Use of Psychiatric Drugs in Dermatology

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Use of psychiatric drugs in Dermatology

∗

Magda Blessmann Weber , Júlia Kanaan Recuero ,

Camila Saraiva Almeida

Dermatology Service, Universidade Federal de Ciências da Saúde de Porto Alegre, Porto Alegre, RS, Brazil

Received 8 October 2019; accepted 15 December 2019

Available online 18 February 2020

Abstract Patients with psychocutaneous disorders often refuse psychiatric intervention in

KEYWORDS

their ﬁrst consultations, leaving initial management to the dermatologist. The use of psy-

Antidepressive

chotropic agents in dermatological practice, represented by antidepressants, antipsychotics,

agents;

anxiolytics, and mood stabilizers, should be indicated so that patients receive the most suit-

Dermatology;

able treatment rapidly. It is important for dermatologists to be familiar with the most commonly

Psychopharmacology;

used drugs for the best management of psychiatric symptoms associated with dermatoses, as

Psychosomatic

well as to manage dermatologic symptoms triggered by psychiatric disorders.

medicine;

Psychotropic drugs

open access article under the CC BY license (http://creativecommons.org/licenses/by/4.0/).

Introduction diseases resulting from the skin-mind interaction, through

its union with psychiatry. It includes skin manifestations

resulting from or worsened by psychological factors and

The prevalence of psychiatric comorbidities is higher and

the assessment of mental and social damage resulting from

more frequent in dermatological patients than in the gen-

1 these dermatoses. The management of psychodermatoses is

eral population. It is estimated that 25---30% of patients

essential in the ﬁeld of dermatology, since dermatologists

have some mental disorder or emotional problem, which

are responsible for most outpatient care due to psycho-

may represent the cause, predisposition, or aggravation

1,2 cutaneous complaints. Moreover, many of these patients

of the skin condition. Psychodermatology studies skin

refuse psychiatric intervention --- either due to the stigma

associated with mental illnesses or the non-acceptance of

ଝ the psychological component in their skin condition, leaving

How to cite this article: Weber MB, Recuero JK, Almeida 5

the management to the dermatologist alone. When there

CS. Use of psychiatric drugs in Dermatology. An Bras Dermatol.

is resistance to psychiatric treatment, the dermatologist

2020;95:133---43.

ଝଝ should support the patient from a non-judgmental posi-

Study conducted at the Dermatology Department, Universidade

tion, prescribe the indicated psychotropic medication, and

Federal de Ciências da Saúde de Porto Alegre, Porto Alegre, RS,

Brazil. encourage evaluation with a psychiatrist as a complement

∗

Corresponding author. and not as a substitute for the therapeutic relationship.

E-mail: [email protected] (M.B. Weber).

https://doi.org/10.1016/j.abd.2019.12.002

BY license (http://creativecommons.org/licenses/by/4.0/).

134 Weber MB et al.

The associated use of psychotropic drugs, such as antide- after, they should be able to prescribe the psychotropic

7,8

pressants, antipsychotics, anxiolytics, and mood stabilizers, drugs indicated for the speciﬁc psychiatric illness.

is essential for these patients, as their skin lesions can

worsen if the underlying psychopathologies are not treated.

Antidepressants

Thus, knowledge and conﬁdence in prescribing the most

used psychotropics aid the management of the psychiatric

The use of antidepressants is based on the monoaminer-

symptoms associated with dermatoses, as well as the mana-

gic theory of depression, in which deﬁciencies in serotonin,

gement of dermatological symptoms triggered by psychiatric

syndromes. norepinephrine, and/or dopamine are implicated in the

genesis of the disease. Thus, the different classes of

Clinical situations in which knowledge of psychotropics is

2 antidepressants act to increase these neurotransmitters,

required of the dermatologist :

either by inhibiting their reuptake, or by inhibiting the

enzyme responsible for their degradation (monoamine oxi-

1. Management of dermatological symptoms associated 9

dase inhibitors). Furthermore, they are also approved for

with psychiatric disorders;

the treatment of anxiety disorders, social phobia, and

2. Management of psychiatric symptoms associated with

obsessive---compulsive disorder.

dermatological conditions, such as social phobia in

None of the antidepressant classes has been shown to

patients with vitiligo;

be the most effective in treating depression and none is

3. Management of adverse effects associated with the use

speciﬁcally indicated for each psychodermatologic disease.

of psychotropic drugs;

They reach their therapeutic dose in a period of four to six

4. Management of other pharmacological effects of these

weeks, but the recommendation is to start with low doses

medications, such as the anticholinergic and antihis-

and gradually increase --- preferably at least every 14 days.

tamine effects of antidepressants and antipsychotics.

In the absence of a response at the end of the initial six

weeks, an alternative drug should be chosen. If a partial

improvement in symptoms is observed, the doses should be

Classiﬁcation of psychodermatoses

increased until the ideal dose for each patient, assessed

6 individually, is reached. The adverse effects are different

Psychodermatoses can be classiﬁed into six categories :

for each class, and are more often reported with the use

of tricyclic antidepressants. While these drugs do not cause

1. Psychophysiological disorders: Primary dermatoses that dependence, symptoms such as insomnia, nausea, sweating,

are exacerbated by emotional factors and stress. Exam- and sensory disturbances are described after abrupt dis-

ples: psoriasis and atopic dermatitis; continuation. For withdrawal, the dose should be gradually

2. Primary psychiatric disorders: Primary psychiatric dis- decreased over several weeks. Treatment should be main-

eases that present self-inﬂicted skin manifestations as tained for at least six months after a therapeutic response

a secondary manifestation of the psychiatric illness. before attempting to withdraw, in order to minimize the risk

10,12

Examples: trichotillomania, parasitic delirium, dermati- of recurrence of symptoms.

tis artefacta, and neurotic excoriations;

3. Secondary psychiatric disorders: Psychiatric illnesses 10

Selective serotonin reuptake inhibitors

that arise as a result of the psychosocial impact of exist-

ing dermatoses. Examples: social phobia, depression that

Selective serotonin reuptake inhibitors (SSRIs), listed in

arises from psoriasis, and alopecia areata;

table 1, act by selectively inhibiting serotonin reuptake,

4. Sensitive skin disease: Psychogenic symptoms, such as

thereby increasing the availability of this neurotransmitter,

pruritus or burning, without evidence of skin disease or

responsible for inﬂuencing mood, cognition, sleep, appetite,

other medical condition. Examples: vulvodynia and glos-

sodynia; and sexual behavior. The monoaminergic theory of depres-

sion postulates that increasing the availability of serotonin

5. Alterations caused by the use of psychoactive drugs for

in the synaptic cleft would modulate the improvement of

dermatological treatment. Examples: pruritus, rash, and

depression symptoms.

Stevens---Johnson syndrome;

They have a good safety proﬁle and tend to have greater

6. Multifactorial diseases: Conditions in which psychoneu-

tolerability when compared with tricyclic antidepressants,

roimmunological factors trigger or aggravate skin con-

being the ﬁrst therapeutic choice for many patients. The

ditions. Examples: atopic dermatitis, psoriasis, alopecia

most reported adverse effects are gastrointestinal changes

areata, chronic pruritus.

(nausea and dyspepsia), insomnia, weight change, and sex-

ual dysfunction, such as anorgasmia and reduced libido.

Most patients with psychodermatoses are classiﬁed

They can be used by pregnant women; for such patients,

among the following psychiatric diagnoses : depressive dis-

those with shorter half-life, such as sertraline and paroxe-

orders; anxiety disorders; psychotic disorders and delirium 15

tine, are preferred.

disorders; obsessive---compulsive disorder; and impulse con-

trol disorders.

Although dermatologists do not have speciﬁc training to Tricyclic antidepressants

perform psychiatric diagnoses, a solid doctor-patient rela-

tionship, developed over several consultations, can assist This is the oldest class of antidepressants, listed in table 2.

them in identifying underlying psychiatric illnesses. There- They act similarly to SSRIs, increasing serotonin and nore-

Use of psychiatric drugs in dermatology 135

Table 1 Main types of selective serotonin reuptake inhibitors (SSRI).

Medication Brand name Presentation Initial dose Observations

---maximum

Fluoxetine Prozac, Daforin 10 and 20 mg tablet/capsule 10---80 mg/day No monitoring required

Oral solution Extensive experience in

20 mg/mL pregnant women

Long half life

Paroxetine Paxil, Pondera, Aropax 10, 20, and 30 mg tablet 20---60 mg No monitoring required

Sertraline Tolrest, Zoloft, Assert 25, 50, and 100 mg tablet 25---200 mg Used in patients with liver

problems

Fluvoxamine Luvox, Revoc 50 and 100 mg tablet 50---300 mg Fractionize dose

if > 150 mg/day

Citalopram Celexa, Procimax 20 and 40 mg 20---60 mg Recommended in liver disease

tablet Higher cardiac risk at

doses > 40 mg/day

Escitalopram Lexapro, Reconter 5, 10, and 20 mg tablet 5---20 mg

Oral solution 20 mg/mL

pinephrine in the synaptic cleft. They have been replaced 10

Other antidepressants

by SSRIs over the years, due to their more sedative effects

and a greater number of other side effects. However,

These antidepressant drugs are listed in table 3.

these drugs (especially doxepin) present properties more

similar to antihistamines, and are therefore widely used

15,16

for insomnia and pruritus. They also perform well in ® ® ®

Mirtazapine (Remeron , Zispin , Norset )

patients with pain of neural origin. Generally, the doses

needed to treat pain and pruritus tend to be lower than

A tetracyclic antidepressant that acts directly, by increasing

antidepressant doses. Nortriptyline has fewer adverse

the amount of serotonin and norepinephrine. Due to its high

effects and should be chosen for elderly patients.

potential for sedation and weight gain, it is preferably used

Among the adverse effects, the literature describes dry 11

in terminal patients.

mouth, constipation, dizziness, blurred vision, tachycardia,

and urinary retention. They should be used with caution

in patients with cardiac conditions, such as conduction dis- ® ®

Bupropion (Wellbutrin , Zetron )

order. There is an absolute contraindication for their use

in patients after a recent episode (up to six weeks) of

15 Bupropion is a selective norepinephrine and dopamine reup-

acute myocardial infarction. They can be used during preg-

take drug. As it has fewer sexual adverse effects and a

nancy, although they should not be prescribed in the ﬁrst

18 similar antidepressant capacity, it is preferred in patients

trimester. 12

with complaints of libido alterations. Its use should also

be considered in patients with sleep disorders. Dose frac-

tioning is necessary, except in cases of slow-release tablets.

It is a generally well-tolerated medication, and its main ®

Doxepin (Sinequan )

side effects are insomnia, agitation, headache, constipa-

tion, dry mouth, nausea, and tremors. Seizures are rare

This tricyclic antidepressant has potent antihistamine prop- effects, but they can be observed; therefore, care should

erties; in dermatology, it is used in patients with chronic be taken when indicating use in patients with a history of

pruritus and urticaria, representing an option to diphenhy- epilepsy. Bupropion should also be avoided in patients with

12,17 12,16

dramine and hydroxyzine. Furthermore, when in topical a history of alcohol and drug abuse. Its use in pregnancy

formulation (5% cream), it does not cause the side reac- is not recommended.

16,19

tions characteristic of oral tricyclic antidepressants.

When used orally, the initial dose is 25 mg/day; it can be

® ®

increased weekly by 10---25 mg, reaching a maximum of Venlafaxine (Efexor , Zyvifax )

100 mg/day.

Sedation is the main adverse effect, and dose schedule

Ofﬁcially released for use in depression and anxiety, ven-

adjustment may be necessary in case of patient complaints.

lafaxine appears to act in the reception of serotonin and

Patients with a history of heart rhythm alterations should

norepinephrine. The initial recommended dose is 75 mg/day,

undergo an electrocardiogram before starting treatment.

increasing every two weeks, reaching a maximum dose of

If the dose is increased, it is suggested that the test be

300 mg/day that should be divided into two doses. The most

repeated when the dosage reaches 100 mg/day. Currently,

commonly reported adverse effects of this drug are insom-

in Brazil, this medicine is only provided by handling phar-

nia and anxiety; when used in high doses, blood pressure

macy. 14,15

should be monitored.

136 Weber MB et al. years years

30 30

> >

mg/day

men men

300

(rare)

and and

patients release above

years years years

effects

40 40 40

dose doses

> > >

years elderly

formulated

immediate 30

gain

the hospitalized >

or women women women

for to

in in in men

Use Anticholinergic Observations Slow Sedative Fractionized Sedative Weight and Observations EKG EKG

maximum

---

maximum

mg/day mg/day ---

mg/day Fractionized

dose mg/day

mg/day Need

mg/day mg/daymg/day EKG

dose

mg/day ---

Initial 150---300 75---300 15---45 Initial 10---250 10---150 mL

capsules mg/2

tablet/capsule

mg tabletstablet/dragée 10---150

mg/mL Safer mg mg

150 2

mg/mL 75 75 tablet

and

solution

tablet 150---600 mg

tablet/capsule 60 and 75

45 50, and and

75, solution

300

25, 25, 25,

and 60 100

50,

solution

and Oral 10, Injectable 10, 30,

and and

Oral 50 tablet Presentation 15, 150 37.5, Brazil --- 100---300

Zispin,

Tryptanol 10,

Zyvifax, Zetron

Cymbalta 30 name Presentation

name

available

antidepressants.

Brand Pamelor Amytril, Not Donaren Zetron, Norset Brand Wellbutrin, Wellbutrin Effexor, Velija, Zaredrop tricyclic other

of of

types types

Main Main

2 3

Amitriptyline Doxepin Venlafaxine Bupropion Clomipramine Anafranil Trazodone Duloxetine Table Medication Nortriptyline Table Medication Mirtazapine Remeron,

Use of psychiatric drugs in dermatology 137

Table 4 Main types of antipsychotics.

Medication Brand name Presentation Initial dose --- maximum

Pimozide Orap 1 and 4 mg tablet 2 --- 4 mg/day --- 20 mg/day

Risperidone Risperdal, Riss 1, 2, and 3 mg tablet 2 mg/day --- 8 mg/day

1 mg/mL solution

Olanzapine Zyprexa, Zopix 2.5, 5, and 10 mg tablet 2.5---5 mg/day --- 15 mg/day

Quetiapine Seroquel, Quetrox, Queropax 25, 100, and 200 mg tablet 25---750 mg/day

Aripiprazole Aristab, Abilify 10, 15, 20, and 30 mg tablet 10---30 mg/day

Ziprasidone Geodon 40 and 80 mg capsule 40---160 mg/day

Haloperidol Haldol 1 and 5 mg tablet 0.5---15 mg/day

Oral solution 2 mg/mL

Injectable solution 5 mg/mL

Regarding the use in pregnancy, despite the lack of stud- be maintained for at least one month after the improve-

ies in pregnant women, experiments with animals have not ment of symptoms. Although rare, due to the low dose

demonstrated teratogenicity. used for skin diseases, the literature describes some adverse

effects, such as akathisia, muscle stiffness, and restlessness.

Antipsychotics Due to the possibility of altering the QT interval, an

electrocardiogram is recommended before treatment in

patients with a history of heart diseaset. In young/healthy

Antipsychotics, listed in table 4, are dopamine recep-

patients, the need for electrocardiographic examination is

tor antagonists, acting mainly by blocking D2 subtype 16

20 still controversial.

receptors. They are divided into typical (pimozide, chlor-

promazine, and haloperidol) and atypical antipsychotics

® ®

(risperidone, olanzapine, sulpiride, and quetiapine). Atyp- Risperidone (Risperdal , Riss )

ical antipsychotics have a lower afﬁnity for D2 receptors, so

they have a lower incidence of extrapyramidal effects, such

The main medication used for parasitic delirium, risperidone

as dystonia and parkinsonism, than typical antipsychotics.

is a new generation antipsychotic and should be started at

The main dopaminergic pathways in the central ner-

a dose of 0.5 mg before bedtime, and should be increased

vous system are the mesocorticolimbic, nigrostriatal, and

weekly until reaching a maximum dose of 4 mg/day. It

tuberoinfundibular. Dysfunctions in the mesocorticolim-

can cause hyperprolactinemia and, consequently, galactor-

bic pathway are associated with psychosis, schizophrenia,

rhea, amenorrhea, and sexual dysfunction. Other adverse

and attention deﬁcit disorder, while dysfunction in the

effects, such as sedation, are uncommon and usually resolve

nigrostriatal pathway is related to Parkinson’s disease, as

within the ﬁrst few days. This medication should also be

well as to motor side effects when used in dopaminergic

used with caution in patients with a history of abnormal

therapy, including extrapyramidal effects. In turn, dys- electrocardiogram.11,22

functions in the tuberoinfundibular pathway cause changes

in prolactin secretion, which can cause galactorrhea and

® ®

Olanzapina (Zyprexa , Zopix )

amenorrhea, as dopamine is responsible for inhibiting pro- 13

lactin secretion.

Olanzapine is recommended in low doses for psychoderma-

Antipsychotics may cause side effects due to binding to

tologic diseases. The suggested initial dose is 5---10 mg/day

other receptors, such as weight gain (histamine receptors),

until reaching a target dose of 15 mg/day. Despite being

orthostatic hypotension (␣-adrenergics), constipation, and

20 a generally well-tolerated medication, its main adverse

xerostomia (muscarinic receptors). They may also increase

effect is weight gain and, consequently, metabolic syn-

the risk of myocardial infarction and transient ischemic

10 drome and increased cardiovascular risk. As a result,

events in elderly patients.

it is necessary to control weight and monitor blood

In dermatology, antipsychotics can be used mainly in

pressure, glucose, and lipids during treatment with this

delusional disorders, such as parasitic delirium and dermati- 17 medication.11,14,17

tis artefacta.

Haloperidol is the best studied drug in relation to use dur-

ing pregnancy, being the preferred antipsychotic for these ® ® ®

Quetiapine (Seroquel , Quetrox , Queropax )

patients.21

Quetiapine is well indicated in patients resistant to previous

Pimozide (Orap ) treatments and in elderly patients. In the treatment of non-

dermatological psychoses, it is initially prescribed at a dose

This is the ﬁrst generation antipsychotic most widely used of 25 mg twice a day and increased to 750 mg/day. How-

in psychodermatology. It acts as a potent antagonist of the ever, for dermatological use it is recommended to reduce

central dopamine receptor. It is indicated to start with the starting and maintenance doses. For example, 150 mg

1 mg/day, with a progressive increase every two weeks, until divided into two doses, is indicated for the treatment of

12,23

reaching the target dose ( 2 --- 6 mg/day). This dose should parasitic delirium.

138 Weber MB et al.

Weight gain, drowsiness and orthostatic hypotension are

11,14

among the most commonly reported side effects. is case

® ®

Aripiprazole (Aristab , Abilify )

Aripiprazole is a new generation antipsychotic, noteworthy glaucoma angioedema

assessment

due to its low relationship with metabolic disorders and convulsion

cholinergic effects. It has been used for patients with par- level

asitic delirium and neurotic excoriations, with good results

acidosis

at doses between 2 and 30 mg/day. It usually does not cause dysfunction

(HLA-B1502 withdrawal, closed-angle behavior behavior,

changes in weight. lithium

rapid

of Metabolic required Cognitive Suicidal Serum SJS/TEN Suicidal --- allele) Myopia, Hepatotoxicity SJS/TEN

Ziprasidone (Geodon ) Pancreatitis Teratogenic

Similar to aripiprazole, ziprasidone is also a new genera-

tion antipsychotic. It differs from the others due to lack of

anticholinergic effects and the low propensity to metabolic

syndrome, in addition to low incidence of sedative effects.

However, it has more risks of causing QT interval alterations Maximum Observations

---

than other atypical antipsychotics. It is successfully used in mg/day

mg/day mg/day

mg/day

the treatment of patients with parasitic delirium with doses mg/day mg/day

dose mg/kg/day

ranging from 20 mg to 80 mg/twice daily. 600---2.400 50---200 150---600 900---3600 50---200 200---1600 15---60

Mood stabilizers

Mood stabilizers, such as antiepileptic drugs and lithium,

are approved for use in bipolar disorder and epilepsy. Their

mechanisms are not completely understood, but they are tablet

believed to act on the central nervous system, with the mg/mL tablet tablet tablet capsule mg mg

24 capsule

power to control neuronal excitation. 20 syrup

mg mg mg mg

100 100

Many of these medications, as mentioned in table 5, are mL

450 400 500 400

used in neuropathic skin pain and are also effective in the

and and 150

management of chronic pruritus, in addition to other skin solution

and and and and mg/5 50, 50,

and

sensory disorders, such as self-induced dermatoses. Primar- Oral 250 300 25, 75 300 tablet 300 200

25,

ily due to their compulsion control power, they are included

in the treatment of dermatoses related to self-excoriation,

such as nodular prurigo and lichen simplex chronicus, as

well as in self-inﬂicted lesions, such as trichotillomania and

dermatitis artefacta. These medications are known to be

teratogenic and should be avoided, if possible, in female 14

Progresse

patients of childbearing age.

Lithium (Carbolitium ) anticonvulsants.

Gamibetal,

Lithium carbonate, used in the treatment of bipolar disorder and Depakene Tegretard

Tegrex,

Lamictal

and severe depression, alters the metabolism of neuronal

Sigmax

name Presentation Initial

catecholamines. Serum lithium dosage should be moni-

tored initially every 60---90 days, and this interval can be

stabilizers

Carmazin, Brand Carbolitium Lamitor, Tegretol, Depakote, Amato, Lyrica Gabaneurin,

extended up to six months, depending on the time of use.

Blood samples should be collected eight to 12 h after taking

mood

the previous dose and before the next dose. It is recom-

mended to maintain serum lithium levels between 0.5 and

1.0 mEq/L, equivalent to a dose of 600---900 mg/day. Signs of

types toxicity may begin to appear as early as 1.0---1.5 mEq/L. The

use of this drug also requires frequent monitoring of renal

Main

and thyroid functions. Caution should be used when pre- valproate

scribing lithium, due to its high rate of adverse skin effects, 5

such as worsening or triggering the onset of psoriasis and

11,24,25

acne. Lithium is indicated for the control of impulsive Lamotrigine Pregabalin Gabapentin Carbamazepine Sodium Topiramate

Table Medication Lithium

behavior in patients with trichotillomania, due to its high

Use of psychiatric drugs in dermatology 139

association with obsessive---compulsive disorder, with doses Pregabalin (Lyrica )

12,26

varying between 900 and 1500 mg. Skin picking patients

can also beneﬁt from the use of lithium for impulse control,

This medication acts in the neuronal calcium channels.

although there is no dose speciﬁed in the literature.

Its formal indication is for neuropathic pain, epilepsy, and

ﬁbromyalgia. Pregabalin has a good action in the control

® ® of neuropathic pain and has a good safety proﬁle, because

Lamotrigine (Lamitor , Lamictal )

it interacts with fewer drugs when compared with other

medications in this class. Some authors also indicate its

Lamotrigine is a medication used to treat seizures. Phar-

use for uremic pruritus. A dose of 300---600 mg/day is indi-

macologically, it acts on neuronal sodium channels, mainly

cated. Generally, it has no serious side effects; the literature

by stabilizing membranes and inhibiting the release of glu-

reports side effects such as drowsiness, dizziness, and even

tamate. Its beneﬁts in the treatment of skin picking have 11,19,24 peripheral edema.

been demonstrated, and the literature suggests the use of

doses between 12.5 and 300 mg/day.

® ®

Gabapentin (Gamibetal , Progresse , ®

® ® ® Gabaneurin )

Carbamazepine (Tegretol , Tegrezin , Tegretard , ® ®

Tegrex , Carmazin )

Generally used for epilepsy and neuropathic pain,

gabapentin is an anticonvulsant derived from the neu-

Although its action has not been fully understood, car-

rotransmitter GABA. It is the most studied mood stabilizer

bamazepine is known to stabilize the hyperexcited nerve

in dermatology; it is especially effective in situations

membrane. It is indicated for the treatment of epilepsy,

where sensitization of the central nervous system is a

bipolar disorder, depression, and pain of neural origin. In

mediating factor. It is used more widely in post-herpetic

dermatology, the use of this medication in post-herpetic

neuralgia, but it can also be used in chronic pruritus and

neuralgia is noteworthy. In addition to dose fractioning, it

other pains of neural origin, such as paresthetic notalgia

is recommended to start with lower doses with progressive 25,27,28

and brachioradial itching. It can be prescribed at a

increase. The recommended dose for neuropathic pain is

dosage of 300---3600 mg/day. This medication has a good

600---1200 mg/day. Adverse effects such as gastrointestinal

safety standard regarding drug interactions and its most

symptoms, dizziness, and blurred vision are reported, as

reported adverse effects are: drowsiness, nausea, double

well as skin effects, reported later in this article. The liter-

vision, and dysphasia, among others. There is insufﬁcient

ature also reports more rare risks, such as agranulocytosis 15,29

data for use in pregnancy and lactation.

24 and aplastic anemia.

Anxiolytics

® ®

Sodium valproate (Depakote , Depakene ,

Zyvalprex®)

Anxiolytic drugs are used to relieve anxiety symptoms,

acting directly on the limbic system. Used in special situa-

The activity of sodium valproate, which converts to valproic

tions, such as panic disorder and post-traumatic stress, for

acid in the body, appears to be related to the increase in

example, they have a high sedative power and may cause

GABA in the central nervous system. The doses indicated

dependence. They are divided into benzodiazepines and

for epilepsy start at 10---15 mg/kg/day, and can be increased non-benzodiazepines.15

by 5---10 mg/kg/day weekly. Doses below 60 mg/kg/day are

considered to have a good clinical response. For neuro-

pathic pain, the literature suggests doses between 250 and Benzodiazepines

1500 mg/day, with a fractioned dose. In addition to the uses

in chronic pain, there are reports of treatments with sodium Pharmacologically, benzodiazepines act as GABA modu-

valproate in patients with inﬂammatory verrucous epider- lators. The use of these drugs should be limited to a

mal nevi (ILVEN). period of three to four weeks, due to the high poten-

tial for dependence and abuse. Some authors mention

a maximum use of six weeks. Moreover, it is neces-

® ®

Topiramate (Amato , Sigmax )

sary to be careful when withdrawing the medication,

due to the possibility of withdrawal symptoms They

An anticonvulsant medication, with multiple mechanisms to

can be divided into short duration: triazolam (Halcion ),

reduce neuronal hyperexcitability, used to treat epilepsy

midazolam (Dormonid ); short-intermediate: alprazolam

® ®

and migraine prophylaxis. It is recommended to start at

(Frontal , Alfron ); intermediate-prolonged: bromazepam

® ®

a dose of 25---50 mg daily for at least one week, and

(Lexotan ), nitrazepam (Sonebon ), Lorazepam (Lorax);

® ®

increase the dose every one or two weeks. The daily dose

prolonged: clonazepam (Rivotril ), diazepam (Valium ),

® ® ®

should range between 200 and 400 mg/day and the maxi-

clobazam (Frisium , Urbanil ), ﬂurazepam (Dalmadorm ).

11,24

mum dose is 1600 mg. There are reports of the use of

Among the adverse effects of these medications, learn-

topiramate in the treatment of trichotillomania, however

ing difﬁculties, amnesia, aggressiveness, and confusion can

studies with larger populations are necessary to conﬁrm its

be mentioned. There is a risk of respiratory depression in

effectiveness.26

patients with chronic lung diseases, as well as with the use

140 Weber MB et al.

of central nervous system-depressant drugs (alcohol). They Mood stabilizers: carbamazepine, gabapentin, lithium,

15,17

are contraindicated in the ﬁrst trimester of pregnancy. valproic acid, lamotrigine, and topiramate.

Antipsychotics: risperidone, olanzapine, quetiapine,

Non-benzodiazepines clozapine, haloperidol, and ziprasidone.

Benzodiazepines: the highest incidence was observed

® with the use of alprazolam.

Buspirone (Ansitec )

30---36

Urticaria and angioedema

Buspirone is a non-benzodiazepine anxiolytic drug that has

no potential for dependence. Its onset of action is a bit

They are common adverse manifestations. They are associ-

slower, two to four weeks, and therefore it should not be

ated with the use of antidepressants, mood stabilizers, and

used in more acute cases. Due to its proﬁle, it is preferred

antipsychotics.

in cases where longer therapies need to be instituted. The

Antidepressants: in all drugs in this class.

initial dose suggested is 15 mg/day, increasing 15 mg every

Mood stabilizers: carbamazepine and lamotrigine.

week, with a maximum dose of 60 mg/day, divided into two

11,16

Antipsychotics: risperidone, olanzapine, clozapine, and

doses, due to its short half-life. haloperidol.

® Benzodiazepines: alprazolam.

Zolpidem (Stilnox )

30---36

Fixed drug eruption

Used as a sleep inducer, zolpidem should be used at a dose of

5---10 mg before bed. This drug acts in a similar way to benzo-

diazepines, and can lead to mental confusion and tolerance Lesions appear within eight hours after taking the medica-

over time; therefore, it should be used for short periods. tion, and are usually asymptomatic.

Antidepressants: in all drugs in this class.

Mood stabilizers: carbamazepine, lithium, gabapentin.

Adverse skin reactions to psychiatric drugs

Antipsychotics: risperidone, olanzapine, quetiapine, and

haloperidol.

Adverse skin reactions triggered by the use of psychotropic

drugs are estimated depending on the drug in up to 39% of

Photosensitivity30---36

cases, with an increased risk associated with females, the

elderly, and those of African descent. Among psychotrop-

ics, mood stabilizers present the highest prevalence and Photosensitivity reactions (divided into phototoxic and pho-

severity of skin reactions, which can be potentially fatal. toallergic) are triggered by exposure to ultraviolet radiation

The management of skin reactions associated with psy- with the use of certain medications.

chiatric drugs and the decision to discontinue treatment Antidepressants: ﬂuoxetine, paroxetine, sertraline, and

must be evaluated taking into account the severity of the escitalopram. There are few cases reported with the use of

skin manifestation and of the psychiatric illness. Moreover, tricyclic antidepressants.

the possible harm in relation to abrupt discontinuation of Mood stabilizers: carbamazepine and lamotrigine.

medication must be considered and evaluated. Antipsychotics: chlorpromazine, risperidone, olanzapine,

quetiapine, clozapine, and haloperidol. Pruritus30---36 30---36

Skin discoloration

Pruritus can occur with the use of any antidepressant, mood

stabilizer, and antipsychotic. It is also reported by those Skin discoloration usually occurs after prolonged use of some

using benzodiazepines, although less frequently. psychotropic drugs. In most cases, it disappears slowly after

Antidepressants: bupropion has the highest incidence of treatment discontinuation. It can take months or years for

pruritus, while the lowest rates are found with ﬂuoxetine, the pigmentation to completely disappear.

paroxetine, sertraline, and venlafaxine. Antidepressants: the highest incidence is observed with

Mood stabilizers: all drugs in this class. tricyclic antidepressants.

Antipsychotics: risperidone, olanzapine, quetiapine, and Mood stabilizers: carbamazepine, gabapentin, and lam-

clozapine. otrigine.

Benzodiazepines: there is a higher incidence for the use Antipsychotics: chlorpromazine, risperidone, olanzapine,

of alprazolam. quetiapine, clozapine, and haloperidol.

Rash30---36 Alopecia30---36

It is the most common adverse skin reaction triggered by It usually occurs diffusely. Hair loss ceases with the discon-

the use of psychotropics. It is associated with the use of tinuation of medication. It is associated with the use of some

antidepressants, mood stabilizers, and antipsychotics. antidepressants, mood stabilizers, and antipsychotics.

Antidepressants: in all drugs in this class. Among tricyclic Antidepressants: selective serotonin reuptake inhibitors.

antidepressants, the highest incidence was observed with Mood stabilizers: lithium, carbamazepine, lamotrigine,

the use of clomipramine. and valproic acid.

Use of psychiatric drugs in dermatology 141

Antipsychotics: risperidone, olanzapine. 30---36

Exfoliative erythroderma

It is a serious adverse reaction. It is more associated with 30---36

Acneiform rashes

the use of some tricyclic antidepressants, and rarely occurs

with the use of antipsychotics.

The lesions usually present as follicular pustules, without Antidepressants: amitriptyline, nortriptyline,

comedones. They occur on the face, chest, and upper back. clomipramine, and mirtazapine.

They are mainly associated with the use of antidepressants. Mood stabilizers: lithium and carbamazepine.

Antidepressants: in all drugs in this class. Antipsychotics: risperidone and quetiapine.

Mood stabilizers: lithium, carbamazepine, lamotrigine,

and topiramate.

Antipsychotics: quetiapine and risperidone. 30---36

DRESS syndrome

30---36 It is a serious adverse reaction; in addition to skin involve-

Psoriasiform reactions

ment, there is fever and involvement of several organs.

Antidepressants: amitriptyline, imipramine, and ﬂuoxe-

The lesions are usually observed bilaterally on the elbows,

tine.

knees, and scalp.

Mood stabilizers: carbamazepine, lamotrigine, and val-

Antidepressants: ﬂuoxetine, escitalopram, and venlafax-

proic acid. ine.

Antipsychotics: olanzapine.

Mood stabilizers: lithium, carbamazepine, and valproic

acid.

Antipsychotics: risperidone and quetiapine. 30---36

Hypersensitivity vasculitis

30---36

Seborrheic dermatitis Initially, it is manifested by purpura in the lower limbs. There

may be systemic involvement of different organs.

Antidepressants: paroxetine, ﬂuoxetine, and sertraline.

It is a common manifestation of psychiatric drugs, especially

Mood stabilizers: carbamazepine and lamotrigine.

due to the use of antidepressants and mood stabilizers.

Antipsychotics: clozapine and haloperidol.

Antidepressants: ﬂuoxetine, paroxetine, and venlafax-

ine.

Mood stabilizers: lithium, carbamazepine, and valproic

acid. Conclusion

Antipsychotics: risperidone, olanzapine, clozapine, and

haloperidol.

The identiﬁcation and psychopharmacological management

of psychocutaneous disorders should not be neglected by

30---36 the dermatologist, since dermatological patients have a

Erythema multiforme

high prevalence of psychiatric comorbidities. The ability to

prescribe psychotropic drugs becomes even more relevant

It is a rare and serious adverse reaction. Cases of erythema

when psychiatric treatment is neglected by the patient.

multiforme-like lesions with the use of antidepressants and

Furthermore, the prescription of psychiatric drugs by a

antipsychotics have been described in the literature.

dermatologist (rather than a psychiatrist) may be better

Antidepressants: ﬂuoxetine, paroxetine, sertraline,

accepted, due to the stigma surrounding mental health and

duloxetine, and bupropion.

treatment with those professionals.

Mood stabilizers: carbamazepine, lamotrigine,

The dermatologist must be aware of the mechanisms,

gabapentin, and valproic acid.

indications, and side effects of the most used psychotropic

Antipsychotics: risperidone and clozapine.

agents so that they can provide the best treatment and

prevent the worsening of psychodermatoses. However, it is

necessary to establish an attitude of empathy and support

Stevens---Johnson syndrome and toxic epidermal for these patients, so that they accept and adhere to the

30---36

necrolysis psychotropic intervention. The choice of the psychotropic

drug must be based on the underlying psychopathology;

These are serious adverse reactions mainly associated with depressive disorders, anxiety disorders, psychotic, delu-

the use of mood stabilizers. They are rarely observed with sional disorders, and obsessive---compulsive disorders are the

the use of antidepressants. The involved medication should most commonly found in dermatological practice.

never be prescribed again. It should also be noted that the use of psychotropic drugs

Antidepressants: ﬂuoxetine, sertraline, paroxetine, is one of the components of a comprehensive treatment

bupropion, and duloxetine. for patients with psychodermatoses. One should continue

Mood stabilizers: carbamazepine, lamotrigine, and val- to encourage the search for psychiatric treatment and

proic acid. psychotherapeutic support so that the patient has better

Antipsychotics: quetiapine and clozapine. therapeutic results and a better quality of life.

142 Weber MB et al.

Financial support c) Neuropathic pain and pruritus respond to treatment at

doses lower than those generally used.

None. d) Patients with cardiovascular disease and those with a

recent history of myocardial infarction can use the drug

without restrictions.

5. Check the correct statement regarding antipsychotics:

Authors’ contributions

a) They are divided between typical and atypical, and

atypical antipsychotics are the newest.

Magda Blessmann Weber: Conception and planning of

b) They can be used in the elderly population without the

the study; effective participation in research orientation;

need for specialized care.

critical review of the literature; critical review of the

c) They rarely cause adverse skin reactions.

manuscript.

d) They have little effect when used for the treatment of

Júlia Kanaan Recuero: Elaboration and writing of the

parasitic delirium and dermatitis artefacta.

manuscript; critical review of the literature; critical review

6. Regarding mood stabilizers, check the incorrect of the manuscript.

statement:

Camila Saraiva Almeida: Preparation and writing of the

a) They include anti-epileptics and lithium.

manuscript; critical review of the literature; critical review

b) They are very effective in the treatment of neuropathic

of the manuscript.

pain and pruritus.

c) They have no teratogenic effects and can be used

without restriction during pregnancy.

Conﬂicts of interest

d) They can also be used in psychodermatoses related to compulsion.

None declared.

7. Check the incorrect statement regarding

benzodiazepines:

a) They are addictive drugs and should not be used for a

CME Questions.

long time.

b) Rapid withdrawal of the drug can cause withdrawal

symptoms.

1. Check the incorrect statement:

c) Side effects such as amnesia, aggressiveness, and mental

a) Psychophysiological disorders include primary

confusion can occur with the use of these drugs.

dermatoses that can be aggravated by emotional factors

d) The can be used without restrictions in patients with

or stress.

chronic lung disease.

b) Primary psychiatric disorders can lead to skin

8. Check the incorrect statement:

manifestations.

a) Psychotropic drugs, in general, can cause unwanted skin

c) Secondary psychiatric disorders are not related to

reactions in patients treated with these drugs.

psychodermatoses.

b) Common manifestations are pruritus, rash, and

d) Sensitive diseases of the skin or mucous membranes do

urticaria/angioedema.

not present primary dermatological lesions.

c) The use of antidepressants of all classes may cause ﬁxed

2. Check the correct statement regarding

drug eruptions.

antidepressants:

d) Photosensitivity reactions are rare in all drugs used for

a) Antidepressants have speciﬁc indications for certain psychodermatoses.

dermatoses.

9. Psoriasiform reactions and seborrheic dermatitis are

b) It may take up to two months for the desired therapeutic

more common with:

effects to be observed.

a) Antidepressants and mood stabilizers

c) Tricyclic antidepressants present the greatest number of

b) Benzodiazepines

side effects.

c) Tricyclic antidepressants

d) Treatment can be withdrawn as soon as the desired

d) Lithium

therapeutic effects are achieved.

10. SJS and TEN occur most frequently with which of the

3. Regarding SSRIs, it is correct to state that:

following medications:

a) They should not be used during pregnancy.

a) Antidepressants

b) They have good tolerability and one of the main side

b) Mood stabilizers

effects is libido reduction.

c) Antipsychotics

c) Regular follow-up of patients is required, regardless of

d) Benzodiazepines

age.

d) Sertraline should not be used in patients with liver ANSWERS

disease. Update on parasitic dermatoses. An Bras Dermatol.

4. For tricyclic antidepressants, check the incorrect 2020;95(1):1---14.

statement:

1. b 3. b 5. c 7. b 9. d

a) It is the oldest class of antidepressants.

2. c 4. d 6. c 8. c 10. a

b) The most relevant side effects are dry mouth,

constipation, dizziness, tachycardia, and urinary retention.

Use of psychiatric drugs in dermatology 143

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