during and after treatment should be routine for patients with acne and psychosocial co-morbidities, especially those for whom isotretinoin is prescribed. **SIDE EFFECTS OF DRUGS: PSYCHIATRIC SIDE EFFECTS OF DERMATOLOGIC DRUGS** Many commonly used dermatological drugs can have psychiatric side effects. **PSYCHIATRIC THERAPIES IN DERMATOLOGY** - Psychiatric treatments are divided into physical and psychological. - Physical treatments mostly refers to medication, but also include some other infrequently used modalities, such as electroconvulsive therapy, light box treatment and even psychosurgery. - Psychological treatments cover a wide range of interventions, including anxiety management techniques, cognitive behavioural therapies and psychoanalytical therapies. - The treatment of psychiatric conditions also often involves social interventions, such as attention to housing, occupational or educational interventions and arranging appropriate access to benefits or resources. - The synthesis of the three approaches is often termed the biopsychosocial approach. **MEDICAL MANAGEMENT:** The commonly used psychotropics can be classified as antipsychotics, antidepressants, antianxiety agents, and mood stabilizers. These drugs affect cognitive function, emotions, and behavior. **Antipsychotic Drugs:** They act by blocking the receptors for the neurotransmitter dopamine and are used to treat symptoms of psychosis such as delusions and hallucinations. They are classified as follows: 1. Typical antipsychotics\ E.g., chlorpromazine, perphenazine, haloperi-dol, fluphenazine, trifluoperazine, thiorida-zine, and pimozide. 2. Atypical antipsychotics\ E.g., clozapine, risperidone, olanzapine, quetiapine, ziprasidone, aripiprazole. Typical antipsychotics are called as first-generation antipsychotics (FGAs) and are potent antagonists of D2 dopamine receptors. They are further classified as high-potency and low-potency FGAs. High-potency FGAs: Fluphenazine, haloperidol, perphenazine. Low-potency FGAs: Chlorpromazine, thioridazine. Side Effects of FGAs a\. EPS: It includes akathisia (movement disorder with inability to stay still), dystonia (involuntary muscle contractions with repetitive movements), Parkinsonism, and tardive dyskinesia (involuntary choreoathetoid movements of the face, mouth, extremities, trunk). All patients should be questioned about rigidity, restlessness, slow movements, and shaking during follow-up visits. b\. Metabolic syndrome: Weight gain, diabetes, and hypertension C. Cardiac effects: Q-T interval prolongation, cardiac arrhythmia, and sudden death D. Others: Cholestatic jaundice, agranulocytosis, sedation, and hyperprolactinemia **Atypical Antipsychotics** They are called as second-generation drugs (SGAs) and have weak D2 receptor-blocking but potent serotonin antagonistic activity. Compared with FGAs, they have fewer EPS symptoms with less propensity to cause tardive dyskinesia. Formulations: They are available as standard oral tablets, mouth-dissolving tablets, or in injectable forms. Side Effects of SGAs 1. Metabolic: Weight gain, diabetes, and dyslipidemia 2. Anticholinergic effects: Dryness of mouth, constipation, urinary retention, and blurred vision 3. Cardiovascular: Prolongation of Q-T interval, nyocarditis, cardiomyopathy, and orthostatic hypertension 4. EPS 5. Tardive dyskinesia 6. Seizures 7. Cataracts 8. Others: Sexual dysfunction, sedation, neuroleptic malignant syndrome, and prolactin elevation. **ANTIDEPRESSANTS**: The ADs can be divided into first-generation and second-generation drugs. First-Generation Ads 1. Tricyclic ADs: Amitriptyline, clomipramine, imipramine, and nortriptyline 2. Monoamine oxidase (MAO) inhibitors: Tranylcypromine, phenelzine, and selegiline Second-Generation AD 1. Selective serotonin reuptake inhibitors (SS-RIs): Escitalopram, fluoxetine, paroxetine, and sertraline 2. Serotonin norepinephrine reuptake inhibitors (SNRIs): Venlafaxine, desvenlafaxine, duloxetine, milnacipran, and levomilnacipran 3. Atypical antidepressants: Mirtazapine, bupropion 4. Serotonin modulators: Nefazodone, traza-done, vilazodone, and vortioxetine **Tricyclic AD** They inhibit the reuptake of both serotonin and norepinephrine. Dose Clomipramine 25-100 mg, desipramine 25-300 mg, doxepin 25-150 mg, and nortriptyline 25-150 mg nightly dose. Side effects They block muscarinic, histamine, and alpha-adrenergic receptors causing various side effects. 1. Cardiac: ECG changes, arrhythmias, and orthostatic hypotension 2. Seizures 3. Bone fractures 1. Dry mouth, urinary retention, and constipation 2. Sedation, increased appetite, weight gain 3. Teratogenicity 4. Others: Sexual dysfunction, diaphoresis, tremors, and acute hepatitis **MAO Inhibitors** These are generally third-line antidepressants with a potential for hypertensive crisis and serotonin syndrome, needing dietary restrictions, and thus can be handled only by mental health professionals. **SSRIS** These are generally used as first-line ADs as they have a good safety profile and are efficacious. In addition, they are effective in anxiety, which usually coexists with depressive disorders. Dose Escitalopram 10-20 mg, fluoxetine 20-40 mg, paroxetine 20-40 mg, sertraline 50-150 mg morning time. Side effects 1. Sexual dysfunction and interference with male fertility 2. Weight gain leading to diabetes mellitus 3. Bleeding: Risk of upper GI bleeding and stroke 4. Bone fractures 5. Cataracts 6. Others: Nausea, GI upset, drowsiness, dry mouth, and insomnia **SNRIS** Although these are primarily used in depressive and anxiety disorders, they are also useful in pain syndromes such as diabetic neuropathy and fibromyalgia. Dose Desvenlafaxine 25-100 mg/day, duloxetine 30-120 mg/day, levomilnacipran 20-40 mg per day. Side effects 1. Nausea-most common 2. Constipation, dry mouth, dizziness, and sweating 3. Hypertension 4. Others: Weight gain, sexual dysfunction, and discontinuation symptoms **Atypical Antidepressants:** These are used in patients who do not tolerate or who develop side effects to SSRIs. Dose 1. Bupropion:\ Immediate release tablets: 100-300 mg per day;\ Sustained release tablet: 150-300 mg/day;\ Extended release tablet: 150-300 mg daily 2. Mirtazapine: 15-45 mg at night Side effects Bupropion: Nausea, dry mouth, insomnia, weight-loss, and seizures. Mirtazapine: Dry mouth, drowsiness, increase in appetite and weight. **Serotonin Modulators** Dose Nefazodone: 200-600 mg/day, trazodone: 100-400 mg/day, vilazodone: 10-40 mg/day, vortioxetine: 10-20 mg/day Side effects Nausea, vomiting, somnolence, constipation, dizziness, and sexual dysfunction. **MOOD STABILIZERS** Lithium, anticonvulsants, and atypical antipsychotics. Lithium Dose 300 mg two to three times daily. The target drug level to be maintained should be between 0.8 and 1.2 mmol/L. Side effects 1. Can affect renal and thyroid function 2. Cardiac rhythm disturbances 3. Drug interactions: Lithium levels are increased by thiazide diuretics, NSAIDs, and ACE inhibitors while levels are decreased by potassium-sparing diuretics and theophylline. Anticonvulsants Dose Valproate-500-750 mg/day Lamotrigine---50-200 mg/day Side effects Valproate causes weight gain, nausea, vomiting, hair loss, and easy bruising Lamotrigine causes nausea, dyspepsia, skin rash, and insomnia **HABIT REVERSAL (HR)** It is found to be efficacious in impulse-control disorders such as trichotillomania, skin-picking, eyelashes picking, atopic dermatitis, etc. In HR, patients are trained to reverse the habits (hair-pulling) and control the impulse. There are four important aspects of HR25: 1. Awareness training 2. Competing response practice 3. Habit control motivation 4. Generalization training **BIOFEEDBACK** - Biofeedback refers to the procedure in which the patient gets information about his physiological changes, which he intends to modify in order to learn to reduce anxiety. - Among the various types of biofeedback, the one commonly used in dermatological conditions, especially in hyperhidrosis, acne vulgaris, and eczema, is temperature biofeedback. **COGNITIVE BEHAVIOR THERAPY (CBT)** Most of the patients with dermatological conditions report worries and negative thoughts related to their illness, appearance, relationship, becoming dysfunctional due to illness. CBT aims to modify the client\'s thinking process in an experimental way. Our thought process influences our emotions and it gets influenced by our emotions. So, if the erroneous thought process is corrected, it improves our emotional state and healthy emotional state in turn gives rise to healthy thinking. **REFERENCES** 1. Bewley A and Ruth E. Taylor. In: Cristopher E M, Jonathan Barker, Robert Chalmers. psychodermatology and psychocutaneous Disease. Rooks textbook of dermatology 9^th^ ed. John Wiley & Sons, Ltd.2016; 86.1-86.26 2. Nakamura M , Howard J & John Y. M. In: Kang S, Amagai M,Anna L. Bruckner et al editors. Psychosocial skin disease.Fitzpatrick's dermatology 9^th^ ed. Mc Graw Hill education ltd.2019; 1693-1703 3. Prabhu S , Narang T In: S.Sacchidanand, Savitha A S editors. Psychodermatological disorders. IADVL textbook of dermatology,5^th^ ed,Bhalani publishing house.2022; 2518-2526