Dermatologic Side Effects of Psychotropic Medications

Desvenlafaxine-Triggered Acneiform Eruptions on the Hand: A Compelling Case Report

A 45-year-old male developed a skin eruption after starting Desvenlafaxine for depressive symptoms associated with schizophreniform disorder. The patient developed a rash on the hand, hyperpigmentation, and itching, which resolved after discontinuing the medication. The Naranjo score suggested a probable link between desvenlafaxine and the skin reaction. Stable vital signs and normal labs supported this conclusion. The case underscores the importance of recognizing and reporting adverse drug reactions, even with generally safe medications like desvenlafaxine. Further research with larger samples is needed to explore this relationship in more depth.

DRESS syndrome: quetiapine associated case report and literature review

Drug rash with eosinophilia and systemic symptoms (DRESS syndrome) is a rare systemic adverse drug reaction with a high mortality rate. Cases of DRESS syndrome have been reported with almost all classes of psychiatric medications, but data remains limited. We describe the case of a 33-year-old woman who presented with acute respiratory distress syndrome secondary to severe pulmonary blastomycosis. Her hospital course was complicated by severe agitation for which the psychiatry consult team was involved and several medications were trialed including quetiapine. She developed a diffuse erythematous rash during her hospital stay and later eosinophilia and transaminitis consistent with DRESS syndrome due to either quetiapine or lansoprazole based on the timeline. Both medications were discontinued, and she was started on a prednisone taper leading to resolution of the rash, eosinophilia, and transaminitis. Her HHV-6 IgG titer later returned elevated at 1:1280. DRESS syndrome along with many other cutaneous drug reactions can be associated with psychiatric medications and familiarity and recognition are imperative. There are limited reports of quetiapine-associated DRESS syndrome in the literature; however, rash and eosinophilia should alert psychiatrists to the potential for quetiapine to be a precipitant for DRESS syndrome.

Escitalopram-induced skin rash: Dermatitis medicamentosa

Selective serotonin reuptake inhibitors (SSRI) are the most prescribed antidepressant medications for the treatment of depression and other psychiatric disorders due to their efficacy, tolerability, and safety profile. The dermatological side-effects or cutaneous reactions due to SSRI class of antidepressants is rare. Though there were few case reports of SSRI-induced rash due to fluoxetine, paroxetine, and sertraline, the evidence associated with escitalopram, the highly prescribed antidepressant is comparatively less. The identification and reporting of the drug-related side-effects/adverse drug reactions either serious or non-serious is very important as it will be helpful in understanding, reviewing, and educating the drug-related information before starting medication to the patient.

The safety of agomelatine in standard medical practice in depressed patients: A 26-week international multicentre cohort study

OBJECTIVE

The present observational cohort study documented the safety of agomelatine in current medical practice in out-patients suffering from major depressive disorder.

METHOD

The 6-month evolution of agomelatine-treated patients was assessed with a focus on safety (emergent adverse events, liver acceptability), severity of depression using the Clinical Global Impression Severity (CGI-S) score, and functioning measured by the Sheehan Disability Scale (SDS).

RESULTS

A total of 8453 depressed patients from 761 centres in 6 countries were analysed (female: 67.7%; mean age: 49.1 ± 14.8 years). Adverse events reported were in accordance with the known safety profile of agomelatine. Cutaneous events were reported in 1.7% of the patients and increased hepatic transaminases values were reported in 0.9 % of the patients. The incidence of events related to suicide/self-injury was 1.0%. Two completed suicides, not related to the study drug, were reported. CGI-S total scores and SDS sub-scores improved and numbers of days lost or underproductive decreased over the treatment period.

CONCLUSIONS

In standard medical practice, agomelatine treatment was associated with a low incidence of side effects. No unexpected events were reported. A decrease in the severity of the depressive episode and improved functioning were observed.

TRIAL REGISTRATION NAME

Observational cohort study to evaluate the safety of agomelatine in standard medical practice in depressed patients. A prospective, observational (non-interventional), international, multicentre cohort study.

TRIAL REGISTRATION NUMBER

ISRCTN53570733.

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.

The color of skin: blue diseases of the skin, nails, and mucosa

Diseases of the skin, hair, nails and mucosa can appear as flesh-colored lesions or may present as any of the colors of the visual spectrum. Diseases associated with blue (or shades of blue) discoloration represent a unique group of conditions that occur de novo or as a reaction to either a topical or a systemic agent to which the individual has been exposed. Blue diseases can affect the skin, the nails or the mucosal membranes of the mouth (buccal mucosa, gingiva, lips, palate or tongue) or eyes (sclera). In addition to appearing blue, they can also appear as blue-black, blue-brown, blue-gray, blue-green, blue-purple, blue-red, and blue-silver. The conditions range from those secondary to exogenous agents (systemic or tattoo or topical) to syndromes to systemic diseases to tumors (adnexal, melanocytic, vascular, or miscellaneous). A comprehensive attempt to include all conditions that have been described as blue (or a shade of blue) has been performed by evaluating the following terms using the medical search engine PubMed: blue and either gingiva, lips, lunula, mucosa, nails, oral, palate, sclera, skin, or tongue. Subsequently, the conditions were organized by color (blue and shades of blue) and within each color by location (skin, nails, oral mucosa and sclera). The results are presented in organized tables; in addition, there is discussion of some of the conditions that are unique to one or more specific locations. In conclusion, 'preserve and cherish the pale blue dot' and remember that a big red rock eater with chrysiasis is the answer to the riddle, "What is big and blue and eats rocks?"

Escitalopram related edema in a patient with Hashimoto's thyroiditis

Advanced Practice Providers recognize and treat the most common side effects patients bring to our attention with the use of antidepressants, including insomnia, weight gain, emotional flattening, and sexual side effects. (https://www.psychcongress.com/article/top-5-side-effects-psychotropics-and-how-manage-them). We are, however, less intuitive and competent at picking up the high risk and rare, problem prone side effects our patients may experience related to the medications we prescribe, particularly in the more medically complex patients. In addition, the medically complex patient may mask a psychiatric concern as the psychiatric provider finds themselves caught up in the ambiguity of numerous somatic symptoms a patient presents with versus the psychiatric concerns that bear our attention. Autoimmune disorders often blur this line all too well affecting both psychiatric and physical well-being.

Cutaneous adverse drug reactions to psychotropic drugs and their risk factors - a case-control study

Cutaneous adverse drug reactions (CADRs) in patients with psychotropic drugs are common. Large studies on the relevant drugs and other risk factors are still scarce. 594 cases of severe CADRs ("cases") were compared with 8085 cases of other adverse drug reactions ("non-cases") documented in a pharmacovigilance program in psychiatry (AMSP) from 1993 to 2014. Logistic regression was carried out to determine risk factors and between-drug differences. CADRs were relatively more prevalent in patients treated with clomipramine, maprotiline, carbamazepine, lamotrigine, acamprosate, clomethiazole and disulfiram as well as with antidepressants and anticonvulsants as drug classes (p < 0.01). For these drugs, significantly more women were found in patients using maprotiline, lamotrigine (not carbamazepine) and in the groups of antidepressants, tricyclics and anticonvulsants (p < 0.01). Women were more vulnerable to CADRs (67% in cases and 56% in non-cases, p < 0.01). The significantly higher rate of CADRs in women was mainly observed under age of 50 years, i.e. during female reproductive years. In a multivariate logistic regression, female sex, the diagnostic group ICD F1 (substance abuse), maprotiline, carbamazepine, lamotrigine and clomethiazole were identified as risk factors of CADRs. The case/non-case approach allowed to identify risk factors based on empirical data rather than experts' evaluations. The new findings of substance abuse and clomethiazole as risk factors for CADRs have to be confirmed in further studies. Since CADRs can be life-threatening, it is important to be aware of risk factors, especially women during their reproductive period and with lamotrigine treatment.

An Interesting Case of Carbamazepine-Induced Stevens-Johnson Syndrome

A 29-year-old Black female patient was admitted to a psychiatric ward with symptoms of major depressive disorder with psychosis. The patient was started on amitriptyline 50 mg/day and haloperidol 10 mg/day. On day 4 post-admission, the preferred first-line antidepressant, fluoxetine, became available and the patient was switched from amitriptyline to fluoxetine 20 mg/day. On the same day, the dose of haloperidol was reduced to 5 mg/day. Thirteen days post-initiation of these medications the patient became talkative, associated with emotional lability, an expansive mood, irritability and restlessness. The working diagnosis was changed to bipolar affective disorder in the manic phase. Fluoxetine was discontinued and carbamazepine 600 mg/day was added to the patient's treatment regimen. Her manic symptoms started to resolve; however, 14 days post-initiation of carbamazepine, the patient had a fever; itchy, discharging eyes; respiratory distress; generalised symmetrical erythematosus rash; buccal ulceration; and conjunctival injection with difficulty opening her eyes. Carbamazepine was immediately discontinued and the patient received intravenous fluid resuscitation. The patient recovered considerably after 12 days of symptomatic and supportive management, and was transferred back to the psychiatric ward for the continuation of bipolar disorder management. Lithium therapy was instituted and the patient was subsequently discharged. Using the Algorithm of Drug causality for Epidermal Necrolysis (ALDEN) Stevens-Johnson Syndrome/toxic epidermal necrolysis (SJS/TEN) drug causality scoring system, carbamazepine and fluoxetine were evaluated as 'very probable' and 'possible' causes of SJS, respectively, in this patient. Fluoxetine-induced SJS was considered on account of previous case reports, however no evidence of causality was found in this patient. Consecutive administration with a potential increase in carbamazepine due to inhibition of cytochrome P450 (CYP) 3A4 metabolism by fluoxetine was also not ruled out. A diagnosis of carbamazepine-induced SJS was made and was considered an idiosyncratic adverse drug reaction.

The Safety, Tolerability and Risks Associated with the Use of Newer Generation Antidepressant Drugs: A Critical Review of the Literature

Newer generation antidepressant drugs (ADs) are widely used as the first line of treatment for major depressive disorders and are considered to be safer than tricyclic agents. In this critical review, we evaluated the literature on adverse events, tolerability and safety of selective serotonin reuptake inhibitors, serotonin noradrenaline reuptake inhibitors, bupropion, mirtazapine, trazodone, agomelatine, vilazodone, levomilnacipran and vortioxetine. Several side effects are transient and may disappear after a few weeks following treatment initiation, but potentially serious adverse events may persist or ensue later. They encompass gastrointestinal symptoms (nausea, diarrhea, gastric bleeding, dyspepsia), hepatotoxicity, weight gain and metabolic abnormalities, cardiovascular disturbances (heart rate, QT interval prolongation, hypertension, orthostatic hypotension), genitourinary symptoms (urinary retention, incontinence), sexual dysfunction, hyponatremia, osteoporosis and risk of fractures, bleeding, central nervous system disturbances (lowering of seizure threshold, extrapyramidal side effects, cognitive disturbances), sweating, sleep disturbances, affective disturbances (apathy, switches, paradoxical effects), ophthalmic manifestations (glaucoma, cataract) and hyperprolactinemia. At times, such adverse events may persist after drug discontinuation, yielding iatrogenic comorbidity. Other areas of concern involve suicidality, safety in overdose, discontinuation syndromes, risks during pregnancy and breast feeding, as well as risk of malignancies. Thus, the rational selection of ADs should consider the potential benefits and risks, likelihood of responsiveness to the treatment option and vulnerability to adverse events. The findings of this review should alert the physician to carefully review the appropriateness of AD prescription on an individual basis and to consider alternative treatments if available.

Medical Complications of Psychiatric Treatment: An Update

Psychiatric medications are used commonly in hospitalized patients and are particularly indicated in patients who are critically ill to manage many conditions. Due to their many indications in the intensive care unit (ICU), psychiatric medications should be closely monitored in these medically compromised patients for adverse reactions and medical complications because they may affect essentially all organ systems. These range from life-threatening reactions to other less significant effects, such as sedation, to other detrimental complications, such as pancreatitis. Knowledge of psychopharmacology as well as the diagnosis and treatment of these complications is imperative in treating patients in the ICU.

EPR spectroscopy of chlorpromazine-induced free radical formation in normal human melanocytes

The purpose of this study was to estimate the effect of chlorpromazine on free radical concentration in HEMn-DP melanocytes using electron paramagnetic resonance (EPR) spectroscopy. It was found that chlorpromazine at concentrations of 1 × 10(-7) and 1 × 10(-6) M contributed to the formation of free radicals (g values ~2) in a dose-dependent manner. The increase in free radical formation was accompanied by an increase in cytotoxicity, as shown by a tetrazolium assay. Homogeneous broadening of EPR lines, slow spin-lattice relaxation processes, and strong dipolar interactions characterized all the tested cellular samples. The performed examination of free radical formation in cells exposed to different chlorpromazine concentrations confirmed the usefulness of electron paramagnetic resonance spectroscopy to determine the effect of a drug on free radical production in a cellular model system in vitro.