Psychodermatology: A practical manual for clinicians

It is a common experience among dermatologists that a significant proportion of the patients in their practice are seen with psychological overlays to their chief complaint.1 For example, there are patients with self-induced lesions, as in the case of neurotic excoriations, for whom an underlying psychopathology plays an etiologic role in the development of their skin manifestations. There are also patients with real skin disorders such as eczema or psoriasis, for whom psychological factors such as stress play an important role in exacerbating the natural course of their skin disease. Also, many patients develop psychological problems as a result of the disfigurement caused by the skin disease. Moreover, there are patients who have only cutaneous sensory disturbances such as chronic, intractable pruritus or intolerable burning sensations in the groin, for which no, dermatologic or medical findings can be ascertained, in spite of thorough investigations, and for which empirical trials with psychotropic/neurotropic medications may be the most likely solution to this puzzling and disturbing phenomenon. Last, there is growing recognition that psychotropic medications are more efficacious in treating certain bona fide skin disease than are the traditional dermatologic therapeutics. For example, the antidepressant doxepin is generally recognized as a more powerful antipruritic and antihistaminic agent than most of the traditional antihistamines that dermatologists use for this purpose. The antidepressant amitriptyline is also the treatment of choice for postherpetic neuralgia, because its well-known analgesic effects can be helpful even for patients who are not depressed. Because so many different types of conditions lie between the fields of psychiatry and dermatology, it is important to have classification systems that will help the clinician understand what he or she is dealing with. There are at least two ways to classify psychodermatologic cases: first, by the category of psychodermatologic condition, and second, by the nature of the underlying Psychopathologie condition. In terms of the categories of psychological conditions, most psychodermatologic conditions can be classified into five different categories. These are psychophysiological disorders, primary psychiatric disorders, secondary psychiatric disorders, cutaneous sensory syndrome, and those that require the use of psychopharmacologic agents for purely dermatologie (i.e., nonpsychiatric) causes. Even though any one of the numerous psychopathologies listed in the Diagnostic and Statistical Manual of Mental Disorders, 4th edition (DSM IV), can be found among dermatologic patients, in general, those cases in which the Psychopathologic condition of the patient is so blatant as to make it difficult for a dermatologist to ignore generally are seen with four different types of underlying psychopathology: anxiety, depression, psychosis, and obsessive-compulsive disorders. The determinations of the exact category of psychodermatologic disorders and the decision about the underlying psychiatric diagnosis are made independent of each other. For instance, the underlying psycho-pathologic condition characterized by anxiety can be found in any of the different categories of psychodermatologic disorders. For example, in a psychophysiological case, a patient may notice a flare-up of psoriasis in response to an intense anxiety-provoking situation. In a primary psychiatric category, the patient with anxiety disorder may respond to the anxiety by scratching on his skin, resulting in manifestations of neurotic excoriations. In the category of secondary psychiatric disorders, the patient with a disfiguring condition such as alopecia areata may develop intense anxiety with regard to interpersonal interactions, and this may lead to a social phobia. Similarly, depression, psychosis, and obsessive-compulsive disorders are found in basically any category of psychodermatologic disorders. Simply knowing the nature of the Psychopathologie condition does not reveal the categories of psychodermatologic disorder. Conversely, knowing the category of psychodermatologic disorder does not eliminate the need to determine the exact nature of the underlying psycho-pathologic condition. It is important to make the distinction among these categories and the underlying nature of the Psychopathologie condition because these distinctions help guide physicians to select the optimal approach to patients. Moreover, if a dermatologist seriously considers the challenge of treating these patients with psychopharmacologic agents, the selection of appropriate agents is generally dictated by the nature of the underlying psychopathologies that need to be treated. For each of these types of psychopathologies, the following psychopharmacologic agents are available: antianxiety agents, antidepressants, antipsychotic agents, and anti-obsessive-compulsive agents. A dermatologist can enhance his or her therapeutic armamentarium by becoming familiar with the use of selected psychotropic medications from each category of the available agents. Among the antianxiety agents, a quick-acting but potentially sedating and dependency-producing benzodiazepine-type of medication called alprazolam (Xanax) and a nonsedating, nondependency-producing, but slow-onset antianxiety agent buspirone (BuSpar) are discussed in detail. The use of both tricyclic antidepressants such as doxepin (Sinequan, Adapin) and nontricyclic antidepressants such as fluoxetine (Prozac) is described. Of the antipsychotic agents, pimozide (Orap), which is the treatment of choice for delusions of parasitosis, is discussed. For anti-obsessive-compulsive agents, the use of clomipramine (Anafranil), fluoxetine (Prozac), and fluvoxamine (Luvox) are described in detail. Last, some practical suggestions are offered to help optimize the working relationship between the dermatologist and the psychiatrist, two specialists who tend to have different perspectives in analyzing a clinical situation, different styles of communication, and different approaches to management.