Psoriasis: Stress has been reported in 44% of patients before the initial flare of psoriasis, and recurrent flares have been attributed to stress in up to 80% of the patients. Most common symptoms attributed to psoriasis are disturbances of body image and impairment in social or occupational functioning, which results in severe interpersonal relationship problems and job-related losses.

Various psychotropics can cause dermatological adverse effects. SSRIs, tricyclic antidepressants (TCAs), mood stabilizers, and antipsychotic medications have been implicated in several cutaneous adverse effects that mimic typical skin disease. A sound knowledge of psychiatric medications and their cutaneous adverse effects is important in the management of psychiatric conditions. In addition, patients should be advised about the adverse-effect profiles of all treatment drugs.

Cutaneous adverse effects of antidepressants include toxic epidermal necrolysis, Stevens-Johnson syndrome, leukocytoclastic vasculitis, and erythema on sun exposed areas. Lithium, which is commonly used in the treatment of bipolar disorder, may cause several dermatological adverse effects. Antidepressants have been used as off-label medications in various psychodermatological disorders. Corticosteroids used in dermatological disorders may cause psychiatric symptoms, such as cognitive impairment, mood disorders, depression, delirium, and psychosis.

Psychiatric disturbances as a result of dermatological medications are still not fully understood. Isotretinoin, which is used in severe recalcitrant acne, has been implicated in depression, suicidal ideation, and mood swings. There are conflicting reports about the relationship between isotretinoin and depression and suicide. The exact causal role has not been established, and caution is recommended when treating patients with isotretinoin.

Treatment approaches

The mainstays of treatment for psychodermatological disorders are an empathetic approach toward the patient; a good physician-patient relationship; and a team approach with psychiatrists, dermatologists, therapists, and social services. The treatment goal is to improve functioning; reduce physical distress; improve sleep disturbances; and manage psychiatric symptoms, such as anxiety, depression, social withdrawal/isolation, and low self-esteem.

Both pharmacological and nonpharmacological treatments are used to manage cutaneous disorders. The medications include antidepressants, antianxiety medications, antipsychotics, and topical skin preparations. The choice of a psychopharmacological agent depends on the nature of the underlying psychopathology (anxiety, depression, psychosis, compulsion). SSRIs and TCAs exert their effects through antihistaminic, anticholinergic, and serotonin blocking properties.

Antipsychotics may be used to augment medications or as monotherapy, particularly in patients with delusions of parasitosis and, more recently, in trichotillomania. Other psychiatric drugs used in the psychodermatological setting include gabapentin (postherpetic neuralgia), pimozide (delusions of parasitosis), topiramate and lamotrigene (skin picking), and naltrexone (pruritus). Recently N-acetylcysteine and aripiprazole have been used successfully in treating trichotillomania. These drugs have been used as evidence-based medications and in research trials, although not all are FDA-approved as psychodermatological treatments.

Several nonpharmacological treatments have also been used in patients with psychocutaneous disorders. Supportive psychotherapy, CBT, hypnosis, relaxation training, biofeedback, stress management, and guided imagery have all been employed successfully.

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Journal of Clinical & Experimental Dermatology Research
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