Fear of Skin Lesions

What the straightforward reading covers

The 2008 encyclopedia of phobias enters dermatophobia only as a cross-reference to its own entry for skin lesion, fear of, and uses it alongside dermatopathophobia for fears of skin diseases and skin lesions in general.

The book's discussion of dermatitis explains why such a fear needs no elaborate mechanism. Persistent itching without relief can produce a feeling of helplessness and anxiety. Dermatitis can also arise from anxiety in the first place, and can intensify anxieties afterwards, social anxiety in particular. A condition that is caused by distress, causes distress, and is visible to everybody is unusually well placed to become a fear.

Where the second meaning came from

Delusional parasitosis, also called delusional infestation, is a persistent delusion that the body is infested with living or nonliving agents such as parasites, insects or bacteria, when no infestation is present. The name delusional parasitosis has been the commonest since 2015, but the condition has carried a long list of others:

• delusory parasitosis and delusional ectoparasitosis
• psychogenic parasitosis
• Ekbom syndrome
• formication, and cocaine bugs
• parasitophobia, and dermatophobia

It is classified as a delusional disorder of the somatic subtype in the fifth revision of the diagnostic manual. Diagnosis requires that the delusion cannot be explained by another medical condition, that it is the only symptom of psychosis, and that it has lasted a month or longer. The cause is not known, though it is thought to involve dysfunctional dopamine transmission of the kind seen in other psychotic disorders.

The alternative name Ekbom's syndrome honours the neurologist Karl-Axel Ekbom, who published the seminal accounts in 1937 and 1938. The condition is rare, is seen about twice as often in women as in men, and has an average age of 57.

Why the skin findings are real

The skin findings are what bring a person to a doctor. The urge to pick at the skin, and formication, the sensation of insects crawling on or under it, come with tactile hallucinations, and the excoriation leaves marks that are entirely real. Morgellons is a self-diagnosed subtype in which somebody believes harmful fibres are emerging from the skin and causing the wounds.

That is the reason the two words overlapped for so long. A person with a delusion of infestation presents with lesions and a conviction about their cause. A person with a fear of skin lesions presents with lesions and a conviction about their consequence. The dermatologist sees the same skin.

Which specialty owns it

A paper in the Journal of the American Academy of Dermatology in December 1993 set out the problem directly: delusional parasitosis is a psychiatric disorder, but patients usually seek care from dermatologists, and it may occur as the sole psychological disturbance or alongside an underlying psychiatric disorder or physical illness. The authors advocated a dermatology and psychiatry liaison for establishing the differential diagnosis and choosing treatment.

They named the antipsychotic pimozide as the most effective treatment when the delusion is encapsulated, meaning contained and not spreading into other beliefs, while warning that it needs careful monitoring for several potentially serious adverse effects and that relapse often follows discontinuation. Antipsychotics and antidepressants can reduce symptoms more generally.

The obstacle sits before any of that. Few people with the condition willingly accept treatment, because they do not recognise the belief as a delusion, which is what a delusion means. A fear of skin lesions can be discussed with the person who has it. The condition that once shared its name cannot.