Use of psychotropic drugs in dermatology: Unique perspectives of a dermatologist and a psychiatrist
Introduction
Psychocutaneous morbidity complicates more than one in three visits to the dermatologist.1., 2. It is well-established that psychiatric issues contribute to the emotional, social, occupational, and physical morbidity of skin diseases and that they can cause significant patient disability, affect patient compliance with treatment, and hinder maximum treatment outcomes.2., 3. It is by minimizing these issues through appropriate identification and treatment that psychologic stress is reduced and outcome is improved.3 Many dermatologists, however, continue to lack awareness of psychiatric morbidity in their patients and are still unable to detect a considerable portion of pathology.2 Nearly 20% of dermatology outpatients are taking a psychotropic medication4; therefore, psychosomatic issues and their management are an important part of day-to-day dermatologic practice.
The motivated clinician can manage patients with a psychocutaneous disorder or its symptoms. He or she should be comfortable in establishing an alliance with the patient: eliciting pertinent psychiatric and emotional information from the patient, translating this into a diagnosis, and constructing a diagnostically driven management plan. Referral to psychiatry is optimal, but many dermatologic patients refuse such a referral.3 Time constraints and limited capabilities of the dermatologist to provide counseling or psychotherapy can be obstacles to providing nonpharmacologic treatment. The most feasible way for dermatologists to approach patients with psychocutaneous conditions is having a working knowledge of the common psychotropic medications used in dermatology.
Section snippets
General approach
The psychiatric complaints in clinical dermatology can be classified into:
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Psychophysiologic disorders. These are preexisting cutaneous diseases that are precipitated or aggravated by stressors or external factors. Examples of these include psoriasis, acne, and atopic dermatitis.
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Primary psychiatric disorders. These are purely psychogenic and cannot be attributed to any organic or cutaneous cause. The cutaneous manifestations of these are wholly self-induced. This category includes delusions of
Psychotic and delusional disorders
Of the psychotic and delusional disorders, the most frequently encountered is neurotic excoriation, followed by trichotillomania, delusions of parasitosis, and dermatitis artefacta.5 These may evolve from a delusion, which is a fixed, false belief that the patient is convinced is true. This delusion revolves around a solitary concern that manifests itself as hypochondriasis and somatic complaints. These patients are otherwise functional and psychologically intact. When offered tactfully, 60% of
Depression
Nearly 25% of patients presenting with a psychocutaneous complaint have a mood disorder, and of these, 13% meet the criteria for major depressive disorder.5 A relationship between skin disease and depression has been established in conditions such as alopecia areata, neurodermatitis, and chronic urticaria.27., 28.
All antidepressants, regardless of class, are 60% to 80% efficacious.8 The antidepressants commonly used in the dermatologic setting are the tricyclic (TCAs) and tetracyclic
Anxiety disorders
Anxiety disorders can be characterized as acute or chronic anxiety or panic disorders, or phobias directed at specific situations or objects. Anxiolytics and antidepressants are the mainstay of treatment and depend on the acuteness and projected time course of the process (ie, acute or self-limited, or chronic). Treatment may relieve the precipitating stress in psychophysiologic cutaneous disease or minimize the anxiety or phobia arising from dermatologic disease as in secondary psychiatric
Approach to obsessive-compulsive and impulse control disorders
Of referrals to the dermatology clinic, 20% of patients were found to have OCD, with 94% of these patients having no previous OCD diagnosis.70 An obsession is defined as an intrusive, recurrent, ego-dystonic idea, while a compulsion is a behavioral response to an obsession. These may manifest as pathologic skin picking, trichotillomania, or neurotic excoriation.
The SSRIs fluoxetine, paroxetine, sertraline, citalopram, escitalopram, and fluvoxamine are first-line medications for OCD. They
Cutaneous sensory disorders
Cutaneous sensory disorders refer to sensations that occur without underlying pathology. Patients may describe uncomfortable feelings of burning, stinging, crawling, or biting.3 These symptoms may generally be classified as cutaneous dysesthesia or pruritus.
Conclusions
The management of psychocutaneous disorders depends on a multidisciplinary approach that includes referral to psychiatry; however, the patient can create barriers to this type of supportive management. In this case, the dermatologist can provide treatment by establishing a working alliance with the patient and offering psychotropic medications. This requires working knowledge of the common psychotherapeutics used in dermatology and frequent follow-up to monitor for clinical efficacy and side
References (78)
- et al.
Prevalence of psychotropic medication use among cosmetic and medical dermatology patients: a comparative study
J Am Acad Dermatol
(2006) - et al.
Aripiprazole in delusional parasitosis: Case report
Prog Neuropsychopharmacol Biol Psychiatry
(2007) - et al.
Therapeutic update: use of risperidone for the treatment of monosymptomatic hypochondriacal psychosis
J Am Acad Dermatol
(2000) - et al.
A clinical paradigm of delusions of parasitosis
J Am Acad Dermatol
(2008) - et al.
Obsessive-compulsive disorder in a dermatology outpatient clinic
Gen Hosp Psychiatry
(2005) - et al.
Adverse effect of paroxetine on sperm
Fertil Steril
(2010) - et al.
Neurotropic and psychotropic drugs in dermatology
Dermatol Clin
(2001) - et al.
Low-dose mirtazapine: a new option in the treatment of antipsychotic-induced akathisia. A randomized, double-blind, placebo- and propranolol-controlled trial
Biological Psychiatry
(2006) - et al.
Severe chronic urticaria: response to mirtazapine
J Am Acad Dermatol
(2005) - et al.
Mirtazapine for reducing nocturnal itch in patients with chronic pruritus: a pilot study
J Am Acad Dermatol
(2004)
Selective activation of postsynaptic 5–HT1A receptors induces rapid antidepressant response
Neuropsychopharmacology
Efficacy and safety of naltrexone, an oral opiate receptor antagonist, in the treatment of pruritus in internal and dermatological diseases
J Am Acad Dermatol
Naltrexone for neurotic excoriations
J Am Acad Dermatol
Psychiatric disorders in patients attending a dermatology outpatient clinic
Dermatology
The classification of psychiatric morbidity in attenders at a dermatology clinic
Br J Psychiatry
Psychodermatology: a practical manual for clinicians
Curr Probl Dermatol
Psycho-cutaneous disorders: an epidemiologic study
J Eur Acad Dermatol Venereol
The presentation and treatment of delusional parasitosis: a dermatological perspective
Int Clin Psychopharmacol
Pimozide in dermatologic practice: a comprehensive review
Am J Clin Dermatol
The recognition and treatment of pathological skin picking: a potential neurobiological underpinning of the efficacy of pharmacotherapy in impulse control disorders
Psychiatry (Edgmont)
Secondary delusional parasitosis treated with paliperidone
Clin Exp Dermatol
Treatment of delusional parasitosis with aripiprazole
Arch Dermatol
Successful treatment of delusional disorder with low-dose aripiprazole
Psychiatry Clin Neurosci
100 years of delusional parasitosis. Meta-analysis of 1,223 case reports
Psychopathology
Pimozide in the treatment of monosymptomatic hypochondriacal psychosis
Acta Psychiatr Scand
Delusional parasitosis: case series of 8 patients and review of the literature
Ann Acad Med Singapore
Delusions of infestation treated with pimozide: a follow-up study
Acta Derm Venereol (Stockh)
Antipsychotic safety and efficacy concerns
J Clin Psychiatry
Psychosomatic dermatology (psychodermatology)
J Dtsch Dermatol Ges
Aripiprazole augmentation of venlafaxine in the treatment of psychogenic excoriation
J Clin Psychiatry
The neurocognitive effects of aripiprazole: an open-label comparison with olanzapine
Psychopharmacology (Berl)
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