By David J. Elpern, M.D.
J Eur Acad Dermatol Venereol. 2018 Jul;32(7):e265-e266
Keywords: medically unexplained symptoms, somatoform disorders, symptoms, illness, disease
Illness is not the same as disease. Illness refers to “the innately human experience of symptoms and suffering.”1 Disease “is what the practitioner creates in recasting illness in terms of theories of disorder.” A person’s subjective experience of how she feels may not assume an underlying pathology. Illness can be organic, psychological or spiritual. A person can feel ill, but not have a disease.
Consider Sara (not her real name), a 31-year-old social worker who sought dermatological care for a seven-year history of painful vulvodynia and generalized pruritus. Her other problems include severe headaches, interstitial cystitis, unexplained chest pain and depression. She sees a primary care provider, a neurologist, a gastroenterolgist, an urologist, a cardiologist and a psychotherapist in addition to me. In addition, her health anxieties bring her to the emergency department a few times a month. Her physical exam, lab tests, biopsies, and scans are all unremarkable. Her symptoms are real, but she has no disease as understood from a biological construct. We all know how difficult these patients are to treat and how daunting it can be to help them get better.
Seeing patients with diagnostic enigmas like Sara’s induced me to consider a broad category of disorders dermatologists see that are manifested by medically unexplained dermatologic symptoms (MUDS). MUDS are defined as dermatologic symptoms that have little, or no, demonstrable disease findings and often have psychiatric or nonphysical comorbidities.
Although common, costly, and distressing most of these patients receive vague and inaccurate diagnostic labels and are ineffectively treated. MUDS may well be rooted in the patient’s psyche but these individuals usually reject psychiatric therapy.
Medically unexplained symptoms (MUS) are relatively well-known in the literature. A recent book, “Is It All In Your Head?: True Stories of Imaginary Illness” by Suzanne O’Sullivan is an important resource. The prevalence of MUS in the outpatient setting varies between 25 and 50% and is present in 20-30% of patients experiencing chronic and disabling symptoms.2 While studied in primary care, neurology, cardiology and rheumatology, a PubMed search found no mention of medically unexplained symptoms in any major dermatology journal.
I surveyed 200 consecutive dermatology patients seen in my clinic and found that ~ 20% had some form of MUDS.3 This rate is congruent with the estimated prevalence of MUS. Thus, MUDS are more common than we might suspect. While there is presently no published information on MUDS, I propose that MUDS is a useful diagnostic concept that will help dermatologists to categorize and treat patients with some poorly-understood cutaneous disorders, many of which are manifested by annoying or disabling symptoms of pain or itch.
An important caveat: Making the diagnosis of MUDS is a weighty responsibility. It should not be a shortcut to dismissing the possibility of an obscure underlying medical diagnosis. Yet even after a thorough evaluation, some patients’ concerns will remain enigmatic and they should be recognized, accepted and labeled as unexplained.
What I have presented here is really old wine in new bottles. It is time for dermatologists to join our colleagues in neurology (non-epileptic seizures), gastroenterology (inflammatory bowel disease), rheumatology (fibromyalgia), and cardiology (non-cardiac chest pain) and study our patients with medically unexplained dermatological symptoms.
- Kleinman A. The Illness Narratives: Suffering, Healing and the Human
Condition. New York, NY. Basic Books; 1988
- Hatcher S, Arroll B. Assessment and management of medically unexplained symptoms. BMJ. 2008 May 17;336(7653):1124-8. .
- Elpern, DJ. MUDS: In Search of Medically Unexplained Dermatological
Symptoms. Online J of Community and Patient-Centered Dermatol. Sept.
2017: Full Text Link.