UK psychodermatology services in 2019: service provision has improved but is still very poor nationally

White paper on psychodermatology in Europe: A position paper from the EADV Psychodermatology Task Force and the European Society for Dermatology and Psychiatry (ESDaP)

Psychodermatology is a subspecialty of dermatology that is of increasing interest to dermatologists and patients. The case for the provision of at least regional psychodermatology services across Europe is robust. Psychodermatology services have been shown to have better, quicker and more cost-efficient clinical outcomes for patients with psychodermatological conditions. Despite this, psychodermatology services are not uniformly available across Europe. In fact many countries have yet to establish dedicated psychodermatology services. In other countries psychodermatology services are in development. Even in countries where psychodermatolgy units have been established, the services are not available across the whole country. This is especially true for the provision of paediatric psychodermatology services. Also whilst most states across Europe are keen to develop psychodermatology services, the rate at which this development is being implemented is very slow. Our paper maps the current provision of psychodermatology services across Europe and indicates that there is still very much more work to be done in order to develop the comprehensive psychodermatology services across Europe, which are so crucial for our patients.

Pharmacological Interventions for Primary Psychodermatologic Disorders: An Evidence Mapping and Appraisal of Randomized Controlled Trials

BACKGROUND

The lack of clinical guidelines for the treatment of primary psychodermatologic disorders (PPDs) hinders the delivery of optimal care to patients. The review aimed to identify, appraise, and summarize the currently available evidence about the safety and effectiveness of pharmacological management of PPDs through randomized controlled trials (RCTs).

METHODS

The Preferred Reporting Items for Systematic Review and Meta-Analyses (PRIMSA) statement and the Global Evidence Mapping Initiative guidance were followed. Medline, Embase, PsycInfo, Cochrane and Scopus were searched, and two reviewers independently completed article review, data extraction, and quality assessment.

RESULTS

Among 2618 unique studies, full texts of 83 were reviewed and 21 RCTs were included. Five PDDs were identified: trichotillomania (n = 12), pathologic skin picking (n = 5), nail biting (n = 2), delusional parasitosis (n = 1), and dermatitis from compulsive hand washing (n = 1). Seven different classes of medications were investigated: SSRIs (i.e., fluoxetine, sertraline, and citalopram), tricyclic antidepressants (i.e., clomipramine and desipramine), antipsychotics (i.e., olanzapine and pimozide), anticonvulsant (i.e., lamotrigine), N-acetylcysteine, inositol, and milk thistle. RCT-derived evidence supports the use of antidepressants in trichotillomania (sertraline and clomipramine), pathologic skin picking (fluoxetine), pathologic nail biting and dermatitis from compulsive hand washing (clomipramine or desipramine); antipsychotics in trichotillomania (olanzapine) and delusional parasitosis (pimozide); N-acetyl cysteine in trichotillomania and skin picking.

CONCLUSION

Few pharmacotherapies for primary psychodermatologic disorders are assessed through controlled trials in the literature. This review serves as a roadmap for researchers and clinicians to reach informed decisions with current evidence, and to build on it to establish guidelines in the future.

Identifying mental health needs of children and youth with skin disease: A systematic review of screening and assessment tools

BACKGROUND AND OBJECTIVES

(1) To identify patient reported outcome measures (PROMs) which have been used to screen and assess mental health symptoms in studies of youth with skin disease. (2) To critically appraise their evidence base in this population.

METHODS

A systematic literature search was conducted within PubMed and PsycINFO combining search terms for pediatric populations, dermatology, screening and assessment tools, and psychological and psychiatric conditions, to identify PROMs which screened or assessed for mental health symptoms in youth with skin disease. PROMs which had undergone validation within this population were assessed for quality and evidence base using the COSMIN risk of bias tool.

RESULTS

One hundred eleven PROMs which assess mental health symptoms in studies of youth with skin disease were identified. These included generic mental health scales which are extensively validated in different populations. Only one PROM, the "Skin Picking Scale-Revised" has undergone specific validation in youth with skin disease. This showed poor quality of evidence for content validity and therefore cannot be recommended.

CONCLUSION

There is an urgent need to identify mental health problems early and treat proactively to improve outcomes in youth with skin disease. This review highlights the current lack of consensus around the best way to assess our patients. It is likely that existing generic mental health methods and PROMS will be appropriate for our needs. More work is required to examine the utility, feasibility, and acceptability of existing generic, validated mental health screening tools in youth with skin disease.

A digital therapeutic for management of psychosocial aspects of psoriasis: A pre‐post proof of concept study

Background

Despite the psychosocial challenges of living with psoriasis many patients may not be able to access appropriate services to manage these challenges. Mobile health interventions may be helpful as a means to support patients in managing the impact of their condition.

Objective

To conduct a preliminary examination of the feasibility and acceptability of a bespoke psoriasis‐specific digital therapeutic solution (hereafter termed Allay), and to provide initial data on psychological changes pre‐post.

Methods

Phase one proof of concept pre‐post study. Eligible patients were provided with Allay on their smartphone and assessed at baseline and at 12 weeks on a range of indices of well‐being. Participants experiences on usability were collected by telephone interview at 4 weeks, 8 and 12 weeks.

Results

Out of 66 participants recruited, 59 persisted in using Allay after the familiarisation phase, and 34 participants completed the 12 weeks programme. Participants showed a statistically significant improvement between induction and the end of the 12 weeks programme on Quality of life, Resilience, Perceptions of ‘Overall impact’ of psoriasis, and ‘Emotional impact’. There was a significant change over the course of using Allay for symptoms of depression but not anxiety. While there was an interaction effect of changes in severity of psoriasis symptoms over the course of the study for dermatology‐specific measures, there was no interaction between such changes in psoriasis symptoms and changes in depression, resilience or beliefs in emotional impact.

Conclusions

Study results suggest that the use of Allay as an adjunct to medical management of psoriasis may help patients improve resilience, mood, beliefs about their condition and enhance their quality of life. Given that this is a phase one proof of concept study, and our rates of attrition further research is necessary to examine comparative effectiveness and stability of these findings.

Associations between psoriasis and mental illness: an update for clinicians

OBJECTIVE

This review explores the association between psoriasis and mental illness and the potential underlying pathophysiologic explanations for this association.

METHOD

Using a search via the MEDLINE database in December 2020, eligible studies with a focus on systematic reviews, meta-analyses, and randomized control trials (RCTs) were retrieved and reviewed.

RESULTS

Psoriasis patients are 1.5 times more likely to show depressive symptoms and experience a higher prevalence of anxiety symptoms (20-50%) than individuals without psoriasis. Schizophrenia (2.82%) and suicidal ideation (12.7%) are found to be more prevalent among psoriasis patients than among the general population. Pro-inflammatory markers, which play an important role in the pathophysiology of psoriasis, have been shown to be elevated in patients with depression, anxiety, and schizophrenia; this suggests shared inflammatory pathways may be involved.

CONCLUSIONS

There is an elevated burden of psychiatric co-morbidity in psoriasis patients which may be explained by an inflammatory model. We recommend that clinicians conduct universal screening of depression, anxiety, and suicidality among their psoriasis patients and remain vigilant for any symptoms of severe psychiatric conditions such as schizophrenia. Collaboration between dermatologists, psychiatrists and primary care physicians is essential in supporting psychological wellbeing and clinical outcomes for psoriasis patients.