When the skin is disfigured by disease, it has an impact on the afflicted person. The intensity of the effect depends on many variables including the natural history of the disease, the characteristics of the individual patients and their life situation, as well as the attitudes and assumptions of the culture at large about the meaning of skin disease. Fantasies about skin disease, shared by patients and onlookers alike, relate to guilt, control of bodily boundaries, and perfectionist yearnings. Some issues involved in these fantasies include distortions about contagion, dirt, and sexuality. Ways of helping patients to manage the impact of their skin disease include an empathic doctor-patient alliance, education of patients and the community, and if indicated, referral for psychiatric consultation.