Elsevier

Clinics in Dermatology

Volume 31, Issue 1, January–February 2013, Pages 92-100
Clinics in Dermatology

Use of psychotropic drugs in dermatology: Unique perspectives of a dermatologist and a psychiatrist

https://doi.org/10.1016/j.clindermatol.2011.11.013Get rights and content

Abstract

Psychocutaneous morbidity is commonly found in dermatologic practice. Patients generally refuse referral to psychiatry, and dermatologists cannot always provide psychotherapeutic support. By establishing an alliance with these patients and with working knowledge of the common psychotherapeutic agents used in dermatology, these patients can be managed comfortably by the clinician. The major categories of psychodermatologic agents include antipsychotics, antidepressants, anxiolytics, and antiobsessive compulsive drugs. In addition, cutaneous dysesthesia and pruritus can be treated with psychotherapeutic agents when other treatments have been exhausted. The motivated dermatologist can apply this knowledge to treat these common yet challenging cases.

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:

  • 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.

  • 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

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