2011

Review

Psychodermatological disorders: recognition and treatment
Philip D. Shenefelt, MD, MS

Department of Dermatology and Cutaneous Surgery, College of Medicine, University of South Florida, Tampa, FL, USA Correspondence Dr. Philip D. Shenefelt, MD, MS Department of Dermatology and Cutaneous Surgery MDC 079 College of Medicine University of South Florida, 12901 Bruce B. Downs Blvd. Tampa FL 33612 USA E-mail: [email protected] Financial disclosure: None. Conflict of interest: None. Generic and (Trade) names: Alazopram (Xanax) Amitriptyline (Elavil) Aripiprazole (Abilify) Bupropion (Wellbutrin)

Abstract
Many dermatological disorders have a psychosomatic or behavioral aspect. Skin and brain continually interact through psychoneuroimmunoendocrine mechanisms and through behaviors that can strongly affect the initiation or flaring of skin disorders. It is important to consider these mind-body interactions when planning treatments for specific skin disorders in individual patients. Mind-influencing therapeutic options that can enhance treatment of skin disorders include standard psychotropic drugs, alternative herbs and supplements, the placebo effect, suggestion, cognitive-behavioral methods, biofeedback, and hypnosis. When individual measures do not produce the desired results, combinations of drugs or addition of non-drug therapies may be more successful. Psychophysiological skin disorders may respond well to non-drug and drug therapies that counteract stress. Treatment of primary psychiatric disorders often results in improvement of associated skin disorders. Psychiatric disorders secondary to skin disorders may also require treatment. Therapeutic options for each of these are discussed.

Buspirone (Buspar) Cetirizine (Zyrtec) Chlorazepate (Tranxene) Citalopram (Celexa) Clomipramine (Anafranil) Clonazepam (Klonopin) Diazepam (Valium) Diphenhydramine (Benadryl) Doxepin (Sinequan) Escitalopram (Lexapro) Fluoxetine (Prozac) Fluvoxamine (Luvox) Gabapentin (Neurontin) Haloperidol (Haldol) Hydroxyzine (Atarax) Imipramine (Tofranil) Isotretinoin (Accutane) Levocetirizine (Xyzal) Lorazepam (Ativan) Nortriptyline (Pamelor) Olanzapine (Zyprexa) Oxazepam (Serax) Paroxetine (Paxil) Pregabalin (Lyrica) Promethazine (Phenergan) Protriptyline (Vivactyl) Quetiapine (Seroquel) Risperidone (Risperdal) Sertraline (Zoloft) Trimipramine (Surmontil) Venlafaxine (Effexor) Ziprasidone (Geodon)

Introduction Many skin disorders have a significant psychosomatic or behavioral component.1 Both the skin and nervous system are derived from ectoderm in the fetus and develop adjacent to each other and remain interconnected throughout life. Cutaneous innervation is vital to skin protection and health. The interaction of skin and nervous system2 allows the use of psychotropic drugs and nonpharmacological psychotherapeutic interventions that
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have positive effects on many skin diseases. These effects are mediated through drug actions, the autonomic nervous system, local hormones and neuropeptides, and habit alterations that change exposures to environmental factors such as sun, heat, cold, or chemicals. Many skin disorders may have adverse psychosocial effects that alter neurochemistry. Psychotropic drugs and non-pharmacological psychotherapeutic interventions may be indicated to counteract these adverse effects of the skin disorder on the psyche.3 Some patients who really should see a psychiatrist or
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psychologist refuse to do so, leaving any psychological treatment up to the dermatologist or family physician. A multimodal approach with both psychotropic drugs and non-pharmacological psychotherapies is often necessary to obtain optimal results in treating complex psychosomatic and somato-psycho-social problems. Discussed below will be the role of stress and stress reduction in specific skin disorders, primary psychiatric disorders affecting the skin, cutaneous sensory neurogenic dysesthesias, secondary psychiatric disorders related to skin diseases, and therapeutic options, drug and non-drug. Recognizing and treating psychophysiological skin disorders
The role of stress and emotion

hair, or nails in addition to other appropriate treatments for the skin disorders can enhance response to treatment. Similarly, ask the patient to self rate on a 0–10 SUDS for anxiety and again on a 0–10 SUDS for depression. Any associated anxiety or depression can be treated with anxiolytic drugs or antidepressants (see list below under therapeutics).10 Have the patient re-rate the stress level, anxiety, and/or depression on the 0–10 SUDS after the intervention. Alexithymia with difficulty recognizing and describing one’s own and other people’s feelings and its associated dissociative somatization has also been reported with skin disorders.11,12 Acne Inflammatory acne vulgaris often flares with stress and premenstrually.13 Many individuals feel even more stressed when their acne worsens. Ask the patient to do a 0–10 SUDS for stress. Conventional acne treatments can help control the acne, which then can help alleviate the patient’s stress about having the acne. Other types of life stress that affect the acne may be reduced with cognitive-behavioral methods, relaxation training14, or self-hypnosis. Alopecia areata Alopecia areata can flare with inflammatory T-lymphocytes attacking the hair follicles more vigorously in response to stress hormones. Stress can either trigger or exacerbate alopecia areata.15 Hair loss visible to others can further stress the patient. Ask the patient to self rate for stress on a 0–10 SUDS. Alexithymia and its associated dissociative somatization is more common in adults with alopecia areata than in controls although less so with higher levels of education.16 The stress and any self-image issues may be treated with cognitive-behavioral methods, relaxation training, hypnosis, or self-hypnosis.17 Atopic dermatitis Atopic dermatitis typically flares with stress through psychoneuroimmune mechanisms18 and through scratching. Worsening atopic dermatitis can further stress the patient. Ask the patient to do a 0–10 SUDS for stress. The stress may be reduced with cognitive-behavioral methods, relaxation training, hypnosis, or self-hypnosis.19 If appropriate, adjunctive anxiolytic drugs or antidepressants may be added (see list below). Dermatitis artifacta Self-induced factitial damage to the skin may occur for secondary gain or may reflect a seriously disturbed patient.20 Anxiolytic drugs or antidepressants (see list below) may be beneficial if indicated,10 but consultation with a psychiatrist is recommended.
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Stress and emotion often significantly affect cutaneous inflammatory and sensory disorders. Griesemer4, who had training both as a dermatologist and a psychiatrist, developed an index of the effect of emotions on various skin disorders. These ratings ranged from zero for keratoses, nevi, and basal cell carcinomas to 15 for contact dermatitis, 33 for vitiligo, 36 for herpes simplex, 41 for seborrheic dermatitis, 55 for acne, 62 for psoriasis, 68 for urticaria, 70 for atopic dermatitis, 76 for dyshidrosis, 82 for lichen planus, 86 for pruritus, 94 for rosacea, 96 for alopecia areata, 97 for neurotic excoriations, 97 for lichen simplex chronicus, and up to 100 for hyperhidrosis. The exact mechanisms of how stress and emotion interact with the nervous system, immune system, and hormonal system, and affect autonomic functioning and inflammation, which in turn affects the skin, are still being clarified.5 These biomechanisms have been recently reviewed for atopic dermatitis, herpes simplex, psoriasis, squamous cell carcinoma, and urticaria.6 Relaxation and meditation can be used to reduce stress and negative emotion.7 In susceptible individuals, stress can also exacerbate anxiety disorders or depression. Drugs that promote anxiolysis or reduction of depression can often benefit those individuals.
Stress recognition and reduction in specific skin disorders

Psychosomatic factors can be significant in a number of inflammatory, immune-mediated, and behavioral skin disorders.8 Ten percent of patients at a dermatology clinic were reported to have psychosomatic disorders, and another 15% had adjustment disorders.9 A simple selfrating subjective units of discomfort scale (SUDS) of 0–10 may be used to assess stress levels, with zero being no stress and 10 being the worst stress imaginable. Ask the patient to self-rate for stress on this 0–10 scale. Reducing stress and changing behavioral habits that damage skin,
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Dyshidrosis Dyshidrosis typically flares with stress.4 It must be differentiated from irritant or allergic contact dermatitis. Along with topical treatments, stress reduction can be beneficial. The stress level should be assessed and may be improved with cognitive-behavioral methods, relaxation training, autogenic training, self-hypnosis, or biofeedback.21 Herpes simplex Herpes simplex recurrences can be triggered or exacerbated by stress.22 In addition to treating the herpes with antivirals, the stress may be treated with cognitivebehavioral methods, relaxation training, or self-hypnosis.23 Hyperhidrosis Hyperhidrosis of hands, feet, axillae, or forehead has a clear relationship with stress.4 One treatment is to paralyze the nerves associated with sweating with injected botulinum toxin (Botox).24 The stress level should be assessed and may be reduced with cognitive-behavioral methods, relaxation training, self-hypnosis, or biofeedback.25 Lichen planus Lichen planus is often triggered or exacerbated by stress. The lichen planus can in turn be stressful both because of the itching and because of the discoloration with hyperpigmentation that typically occurs. Elevated anxiety and salivary cortisol levels have been detected in patients with oral lichen planus.26 The stress level should be assessed and may be treated with cognitive-behavioral methods, relaxation training, or self-hypnosis.23 Lichen simplex chronicus Lichen simplex chronicus is triggered or exacerbated by stress. Dissociation may play a role.27 In addition to topical treatments, stress reduction can be beneficial. The stress level should be assessed and may be ameliorated with cognitive-behavioral methods, relaxation training, or self-hypnosis.23 Neurotic excoriations Neurotic or psychogenic excoriations are exacerbated by stress. The stress level should be assessed and may be reduced with cognitive-behavioral methods, relaxation training, or self-hypnosis,28 and any associated anxiety or depression should be assessed and treated with adjunctive anxiolytic drugs or antidepressants (see list below). Nummular dermatitis Nummular dermatitis can flare in some individuals with stress. Basement membrane zone nerve to mast cell connections have been noted in nummular dermatitis.29 In
ª 2011 The International Society of Dermatology

addition to topical treatments, stress reduction can be beneficial. The stress level should be assessed and may be treated with cognitive-behavioral methods, relaxation training, or self-hypnosis.23 Perioral dermatitis Perioral dermatitis, like acne, can be exacerbated by stress or other neurogenic factors.30 In addition to topical treatments, stress reduction can be beneficial. The stress level should be assessed and may be reduced with cognitivebehavioral methods, relaxation training, or self-hypnosis.23 Pruritus Pruritus often flares with stress. Many inflammatory skin diseases are pruritic and flare via neuroimmunoendocrine mechanisms.31 See below under cutaneous sensory neurogenic dysesthesias for further discussion of pruritus and its treatment. In addition, stress reduction can be beneficial. The stress level should be evaluated and may be lessened with cognitive-behavioral methods, relaxation training, or self-hypnosis.23 Psoriasis Psoriasis often flares with stress.32 In addition to conventional treatments, stress reduction can be beneficial. Disfigurement of the skin by the red scaly lesions can be quite distressing to many patients. The stress level should be evaluated, and stress and body image issues may be reduced with cognitive-behavioral methods, relaxation training, or self-hypnosis.33 Alexithymia and its associated dissociative somatization was found to be more prevalent in a case control study at 39.6% in patients with psoriasis compared with 13.2% in controls.34 If depression is also present, an antidepressant (see list below) may also be added.10 Rosacea Facial flushing of rosacea flares with stress as does the papular inflammatory component.35 Many patients are distressed further by their facial appearance. Stress level should be assessed and may be lessened with cognitivebehavioral methods, relaxation training, or self-hypnosis.23 Seborrheic dermatitis The scaling and itching of seborrheic dermatitis exacerbates with stress.31 The stress level should be assessed and may be reduced with cognitive-behavioral methods, relaxation training, or self-hypnosis.23 Telogen effluvium The hair loss of telogen effluvium may be acute or chronic. Stress and hormonal changes are common triggers.36 The
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stress level should be assessed and may be treated with cognitive-behavioral methods, relaxation training, or selfhypnosis. If depression is also present, an antidepressant (see list below) may also be added.10 Trichotillomania Stress can exacerbate the repetitive pulling and twisting behavior in trichotillomania. The stress level should be ascertained and may be lessened with cognitive-behavioral methods, relaxation training, or self-hypnosis.37 Urticaria Urticaria may be triggered or exacerbated by stress.31 Having the itchy red welts can in itself be stressful. The stress level should be assessed and may be ameliorated with cognitive-behavioral methods, relaxation training, or self-hypnosis.38 Recognizing and treating primary psychiatric disorders affecting the skin
Anxiety

delusions. Delusions of foul odor arising on the skin with sweating is another. Yet another is delusions of fibers coming out of the skin, called Morgellons by lay groups and popularized on the internet. Patients generally respond best to typical antipsychotics such as pimozide or atypical antipsychotics such as olanzapine or risperidone (see below for dosages). Many of these patients refuse to accept the diagnosis and continue to doctor shop. Intramuscularly administered atypical antipsychotics such as risperidone were found to be particularly effective, as this route of administration did not rely on the patient to comply by taking the oral doses.41
Depression

Depression and risk of self harm can be primary or secondary to skin disease. Primary depression may lead to acts that self harm the skin, such as scratching, picking, digging, burning, cutting, pulling, tearing, or otherwise harming the skin, hair, or nails.42 Thirty-two percent of patients at a dermatology clinic had depression.9 Risk of suicide is higher in depressed patients. Psychiatric consultation should be sought when indicated.
Neurodermatitis

Anxiety is a common condition in the general population. Assessment for anxiety may be done with a SUDS or with more sophisticated tests. Acute or chronic anxiety can be an exacerbating factor for a number of skin disorders. Having the skin disorder can trigger or exacerbate anxiety in susceptible individuals. Thirteen percent of patients at a dermatology clinic had an anxiety disorder.9 Onychotillomania In onychotillomania, self-induced anxious manipulation causes damage to the nails. It may be a form of anxiety disorder with a component of obsessive-compulsive disorder.39 Cognitive-behavioral methods may be helpful, as may selective serotonin reuptake inhibitor (SSRI) antidepressants.40 Psychogenic pruritus When other causes of pruritus are excluded, psychogenic pruritus initiated or exacerbated by anxiety or psychological trauma or stress should be considered.31 The stress and anxiety may be assessed with a SUDS and treated with cognitive-behavioral methods, relaxation training, or self-hypnosis.23 Anxiety may also be treated with anxiolytics (see list below). If depression is also present, an antidepressant (see list below) may also be added.10
Delusion

Most patients who have self-inflicted dermatoses such as neurotic excoriations suffer from depression with somatization.43 Assessing for depression may be preliminarily estimated by a SUDS but is much more accurately measured with more sophisticated tests such as Beck’s depression inventory,44 Hamilton depression rating scale, or the Caroll rating scale for depression. Treating the depression with an antidepressant (see list below)10 may improve treatment responsiveness for the self-damaging habit.

Impulse control

Acne excoriee ´ With patients who pick at their acne impulsively, in addition to treating the acne, it is necessary to reduce or stop the picking habit. Decreasing the picking may be accomplished with cognitive-behavioral methods or hypnosis and self-hypnosis.45 Neurodermatitis Patients with neurodermatitis who are primarily impulsive in their picking46 may be treated with cognitivebehavioral methods47 or hypnosis and self-hypnosis.23 Trichotillomania Trichotillomania is classified as an impulse control disorder.48 Habit reversal therapy may be helpful.49
ª 2011 The International Society of Dermatology

Delusions of parasitosis, bromhidrosis or ‘‘Morgellons’’ Delusions of being infected with parasites, worms, or insects is one of the monosymptomatic hypochondriasis
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Obsessive-compulsive

Obsessive-compulsive disorder spectrum tendencies may produce a skin disease such as irritant contact dermatitis from excessive handwashing or lip-licking, or may exacerbate a preexisting skin disease such as acne, atopic dermatitis, or psoriasis. About 5% of patients at a dermatology clinic had obsessive-compulsive disorder.9 Acne excoriee ´ Some patients who pick at their acne are primarily obesessivecompulsive in their picking.45 Cognitive-behavioral methods may be helpful, as may SSRI antidepressants.40 Neurodermatitis Some individuals with neurodermatitis seem to fit best into the obsessive-compulsive category.43 Cognitive-behavioral methods may be beneficial, as may SSRI antidepressants.40
Somatoform disorders with or without dissociation

nal diseases. After ruling these out, CNS dysfunction should be considered. Neurogenic pruritus originates in the CNS without any overt evidence of neural or cutaneous pathology. Pruritus associated with neurotic excoriations is an example.55 Unexplained pruritus may also occur with somatoform dissociation.56 Antihistamines that are sedating such as hydroxyzine or doxepin have some antipruritic effect, but there is currently no really potent antipruritic medication.
Arising in peripheral nervous system

Somatic symptoms with no explainable underlying physical pathology occur commonly both in general medicine and dermatology. Examples of general medicine functional somatic syndromes include irritable bowel syndrome, fibromyalgia, chronic fatigue syndrome, and interstitial cystitis.50 Examples in dermatology include unexplained cutaneous sensory syndromes (see below), post-traumatic stress syndrome where body memories from traumatic stress may manifest as pruritus, urticaria, or angioedema, self-induced dermatoses such as dermatitis artifacta and trichotillomania associated with dissociative states, and body dysmorphic disorder, where the patient has a somatic preoccupation involving the skin or hair usually without dissociation.43 Fourteen to twenty-one percent of patients with acne have aspects of body dysmorphic disorder.51 Somatization was also found to be strongly associated with non-specific dermatitis.52 In general, functional somatic syndromes are more responsive to active non-pharmacological treatments requiring active patient participation such as exercise and psychotherapy compared with passive physical procedures and injections. Likewise, drugs with CNS action generally are more effective than those used to affect peripheral physiological function.53 If antidepressant treatment alone is ineffective, adding pregabalin may be helpful.54 Recognizing and treating cutaneous sensory neurogenic dysesthesias
Arising in CNS

Brachioradial pruritus Brachioradial pruritus tends to occur in fair-skinned individuals with extensive chronic sun exposure.57 It is usually exacerbated during the summer. In some patients, neuropathic pruritus associated with cervical spinal foramen impingement may be the etiologic factor.58 Topical menthol or capsaicin may provide relief, as may oral gabapentin. Glossodynia Glossodynia is a painful or burning sensation of the tongue. After organic factors such as vitamin deficiency are ruled out, treatment is symptomatic with topical anesthetics. Oral gabapentin may provide relief in some cases, as may olanzapine.59 Notalgia parasthetica Notalgia parasthetica is a neuropathic pruritus of the medial subscapular area. In some cases it may relate to nerve impingement in a thoracic spinal foramen.60 Topical antipruritics such as menthol or capsaicin may provide relief, as may oral gabapentin.60 Post-herpetic neuralgia Post-herpetic neuralgia occurs more frequently in individuals older than 60 years. Topical treatment with capsaicin, which depletes neuropeptide substance P, may reduce pain or pruritus. Oral gabapentin may help alleviate the neuropathic sensations.61 In some patients, acupuncture and hypnosis23 have been successful in relieving the sensations. Pruritus ani and pruritus vulvae After organic pruritoceptive factors such as pinworms, candidal or fungal infections, and inflammatory skin diseases are ruled out, the origin of the pruritus ani and vulvae may be neuropathic62 or psychogenic. Topical pramoxine and hydrocortisone may improve some patients. Some patients may have relief with oral antihistamines.63
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Pruritus Generalized pruritus with no skin eruption can be due to metabolic, renal, thyroid, hematological, and other interª 2011 The International Society of Dermatology

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Recognition and treatment of secondary psychiatric disorders related to skin diseases About 30% of patients who have skin disorders are reported to have concurrent psychiatric disorders and psychosocial impairments.64 While the overall prevalence of psychological disorders among patients with skin disease is about 25–30%, there are even higher prevalence rates over 30% among patients with acne, alopecia, herpes simplex, pruritus, and urticaria.65 Having psychological morbidity in conjunction with skin disease is associated with poorer quality of life than having the skin disease alone.66
Anxiety

be recommended. Cognitive-behavioral therapy may also be effective. When available, psychiatry–dermatology liaison should be sought. Alopecia Hair loss may result from genetic influences such as androgenetic alopecia, from inflammatory processes such as alopecia areata, discoid lupus, or lichen planopilaris, from stress or hormonal changes such as telogen effluvium or thyroid dysfunction, as side effects of drugs, especially with cancer chemotherapy, or with behavior such as trichotillomania. Because hair appearance can affect psychosocial functioning, depression can be induced or exacerbated in susceptible individuals following hair loss. Alopecia areata can exacerbate with depression.14 Patients with alopecia with major depression should be referred to a psychiatrist for care. For lesser depression, SSRIs or tricyclics may be prescribed,10 or the herb St John’s wort may be recommended. Cognitive-behavioral therapy may be effective. Atopic dermatitis Chronic pruritus in atopic dermatitis can be very upsetting to some patients. The pruritus can aggravate depression in depression-prone individuals, often causing them to scratch more and worsen their skin disorder.70 The antihistamines hydroxyzine and doxepin cause sedation and can reduce pruritus and scratching through their antihistaminic effect. Doxepin also is a tricyclic antidepressant. Patients with atopic dermatitis with major depression should be referred to a psychiatrist for care. For lesser depression, SSRIs or tricyclics may be prescribed,10 or the herb St John’s wort may be recommended. Cognitive-behavioral therapy may be helpful. The patient should be asked to rate both the pruritus and the depression on a 0–10 SUDS before and during treatment. Self-hypnosis can reduce pruritus and give a sense of greater control, which in turn can lessen the depression. Disfigurement Various skin disorders, traumatic injuries71, and skin surgeries can result in disfigurement, which can aggravate depression in depression-prone individuals. Disfigured individuals with major depression should be referred to a psychiatrist for care. For lesser depression, SSRIs or tricyclics may be prescribed, or the herb St John’s wort may be recommended. Cognitive-behavioral therapy may be beneficial. Hypnosis can also alter the patient’s perspective on their disfigurement, secondarily lessening depression. Malignant melanoma Having metastatic melanoma can induce situational depression, which in turn degrades the body’s immune
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Acne Acne in susceptible individuals can induce problems with self-esteem, self-confidence, embarrassment, and impaired social functioning. For anxiety-prone individuals, acne can increase anxiety substantially. Because stress and anxiety can also cause acne to worsen, a vicious cycle can occur.67 Obtaining an anxiety self-rating of 0–10 SUDS before and during treatment can help gauge effectiveness. Drug treatments for anxiety include low-dose benzodiazepine monitored carefully to minimize dependence, buspirone, or herbal options such as magnolia bark or passion flower. Relaxation techniques or self-hypnosis for relaxation can enhance treatment of anxiety. Urticaria Pruritus from urticaria and the release of histamine can induce anxiety in anxiety-prone individuals. Because anxiety can exacerbate the urticaria, a vicious cycle can occur.31 The antihistamines hydroxyzine and doxepin cause sedation and can help reduce anxiety, while also reducing the urticaria through their antihistaminic effect.
Depression

Acne Adolescents with severe acne had a prevalence of depression of about 18–29%, compared with a prevalence of depression of about 5–8% for the general adolescent population.68 Adolescents often conceal or deny depressive symptoms or express them through aggressive or disruptive behavior. The drug isotretinoin used to treat nodulocystic acne has been questionably associated with depression and suicide.69 Asking the patient to self-rate for depression on a 0–10 SUDS can be helpful if the patient is cooperative and has some insight. Acne patients with major depression should be referred to a psychiatrist for care. For minor depression, SSRIs or tricyclics may be prescribed (see below), or the herb St John’s wort may
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response72 against the melanoma metastases. Patients with melanoma with major depression should be referred to a psychiatrist for care. For lesser depression, SSRIs or tricyclics may be prescribed, or the herb St John’s wort may be recommended. Cognitive-behavioral therapy may be of benefit. Psoriasis Psoriasis can initiate or exacerbate depression in depressionprone individuals, which in turn can increase the pruritus.70 Scratching the pruritic psoriatic plaques can exacerbate the psoriasis. Patients with psoriasis with major depression should be referred to a psychiatrist for care. For lesser depression, SSRIs or tricyclics may be prescribed, or the herb St John’s wort may be recommended. Cognitivebehavioral therapy may be effective. Self-hypnosis can reduce pruritus and give a sense of greater control, which in turn can lessen the depression. Urticaria Chronic urticaria can initiate or exacerbate depression in depression-prone individuals, which can in turn exacerbate pruritus.70 Patients with urticaria with major depression should be referred to a psychiatrist for care. For lesser depression, SSRIs or tricyclics may be prescribed, or the herb St John’s wort may be recommended. Self-hypnosis can reduce pruritus and give a sense of greater control, which in turn can lessen the depression. Hypnosis has produced resolution in some cases of chronic urticaria.73 Vitiligo Vitiligo, especially in darkly pigmented individuals74 can initiate or exacerbate depression in depression-prone individuals. Patients with vitiligo with major depression should be referred to a psychiatrist for care. For lesser depression, SSRIs or tricyclics may be prescribed,10 or the herb St John’s wort may be recommended. Cognitivebehavioral therapy may be helpful. Hypnosis can also help to alter the patient’s perspective on their vitiligo, secondarily lessening depression.

increased to therapeutic range, then tapered for termination of treatment as appropriate.10 When available, psychiatry–dermatology liaison should be sought. Appropriate psychiatric evaluation and monitoring should be obtained as appropriate. Some patients may be resistant to accepting psychiatric care. Antidepressants SSRIs are used in dermatology for depression, anxiety, and obsessive-compulsive spectrum disorders. Side effects include nausea, diarrhea, insomnia, or sedation.10 They should be started at low dose and titrated upward. Response to SSRIs is slow, usually taking 3–6 weeks. See Table 1 for common adult dosages, and Table 2 for side effects. Lower initial dosages are recommended in the elderly. Tricylics are also used in dermatology for depression and obsessive-compulsive spectrum disorders. They should be started at low dose and titrated upward. See Table 3 for common adult dosages, and Table 4 for side effects. The norepinephrine and dopamine reuptake inhibitor bupropion, an aminoketone antidepressant, is dosed at 75–150 mg bid or tid. Antipsychotics Typical (dopamine receptor antagonists) antipsychotics are used in dermatology for delusional psychoses, such as delusions of parasitosis and bromhidrosis. Atypical (serotonin–dopamine antagonists) antipsychotics are used in dermatology often as a second agent in addition to SSRIs for treatment of resistant cases of obsessive-compulsive spectrum disorders. See Table 5 for common adult dosages, and Table 6 for side effects. Anticonvulsants c-Aminobutyric acid (GABA) elevators are used in dermatology for relief of pain, itching, or paraesthesias in peripheral neuropathies including post-herpetic neuralgia.
Table 1 SSRI antidepressants
SSRI antidepressant Dose 20–40 mg daily 10 mg daily 20–80 mg daily 25–150 mg bid 20–50 mg daily 25–200 mg daily 25–75 mg tid

Therapeutic options
Standard pharmacological psychocutaneous therapies

For the most current information on specific products, see the current Physicians’ Desk Reference,75 package inserts, or other appropriate information sources, such as Kaplan and Sadock’s Synopsis of Psychiatry76 to check dosages, indications, and usage, review pharmacokinetics, and note contraindications, warnings, precautions, drug interactions, and adverse reactions. Many psychotropic drugs should initially be started at a low dose and progressively
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Citalopram (Celexa) Escitalopram (Lexapro) Fluoxetine (Prozac) Fluvoxamine (Luvox) Paroxetine (Paxil) Sertraline (Zoloft) Venlafaxine (Effexor)

Start low, titrate upward. Response is slow, usually taking 3–6 weeks. SSRI, selective serotonin reuptake inhibitor.
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Table 2 SSRI antidepressants: side effects
Multiple drug interactions avoid abrupt discontinuance Citalopram Escitalopram Fluoxetine Fluvoxamine Paroxetine Sertraline Venlafaxine

Anxiety/insomnia 0 0 3+ 0 0 0 1+

Sedation 2+ 0 0 0 3+ 1+ 0

GI symptoms 1+ 1+ 1+ 3+ 2+ 3+ 1+

Emotional blunting 2+ 2+ 2+ 2+ 3+ 2+ 2+

Sexual dysfunction 2+ 2+ 2+ 2+ 2+ 2+ 2+

Adapted from Kaplan and Sadock,76 pp. 1087–1089.

Table 3 Tricyclic antidepressants
Tricyclic antidepressant Amitriptyline (Elavil) Clomipramine (Anafranil) Doxepin (Sinequan) Imipramine (Tofranil) Nortriptyline (Pamelor) Protriptyline (Vivactyl) Trimipramine (Surmontil) Dose 25–50 mg daily 25–250 mg daily 25–300 mg daily 25–300 mg daily 25–150 mg daily 5–20 mg tid 5–50 mg tid

Start low, titrate upward. Response is slow, usually taking 3–6 weeks.

tid. Clorazepate is long acting (half-life more than 1 day) and is dosed at 7.5–15 mg bid to qid. Clonazepam is long acting, is dosed at 0.25–0.5 mg bid or tid, and is also an anticonvulsant. Diazepam is long acting and is dosed at 2–10 mg bid to qid. Lorazepam is short-acting and is dosed at 1 mg bid to tid. Oxazepam is short acting and is dosed at 10–15 mg tid to qid. The serotonin agonist buspirone is an azaperone. Its advantages are not being a controlled substance and being non-sedating. It is dosed at 5–30 mg bid in adults. Its disadvantage is that it has a delayed onset of action of a couple of weeks. This results in it not being useful for pre-procedure anxiety. Sedatives Sedating antihistamines are used extensively in dermatology for pruritus. They are also used for angioedema, dermatographism, and urticaria. Cetirizine is usually dosed in adults at 10 mg daily and levocetirizine at 5 mg daily. Diphenhydramine is dosed at 25–50 mg tid or qid. Doxepin has antihistaminic as well as antidepressant properties. As an antihistamine, it is dosed at 25–100 mg tid. Hydroxyzine is dosed at 25–100 mg tid or qid and is also mildly anxiolytic. Promethazine is dosed at 25–100 mg tid

Gabapentin is typically dosed in adults at 300–1800 mg daily in three divided doses, while pregabalin is dosed at 50–100 mg tid. Anxiolytics Benzodiazapines are Schedule IV controlled substances due to risks of potential abuse and addictive dependence. They tend to be sedating and are used in dermatology for pre-procedure anxiety. Alazopram is short acting (half-life <1 day) and usually is dosed for adults at 0.25–0.5 mg

Table 4 Tricyclic antidepressant side effect profiles
Anticholinergic Amitriptyline Clomipramine Doxepin Imipramine Nortriptyline Protriptyline Trimipramine 4+ 4+ 3+ 3+ 3+ 3+ 3+ Orthostatic hypotension 3+ 3+ 2+ 4+ 1+ 2+ 3+ Heart dysconduction 4+ 4+ 2+ 4+ 3+ 4+ 4+

Sedation 4+ 4+ 4+ 3+ 3+ 1+ 4+

Seizures 3+ 3+ 3+ 3+ 2+ 2+ 3+

Adapted from Kaplan and Sadock,76 p. 1109.
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Table 5 Antipsychotics
Typical (dopamine receptor antagonist) Haloperidol 5–20 mg daily acutely, maintenance 1–10 mg daily Atypical (serotonin–dopamine antagonists) Aripiprazole 10–15 mg daily Olanzapine 2.5–10 mg daily, side effects weight gain and diabetes Quetiapine beginning at 50 mg bid and increasing to 200–400 mg bid Risperidone 1–3 mg bid Ziprasidone beginning at 20 mg bid and increasing up to 80 mg bid

Supplements, and Herbs for details of their actions, interactions, adverse effects, and literature references.
Anxiolytics

Lemon balm is approved by the German Commission E for nervousness and insomnia. Kava Kava is moderately anxiolytic, but its use is not recommended due to its hepatotoxicity. Magnolia bark is moderately anxiolytic.85 Passion flower is approved by the German Commission E for nervousness and insomnia.
Antidepressants

or qid for sedation. It is also mildly to moderately anxiolytic. Psychotropic drug adverse events Psychotropic drugs can have cutaneous side effects ranging from exacerbations of acne and psoriasis by lithium to drug exanthems, urticaria, purpura, photosensitivity, fixed drug eruption, erythema multiforme, toxic epidermal necrolysis, erythema nodosum, lichenoid dermatitis, exfoliative dermatitis, lupus, hair loss, and vasculitis. Antipsychotics, anxiolytics, antidepressants, barbiturates, anticonvulsants, and lithium all have most or all of these potential side effects.77–81 Conversely, oral corticosteroids such as prednisone used to treat skin disorders can have psychiatric effects, such as mood alterations or even psychosis.

St John’s wort is approved by the German Commission E for mild to moderate depression but not for severe depression.86 It has significant interactions with the metabolism of a number of other drugs through activating cytochrome p-450. S-adenosyl-L-methionine (SAMe) is also an antidepressant. A meta-analysis of studies comparing SAMe with controls showed significant clinical improvement with SAMe equivalent to that of standard SSRI treatment with fewer side effects.87
Soporifics

Melatonin is effective at producing drowsiness. Valerian is approved by the German Commission E for insomnia caused by nervousness. Non-pharmacological treatments for psychocutaneous disorders
Biofeedback

Complementary pharmacological psychocutaneous therapies Herbal therapy in dermatology was reviewed by Bedi and Shenefelt.82 Information about individual herbs, their actions, interactions, and adverse effects, is available in the PDR for Nonprescription Drugs, Dietary Supplements and Herbs,83 The Complete German Commission E Monographs,84 and in many other textbooks and monographs. Psychoactive herbs and supplements (see below) may have some indirect effects on skin diseases through anxiolytic, antidepressant, or soporific activities. See the current PDR for Nonprescription Drugs, Dietary
Table 6 Antipsychotics: adverse effects

Biofeedback can improve skin problems that have an autonomic nervous system component, such as biofeedback of galvanic skin resistance for hyperhidrosis and biofeedback of skin temperature for dyshidrosis and Raynaud’s syndrome.88 Hypnosis may enhance the effects obtained by biofeedback.89 Heart rate variability biofeedback with handheld devices such as the emWave Personal Stress Reliever or StressEraser can promote relaxation, improving skin conditions worsened by stress.

Tardive dyskinesia Typical (dopamine receptor agonist) Haloperidol 3+ Atypical (serotonin–dopamine antagonists) Olanzapine 0 Risperidone 1+

Seizures

Sedation

Neuroleptic malignant syndrome

Weight gain/diabetes

0 1+ 0

1+ 1+ 1+

1+ 1+ 1+

1+ 3+ 1+

Adapted from Kaplan and Sadock,76 pp. 1047, 1093.
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Cognitive-behavioral methods

Cognitive-behavioral methods help to alter dysfunctional thought patterns (cognitive) or actions (behavioral)90 that damage the skin or interfere with dermatological therapy. These methods include habit reversal therapy. Skin diseases that are responsive include acne excoriée, atopic dermatitis, factitious cheilitis, hyperhidrosis, lichen simplex chronicus, needle phobia, neurodermatitis, onychotillomania, prurigo nodularis, trichotillomania, and urticaria. Adding hypnosis to cognitive-behavioral therapy can facilitate virtual aversive therapy and enhance desensitization and other cognitive-behavioral methods.89
Emotional freedom techniques (EFT)

EFT91 involve selecting a negatively emotionally charged memory or problem area, focusing on that thought, and repeating an affirmation such as ‘‘Even though I have this problem with X, I deeply and completely accept myself’’, while progressively tapping with the finger on a series of up to 14 specific acupuncture sites on the head, chest, and hand. EFT can neutralize negative emotionally-charged memories or problem areas, reducing anxiety and enhancing performance.92 Anecdotally reported improvements or resolution of skin conditions on http://www.emofree.com accessed June 4, 2010, include acne, allergic contact dermatitis, atopic dermatitis, needle phobia, post-herpetic neuralgia, psoriasis, scleroderma, and warts.
Eye movement desensitizing and reprocessing (EMDR)

include acne excoriée, alopecia areata, atopic dermatitis, congenital ichthyosiform erythroderma, dyshidrotic dermatitis, erythromelalgia, furuncles, glossodynia, herpes simplex, hyperhidrosis, ichthyosis vulgaris, lichen planus, neurodermatitis, nummular dermatitis, post-herpetic neuralgia, pruritus, psoriasis, rosacea, trichotillomania, urticaria, verruca vulgaris, and vitiligo.96 Hypnosis is most useful in high and medium hypnotizables and should generally not be used with schizophrenics or others who are not mentally intact. Relaxation with hypnosis can reduce anxiety and pain associated with dermatological procedures. Hypnoanalysis has been successful in reducing erythema nodosum, herpes simplex reactivation, neurodermatitis, neurotic excoriations, rosacea, urticaria, and verrucae.73,97
Placebo

Positive placebo expectations and a positive doctor– patient relationship can affect the patient’s experience of treatment, can reduce pain, and may influence outcome. Negative expectations can produce negative nocebo results.98 Research on the placebo effect illustrates that the natural healing capacities of individuals can be enhanced and nurtured.99 The placebo effect for some common dermatological conditions, such as acne and urticaria, is about 30%.100 Those disorders higher on the Griesemer scale are more likely to have a significant placebo effect.
Suggestion

EMDR also involves selecting a negatively emotionally charged memory or problem area, focusing on that thought, and doing an alternating bilateral activity such as following a finger from side to side with the eyes,93 hearing alternating left and right tones through headphones, feeling alternating left and right vibrations in handheld paddles, or alternately tapping left and right distal thighs or upper arms. When combined with the EFT affirmations, it becomes a hybrid known as wholistic hybrid derived from EMDR and EFT, reducing anxiety and enhancing performance.90 EMDR has been reported effective for improving atopic dermatitis and the blushing component of rosacea.
Hypnosis

Suggestion used to promote healing is as old as language. It can be used to change subjective perceptions and to reduce pain. Suggestion may influence outcome. Reports on the efficacy of suggestion in treating verruca vulgaris have since been confirmed numerous times to a greater or lesser degree.101 Conclusion Skin disorders can have a significant effect on the psyche, and the psyche through psychoneuroimmunoendocrine and behavioral mechanisms can have a significant effect on skin disorders. Assessing levels of stress, anxiety, and depression on a simple 0–10 SUDS before and during treatment can provide a rough measure of treatment progress. Because many inflammatory skin disorders are triggered or aggravated by stress, teaching patients to practice safe stress using non-pharmacological methods, supplemented if necessary with anxiolytic standard drugs or herbal alternatives, deserves more attention in treatment planning. Adding non-drug psychocutaneous treatments such as biofeedback, cognitive-behavioral methods, hypnosis, or suggestion often enhances the effectiveness of treatment. A
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Hypnosis involves guiding the patient into a trance state of narrowed awareness, focused attention, selective wakefulness, and heightened suggestibility for a specific purpose, such as relaxation, pain or pruritus reduction, or habit modification. The hypnotic trance has objectively documented differences in regional cerebral blood flow94 and electroencephalogram95 patterns compared with the usual waking state. The use of hypnosis may improve or clear numerous skin disorders. Examples
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multidimensional approach often enhances and optimizes the treatment response. Much additional research is needed to compare the single mode and multimodal treatment effectiveness of drugs, drug combinations, and nonpharmacological methods for improving skin disorders that have a significant psychological component.

8. A primary concern with kava kava is its potential: a. soporific effect b. antihistamine effect c. anxiolytic effect d. hepatotoxicity 9. SSRIs tend to cause less ______ than tricyclics: a. sedation b. orthostatic hypotension c. heart dysconduction d. all of the above 10. Olanzapine treatment carries a high risk of: a. tardive dyskinesia b. weight gain and diabetes c. sedation d. neuroleptic malignant syndrome

Questions 1. The prevalence of concurrent psychiatric disorders in patients with skin disorders is about: a. 5% b. 10% c. 30% d. 50% 2. The Griesemer index for the given skin disorder is about: a. 62 for psoriasis b. 100 for urticaria c. 55 for acne d. a. and c. 3. Oral lichen planus has been associated with: a. a Griesemer index of 35 b. anxiety and elevated saliva cortisol levels c. pruritus d. a. and c. 4. Basement membrane zone nerve to mast cell connections have been noted in: a. nummular dermatitis b. psoriasis c. lichen planus d. herpes simplex 5. SUDS is: a. a cleanser b. subjective units of discomfort scale c. an objective quantification method d. always done on a 0–10 scale 6. Somatoform disorders related to the skin include: a. unexplained cutaneous sensory syndromes b. psoriasis c. chronic fatigue d. tinea corporis 7. St Johns wort may: a. decrease metabolism of some other drugs via the cytochrome p-450 pathway b. prolong clotting time c. increase metabolism of some other drugs via the cytochrome p-450 pathway d. be used as primary treatment for severe depression

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Answers 1. c. 2. d. 3. b. 4. a. 5. b. 6. a. 7. c. 8. d. 9. d. 10. b.

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