An Bras Dermatol. 2020;95(2):133---143 Anais Brasileiros de Dermatologia www.anaisdedermatologia.org.br CONTINUING MEDICAL EDUCATION ଝ,ଝଝ 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; © 2020 Sociedade Brasileira de Dermatologia. Published by Elsevier Espana,˜ S.L.U. This is an 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 3 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 4 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 0365-0596/© 2020 Sociedade Brasileira de Dermatologia. Published by Elsevier Espana,˜ S.L.U. This is an open access article under the CC 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 10 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 11 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- 13 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- 14 ual dysfunction, such as anorgasmia and reduced libido. Most patients with psychodermatoses are classified They can be used by pregnant women; for such patients, 7 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. 10 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