Use of antipsychotic drugs in dermatology

Sears C, N. Karlin J. Perceived Conjunctival Foreign Material Egress in Morgellons Disease: A Case Study

The purpose of this report is to present a case of a 63-year-old man with orbital Morgellons disease. A 63-year-old man presented reporting 15 years of daily egress of different foreign bodies apparently found in the superior fornices of both eyes, exhibiting a classic manifestation known as the matchbox sign. He described the symptoms starting after a facial trauma. The patient stated that at several points over the 15-year course of his condition, he was so distressed that he had contemplated suicide. On multiple exams by a range of ophthalmic professionals, there was no evidence of foreign body. Further investigation involving MRI and plain radiographs demonstrated similar lack of findings. A trial of gabapentin was performed without improvement in symptoms. He discontinued care 5 months later. Morgellons disease is a poorly understood condition, particularly ophthalmic presentations of the disease. Despite extensive investigation, the exact cause of Morgellons disease remains unclear, and there is no definitive treatment for the condition. We highlight the importance of empathetic listening in building trust, as a means of helping the patient to seek psychological help.

The challenge of Morgellons disease: A patient with clinicopathologic correlation

Morgellons disease is a rare condition characterized by patient-reported multicolored fibers and other nonorganic particles or organic particles embedded in and protruding from diffuse skin ulcerations. Although the scientific community is prone to believe that Morgellons disease is a psychiatric disorder, an infectious pathogenesis associated with Borrelia burgdorferi in the setting of Lyme disease has also been proposed. The histopathology is usually considered as nonspecific. To illustrate this condition, we present the case of an adult woman with significant ulcerative skin lesions and cicatricial changes on the face, trunk, and arms. After multiple biopsies and successful microscopic visualization of the fibers, she received a diagnosis of Morgellons disease in the setting of delusional infestation. No evidence of Borrelia infection was found. Treatment with antipsychotics was initiated, but the patient was lost to follow-up, as is often the case with patients with Morgellons disease.

Collaboration between Psychiatrists and Other Allied Medical Specialists for the Treatment of Delusional Disorders

Background: There is increasing evidence that individuals with psychosis are at increased risk for cardiovascular disease, diabetes, metabolic syndrome, and several other medical comorbidities. In delusional disorder (DD), this is particularly so because of the relatively late onset age. Aims: The aim of this narrative review is to synthesize the literature on the necessity for medical collaboration between psychiatrists and other specialists. Methods: A non-systematic narrative review was carried out of papers addressing referrals and cooperation among specialists in the care of DD patients. Results: Psychiatrists, the primary care providers for DD patients, depend on neurology to assess cognitive defects and rule out organic sources of delusions. Neurologists rely on psychiatry to help with patient adherence to treatment and the management of psychotropic drug side effects. Psychiatrists require ophthalmology/otolaryngology to treat sensory deficits that often precede delusions; reciprocally, psychiatric consults can help in instances of functional sensory impairment. Close collaboration with dermatologists is essential for treating delusional parasitosis and dysmorphophobia to ensure timely referrals to psychiatry. Conclusions: This review offers many other examples from the literature of the extent of overlap among medical specialties in the evaluation and effective treatment of DD. Optimal patient care requires close collaboration among specialties.

Psychodermatology in Canada: A National Survey Assessment of Dermatologists' Perception, Practice Patterns, and Challenges

OBJECTIVES

We aimed to assess the perception of psychodermatology, practice patterns, and challenges reported by Canadian dermatologists.

METHODS

We designed an online questionnaire based on previous literature, including questions about practitioners' perceptions, practice patterns, training, and challenges in psychodermatology. We solicited their opinions on desired training, research needs, and clinical approach recommendations. Our survey was distributed nationally by the Canadian Dermatology Association (CDA).

RESULTS

Of the total of 78 participating dermatologists, >75% reported treating patients with psychodermatological conditions, with higher frequencies of secondary than primary psychodermatological conditions. While practitioners had some confidence in their understanding of psychodermatology (median = 4 on a 5-point scale), their comfort levels to approach these patients were lower (median = 3), and their confidence in prescribing psychotropic medication was markedly low (median = 2). A total of 50% reported that a "multidisciplinary approach" would be best for these patients. Poor access to psychiatry was the most reported (26.9%) challenge, together with time constraints, lack of training, poor communication with patients, and lack of patient insight and resources. While 46.2% reported having never participated in psychodermatology training, 55.1% expressed interest in doing so.

CONCLUSION

We identified several challenges with knowledge, awareness, and healthcare delivery in psychodermatological practice in Canada. Increasing dermatologists' access to psychiatric consultations/services, a multidisciplinary approach with dermatologists and psychiatrists co-providing care, and more specialized training in this area are recommended to narrow the identified gaps.

Estimated Frequency of Psychodermatologic Conditions in Alberta, Canada

BACKGROUND

Psychodermatologic disorders are difficult to identify and treat. Knowledge about the prevalence of these conditions in dermatological practice in Canada is scarce. This hampers our ability to address potential gaps and establish optimal care pathways.

OBJECTIVES

To provide an estimate of the frequencies of psychodermatologic conditions in dermatological practice in Alberta, Canada.

METHODS

Two administrative provincial databases were used to estimate the prevalence of potential psychodermatological conditions in Alberta from 2014 to 2018. Province-wide dermatology claims data were examined to extract relevant International Classification of Disease codes as available. Claims were linked with pharmacy dispensation data to identify patients who received at least 1 psychoactive medication within 90 days of the dermatology claim.

RESULTS

Of 243 963 patients identified, 28.6% had received at least 1 psychotropic medication (mean age: 47.9 years; 67.5% female). Rates of concurrent psychotropic medications were highest for pruritus and related conditions (46.7%), followed by urticaria (44.5%) and hyperhidrosis (32.8%). Among patients with psychotropic medications, rates of antidepressants were highest (56.3%), followed by anxiolytics (37.1%). Across billing codes, besides hyperhidrosis (71.2%), diseases of hair (61.4%) and psoriasis (59.1%) had the highest rates of antidepressant dispensations. Patients with atopic dermatitis had the highest rates for anxiolytic prescriptions (54.3%).

CONCLUSION

In a 5-year window, more than a quarter of the identified dermatology patients in Alberta received at least 1 psychotropic medication, pointing to high rates of potential psychodermatologic conditions and/or concurrent mental health issues in dermatology. Diagnostic and care pathways should include a multidisciplinary approach to better identify and treat these conditions.

Historical and clinical considerations on Ekbom's syndrome

Ekbom's syndrome represents a relatively uncommon neuropsychiatric condition characterized by the recurrent and bizarre fixed delusional belief to be infested by small organisms or even unanimated materials ('Morgellons disease'), without any objective evidence of infestation/parasitosis. The condition, mainly diagnosed in a nonpsychiatric setting, is supposed to be largely underestimated and, hence, undermanaged. The present comprehensive review aims at investigating Ekbom's syndrome, from a historical, epidemiological, clinical and therapeutic perspective, by providing diagnostic-treatment strategies in managing this condition in routine psychiatric clinical settings. The prototypical patient is a middle-aged woman (or a younger subject in those cases in which substance and/or alcohol abuse is implicated), often single, divorced or widowed (loneliness component and social withdrawal), who has already consulted several specialists due to skin lesions associated with a firm and delusional belief to be infested. The identification and diagnosis are challenging due to poor patient's insight, poor knowledge and collaboration between specialists and differential diagnoses to be considered before asking for a psychiatric referral. Management and treatment strategies mainly derive from isolated case reports or observational studies with a small sample size. Further randomized clinical trials should be performed to evaluate the efficacy of newer antipsychotic drugs, including long-acting injectable formulations.

Update on Pharmacotherapy in Psychodermatological Disorders

Psychodermatological (PD) conditions encountered in dermatologic practice include primary psychiatric conditions such as delusions of parasitosis or secondary psychiatric conditions such as anxiety and depression due to dermatologic disease. The psychotropics include antipsychotic agents, anti-anxiety agents, antidepressants, and miscellaneous drugs such as anti convulsants. Anti psychotics are further divided into first-generation and second-generation drugs. Currently, second-generation drugs e.g., risperidone are preferred over first-generation drugs e.g., pimozide in delusional infestation owing to the side effect profile of the latter. Anti-anxiety agents include benzodiazepines used in acute anxiety and buspirone in chronic anxiety disorders. They are frequently prescribed along with antidepressants. Although dependence and necessity of tapering is a problem with benzodiazepines, delayed onset of action is a feature of buspirone. The commonly used antidepressants in dermatology include selective serotonin reuptake inhibitors (citalopram, escitalopram, fluoxetine, fluvoxamine, paroxetine, and sertraline), selective serotonin norepinephrine reuptake inhibitors (venlafaxine, desvenlefaxine, and duloxetine), norepinephrine dopamine reuptake inhibitors (bupropion), tricyclic antidepressants (doxepin, amitriptyline, imipramine, and clomipramine), and tetracyclic antidepressants (mirtazapine). Miscellaneous drugs include anticonvulsants such as gabapentin and pregabalin, naltrexone, and N-acetyl cysteine. The principles of PD treatment are first establish the psychiatric diagnosis, followed by initiating drug treatment. The choice of drugs is dependent on multiple factors such as side-effect profile, drug interactions, and co-morbid conditions. Usually, drugs are started at a low dose and gradually increased. A literature search was done in Pubmed, Google Scholar, and Medline databases, and articles on treatment were analyzed.

Use of psychiatric drugs in Dermatology

Patients with psychocutaneous disorders often refuse psychiatric intervention in their first consultations, leaving initial management to the dermatologist. The use of psychotropic agents in dermatological practice, represented by antidepressants, antipsychotics, anxiolytics, and mood stabilizers, should be indicated so that patients receive the most suitable treatment rapidly. It is important for dermatologists to be familiar with the most commonly used drugs for the best management of psychiatric symptoms associated with dermatoses, as well as to manage dermatologic symptoms triggered by psychiatric disorders.

Delusions of Parasitosis: An Update

Delusional parasitosis, also known as delusional infestation or Ekbom syndrome, is a relatively infrequent psychotic disorder characterized by an unwavering false belief that there is a parasitic infestation of the skin, despite the absence of any medical evidence that could support this claim. Delusional parasitosis can be categorized into primary, secondary, and organic forms. Sometimes, close relatives also experience identical delusions. This phenomenon was reported to occur in 5-15% of cases, and is known as shared psychotic disorder-delusional parasitosis with folie à deux. Patients with delusional parasitosis frequently seek help from many physicians. Close multidisciplinary cooperation between clinicians is often key to shortening the time taken to diagnose this disorder. Initiation of psychopharmacological therapy is a challenge, as many patients refuse any psychiatric treatment because of the stigma associated with mental illness and because of their firm belief that they have a parasitic infestation, not a psychiatric condition. For many patients, a sense of a lack of understanding leads to isolation and the development of depression symptoms, which is why it is crucial to earn the trust of such patients while taking care of them.