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Vol. 106. Núm. 6.
Páginas 507-509 (julio - agosto 2015)
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Vol. 106. Núm. 6.
Páginas 507-509 (julio - agosto 2015)
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Psychotropic Drugs in Dermatology
FR-Utilización de psicofármacos en dermatología
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A.M. Rodríguez Martín
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, M. González Padilla
Servicio de Dermatología, Hospital Universitario Reina Sofía de Córdoba, Córdoba, Spain
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Table 1. Main Psychotropic Drugs Used in Dermatology.
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In daily dermatology practice it is not uncommon to encounter psychiatric disturbances that can present as psychodermatoses or as psychological complications of chronic diseases. Delusional parasitosis, psychogenic pruritus, dermatitis artefacta, trichotillomania, and the somatoform disorders belong to the first group, while the archetypal diseases in the second group are psoriasis, atopy, and acne. These patients are usually unwilling to be referred to a psychiatrist and, if referral is achieved, the therapeutic alliance achieved in the clinical interview is lost in many cases. It is therefore necessary for the dermatologist to have a basic understanding of the psychotropic drugs in order to initiate appropriate treatment.1,2

The psychotropic drugs most frequently prescribed in daily clinical practice are the antidepressants, the benzodiazepines, and the antipsychotics (Table 1). Of these 3 groups, the antidepressants—specifically, the serotonin reuptake inhibitors—are the drugs most commonly employed in dermatology consultations. These drugs are safe and have few side effects, the most important of which are gastrointestinal disturbances, insomnia, and sexual dysfunction. They are used particularly in cases of neurotic excoriation, dysmorphophobia, trichotillomania, and chronic pruritus. They must be administered for a minimum of 4 to 6 weeks before the effects become evident, and treatment must be continued for several months. Drug withdrawal must be gradual to avoid recurrence or withdrawal symptoms (anxiety, nausea, diaphoresis, and others).

Table 1.

Main Psychotropic Drugs Used in Dermatology.

Drug  Classification  FDA Indications  Dermatologic Indication  Side Effects  Starting Dose  Maintenance Dose 
Antidepressants
Fluoxetine  SSRI  OCD, MD, EBD, agoraphobia  Neurotic excoriationDysmorphophobiaTrichotillomaniaChronic pruritus  Gastrointestinal effectsInsomniaSexual dysfunctionNo weight gain, except with paroxetine  20mg/d  20-60mg/d 
Paroxetine  SSRI  OCD, MD, GAD, PTSD, agoraphobia, social phobia      20mg/d  20-50mg/d 
Sertraline  SSRI  OCD, MD, PTSD, agoraphobia, social phobia      50mg/d  50-200mg/d 
Citalopram  SSRI  MD      20mg/d  20-60mg/d 
Escitalopram  SSRI  MD, GAD      10mg/d  10-20mg/d 
Fluvoxamine  SSRI  OCD, social phobia      50mg at night  100-300mg at night 
Amitriptyline  TCA  MD  Neurotic excoriationGeneralized pruritusChronic urticariaPostherpetic neuralgia with amitriptyline  Anticholinergic effectsSedationIncreased IOPProlongation QT intervalWeight gain  25mg at night  25-75mg at night 
Doxepine  TCA  MD, GAD, insomnia, chronic pruritus      25mg at night  25-100mg 
Mirtazapine  TeCA  MD      15mg at night  15-45mg 
Anxiolytics
Alprazolam  Short-acting BZ  GAD, agoraphobia  Anxiety states related to chronic diseaseShort-term use(7-10 d)  ToleranceDependenceSedationAnterograde amnesiaParadoxical reactions  0.125-0.250mg up to 4 times/d  0.25-0.5mg up to 3 times/d 
Lorazepam  Intermediate acting BZ  Anxiety, insomnia      1-2mg up to 2-3 times/d  1-2mg up to 2-3 times/d, maximum dose 4mg/d 
Clorazepate dipotassium  Long-acting BZ  GAD, anxiety      10-45mg up to2-3 times/d  10-45mg up to2-3 times/d, Maximum dose 90mg/d 
Antipsychotics
Pimozide  1st generation  Gilles de la Tourette syndrome  Delusional parasitosis  Extrapyramidal symptomsAnticholinergic effectsIncreased PRLProlongation QT interval  0.5-1mg/d  1-6mg/d 

Abbreviations: BZ, benzodiazepine; EBD, eating behavior disorder; FDA, Food and Drug Administration of the United States; GAD, generalized anxiety disorder; IOP, intraocular pressure; MD, major depression; OCD, obsessive-compulsive disorder; PTSD, posttraumatic stress disorder; SSRI, selective serotonin reuptake inhibitor; TCA, Tricyclic antidepressant; TeCA, Tetracyclic antidepressant.

Other antidepressants used in dermatology are the tricyclic (doxepine and amitriptyline) and the tetracyclic (mirtazapine) antidepressants. Both types block serotonin, norepinephrine, and dopamine reuptake, whilst also acting as histaminergic, cholinergic, and α-adrenergic receptor antagonists. These drugs are useful in neurotic excoriation, generalized pruritus, and chronic urticaria. Amitriptyline is used in the treatment of postherpetic neuralgia. The main side effects are sedation, blurred vision, dryness of the mouth, urinary retention, constipation, and increased intraocular pressure. Amitriptyline can produce cardiovascular effects, including arrhythmias and prolongation of the QT interval.

The benzodiazepines act mainly as anxiolytics and sedatives and, in dermatology, they are therefore mainly employed to minimize anxiety secondary to a dermatologic disease. They should only be used for short periods as they can induce tolerance and dependence.

The antipsychotics are a group of drugs that are difficult for dermatologists to manage. The most widely used is pimozide, employed as first-line treatment in delusional parasitosis. Remission is achieved in 50% of cases with doses of 2 to 4mg/d.2–4 Pimozide is a dopamine receptor antagonist, and its side effects include extrapyramidal symptoms, blurred vision, orthostatic hypotension, constipation, and urinary retention. It is important to remember that pimozide can stimulate prolactin secretion and prolong the QT interval.

In conclusion, the management of the psychocutaneous disorders requires a multidisciplinary approach in the emerging psychosomatic medicine units. Collaboration between dermatologists, psychologists, and psychiatrists will provide integral treatment for the patient. It is important to perform an adequate psychological evaluation and be prepared to initiate treatment with psychotropic drugs when necessary. The dermatologist should therefore be aware of the main psychotropic drugs.

Conflicts of Interest

The authors declare that they have no conflicts of interest.

References
[1]
J. Escalas, A. Guerra, M.C. Rodríguez-Cerdeira.
Tratamientos con psicofármacos de los trastornos psicodermatológicos.
Actas Dermosifiliogr, 101 (2010), pp. 485-494
[2]
K.K. Park, J. Koo.
Use of psychotropic drugs in dermatology: Unique perspectives of a dermatologist and psychiatrist.
Clin Dermatol, 31 (2013), pp. 92-100
[3]
J. Gordon-Elliott, P. Muskin.
Managing the patient with psychiatric issues in dermatologic practice.
[4]
S.A. Bliss, J.K. Warnock.
Psychiatric medications: Adverse cutaneous drug reactions.
Clin Dermatol, 31 (2013), pp. 101-109

Please cite this article as: Rodríguez Martín AM, González Padilla M. FR-Utilización de psicofármacos en dermatología. Actas Dermosifiliogr. 2015;106:507–509.

Copyright © 2014. Elsevier España, S.L.U. and AEDV
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