Don’t be put off, familiarising yourself with just these medications will cover most presentations.
Psychodermatology will soon become normal, standard practice, according to one expert, but there are simple steps to feel confident during the transition.
“I think we’re going to see this becoming increasingly accepted as being part of normal, standard derm practice,” said Dr Ahmed Kazmi, specialist dermatologist at Fairfield Dermatology Clinic and Sinclair Dermatology.
“I don’t think we’re going to be able to escape it,” the University of Western Australia clinical senior lecturer at told Dermatology Republic.
While anxiety and depression were often present among people with skin disorders, Dr Kazmi’s specific focus was on the primary psychodermatological disorders such as body dysmorphic disorder [BDD], delusional infestation, trichotillomania, skin picking disorder and body-focused repetitive behaviours, psychogenic pruritus, neurogenic pruritus, cutaneous dysaesthesias and dermatitis artefacta.
Managing these issues may seem complex, but Dr Kazmi said that a familiarity with just four drugs would equip doctors to initiate first-line treatment for all of the major presentations.
These were fluoxetine (SSRI), risperidone (antipsychotic), pregabalin (anti-epileptic) and N-acetylcysteine (NAC).
Treating these conditions was not all or nothing, Dr Kazmi told DR.
“If every six months or one year, doctors got better at managing prescribing one of the drugs, within a few years, they’d have a really nice repertoire of psychotropic medication that they could use,” he said.
Doctors may incrementally begin prescribing these medications as they gain confidence, saying “Look, I’m happy to prescribe anti-epileptics and antidepressants, but I don’t want to prescribe antipsychotics,” Dr Kazmi said.
“I think sometimes we fall into this trap of ‘You’re just pure skin, or pure psychoderm’, but the reality is, there’s a psychoderm element to every presentation,” he said.
He gave a step-by-step presentation of what dermatologists should know about safely prescribing psychotropic medication at the recent annual scientific meeting of the Australasian College of Dermatologists in Brisbane.
Fluoxetine
Guidelines backed high-dose SSRIs for body dysmorphic disorder, particularly fluoxetine, sertraline and escitalopram.
The first step was to confirm the diagnosis, excluding OCD, delusional disorder or depression with somatic features. Patients should be screened for suicidality, self-harm and psychiatric comorbidities, he advised.
Absolute contraindications included allergy and monoamine oxidase inhibitors, which needed 14 days to wash out to reduce the risk of serotonin syndrome.
QT prolongation was one caution that might be off putting, but Dr Kazmi noted the susceptible patient groups were those with congenital long QT syndrome, people on QT-prolonging drugs, those with electrolyte abnormalities, cardiac disease, elderly patients, women and people with severe renal or hepatic impairment.
Drug interactions were another caution, particularly with other serotonergic drugs, antiplatelet/anticoagulant therapy, tricyclic antidepressants and antipsychotics and QT-prolonging agents.
The next step was dosing.
“I think it’s important to realise that the doses used for BDD are generally higher than those used for anxiety and depression,” Dr Kazmi told delegates.
“A lot of patients would already come in on these drugs, but the reason they may not be working is because they are sub-optimally dosed.”
Patients would be started on fluoxetine 20mg and increased to doses of up to 60-80mg, with the effects kicking in over months.
It was important to flag with patients that treatment may need to continue for 12 months or more to reduce the risk of relapse, he said.
Common side effects were GI symptoms such as nausea and diarrhoea – which usually had an early onset – as well insomnia, agitation, and sexual dysfunction such as low libido and anorgasmia.
There was a black box warning about suicidal ideation, so patients should be monitored closely in the first four weeks, Dr Kazmi said, noting that the drugs were not linked to more actual suicides.
Consider co-managing with psychiatry if the patient has severe disease, there was no response from the maximum dose after 12 weeks, there was diagnostic uncertainty or the emergence of mania, psychosis or suicidality, he said.
CBT and psychotherapy were also highly effective in these patients.
Risperidone
Anti-psychotics were the first-line treatment for delusional infestation, and the British Association of Dermatologists guidelines recommended risperidone, olanzapine and amisulpride.
Dr Kazmi said it was important to confirm the diagnosis of primary delusional infestation, and exclude secondary causes such as neurological diseases such as Parkinson’s disease, substance use, psychotic disorders or true dermatological conditions.
Contraindications included a known hypersensitivity to risperidone and a prolonged QTc of over 500ms or a history of Torsades de Pointes.
Drug interactions were important to watch for, and these included QT-prolonging drugs, CYP2D6 inhibitors, antihypertensives, CNS depressants and dopaminergic drugs.
Risperidone should be initiated at 0.5mg, with most patients finding 1-2mg per day an effective dose.
“Symptom improvement is actually often relatively fast – it’s not clearance, but it’s an improvement at four to six weeks,” Dr Kazmi said.
“And you always want to continue for at least six to 12 months after resolution of symptoms.”
As with fluoxetine, it was important not to stop abruptly, but to instead taper slowly to avoid discontinuation symptoms, he said.
Monitoring was needed because of the cardiovascular risk, and this included assessing vitals, BMI, waist circumference, fasting glucose, HbA1c, lipid levels. An ECG was needed in patients over age 40, with a cardiac risk or who were on QT-prolonging medication.
“If you feel it’s outside of your realm of practice, see if the GP will be happy to co-manage some of that cardiovascular risk with you,” Dr Kazmi said.
Ideally these patients would be co-managed between psychiatry and dermatology, but it could be challenging, and more complex patients may be better managed by psychiatrists depending on what the local service provision was, he added.
Risperidone should be tapered slowly to avoid dopamine rebound, withdrawal dyskinesia, cholinergic rebound or symptom relapse.
Dr Kazmi said it could help to refer to the medications as “neuroleptics” rather than “antipsychotics” to avoid the negative connotations that might put patients off.
He said he sometimes pre-empted such concerns by saying, “I am aware this drug is also used at much higher doses, sometimes in schizophrenia. I do not think you have that disease. I am not treating you for that disease, and I’m not using the medication in the same way”.
Dr Kazmi said it could also be helpful to mention that many drugs are used in multiple areas of medicine for different conditions, and to build trust and rapport before starting the medication.
N-acetlcysteine
N-acetlcysteine, or NAC, is indicated for trichotillomania, excoriation disorder, nail biting and other body-focussed repetitive behaviours.
“It is an amino acid which is a precursor to glutathione, which modulates glutamate in the nucleus accumbens, which is the area of the brain responsible for impulse, and it restores glutamate balance and reduces compulsive urges,” Dr Kazmi said.
“It’s a lovely drug. Safe, with very few side effects.”
Cautions were for patients with peptic ulcer disease, severe asthma, and pregnancy or lactation.
“The dosing is really easy: it’s 600 milligrams BD, up to a maximum of 3000 milligrams in divided doses,” he said.
“I would recommend a trial of at least 12 weeks, because it can be slow to work and, if you want, you can continue it to get long term effects, especially if they’re a chronic picker.”
No routine blood tests or ECGs were needed, although doctors could consider baseline LFTs and renal function in the elderly, patients on polypharmacy and those with liver or renal disease, Dr Kazmi said.
It could be used alone but was much more effective in combination with SSRIs and CBT, he added.
Pregabalin
Dr Kazmi prefers pregabalin over gabapentin for psychodermatology patients.
“Pregabalin has better bioavailability, better absorption, faster onset of action. It’s more flexible in its up-tapering and, most importantly, it’s licenced in most countries for generalised anxiety disorder – which puts it within the bracket of psychotropic medication,” he said.
As well as neuropathic pain, it was effective for neuropathic itch, secondary significant anxiety, depression or sleep disturbance from a primary dermatosis, he added.
The drug was indicated for neuropathic or psychogenic chronic itch, brachioradial pruritus, notalgia paraesthetica, burning/stinging syndromes, psychogenic paraesthesias , cutaneous dysaesthesia, and itch related to anxiety, insomnia or stress.
Allergy was the only absolute contraindication, but caution was needed primarily around a history of substance misuse, as well as renal impairment, older age and in pregnancy or lactation.
“My dosing tips are to start low and go slow,” Dr Kazmi said.
“So 25 milligrams at night built up slowly and gradually, then at three-to-seven-day intervals, up to 75 milligrams BD, and then up to 150 milligrams BD, with a maximum total 24-hour dose of 600 milligrams split up over the day.”
The dose and side effects would vary a lot from person to person, Dr Kazmi said.
No routine monitoring was needed, other than assessing the disease. But the dose would need adjusting if the patient had renal impairment.
Side effects often happened early and resolved, Dr Kazmi said. The most common were dizziness, drowsiness and incoordination and, less commonly, constipation and dry mouth.
Rarer side effects were weight gain, peripheral oedema and, at high doses, euphoria.
Benefits were seen within one to two weeks, and avoiding alcohol and other sedatives was important, especially in the elderly, Dr Kazmi said.
As with the other medications, a gradual taper over one to two weeks was important to reduce the risk of withdrawal.
Barriers
Dr Kazmi noted the time constraints and difficulty liaising with psychological services were often barriers to managing these patients.
“It’s because some of these cases are difficult, they’re time consuming, they don’t fit the model of consulting that we generally have in private dermatology and require much longer consult,” he said.
“The other reason is that they often do require input from psychological or psychiatric services, and that’s often not streamlined in private practice.”
It was important to understand local service provisions and have emergency protocols for managing suicidal patients, he said.
“So that even if you’re unable to on offer ongoing management, there’s a very clear, streamlined process for accessing that,” Dr Kazmi said.
“And everyone should know that in an emergency – if you do have a patient who’s in your clinic saying that they feel suicidal – you know what the number is to call or how to escalate at that moment.”
Doctors didn’t have to become an expert in psychodermatology overnight though.
“All dermatologists probably already are doing it to some degree, but maybe more subconsciously than consciously. But we can, just in our own practice, start to weave in small changes that mean that we’re being more holistic and more three dimensional with the care of our patients,” Dr Kazmi said.
For example, screening patients for anxiety and depression and including that information in letters back to the GP.
Having a repertoire of sentences at your disposal to elegantly and respectfully discuss these topics was also useful, he said.
“If I see somebody with acne with deep excoriations, I say, ‘I’m fairly holistic in my management. So if you don’t mind, I just like to talk to you a little bit about the picking aspect of your acne. And lots of studies show, and my personal experience shows, that people who pick often may have underlying stress or worries or anxieties that often are unrelated to their skin. Do you think this might be relevant to you? If so, I think it’s probably worth exploring that alongside treating your acne, and with your permission, I’d like to include reference to that in your GP letter’,” he said.
“That way, I haven’t actually even done it, but the patient leaves feeling fully seen, and you’ve opened a door to that element of their care – and that benefits the patient.”
