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Psychodermatology: The Mind and Skin Connection

American Family Physician, Dec 1, 2001 by John Koo, Andrew Lebwohl

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In younger patients, pimozide can be continued at the lowest effective dosage for several months and gradually tapered off without necessarily inviting the recurrence of symptoms. If the condition recurs, another course of therapy with pimozide can be instituted.(11) In elderly patients, long-term maintenance with low dosages of pimozide (1 to 2 mg per day) is sometimes required. Tardive dyskinesias can occur, but with low-dose (6 mg per day or less) intermittent usage, the risk is lessened. In patients with cardiac arrhythmias, advanced age or dosages of more than 10 mg per day, serial electrocardiography is required.

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As with other antipsychotic agents, extrapyramidal side effects (i.e., pseudo-parkinsonian effects) may develop with the use of pimozide.(12) Stiffness and restlessness respond to benztropine (Cogentin), in a dosage of 2 mg up to four times per day, as needed. Diphenhydramine (Benadryl), in a dosage of 25 mg up to three times per day as tolerated and needed, may be substituted.

The challenge in managing patients with delusions of parasitosis is in introducing the use of an antipsychotic medication without offending the patient. This step requires a delicate balance between the patient's right to informed consent and the goal of pursuing the most appropriate therapy. The authors recommend a sensitive, empathic and diplomatic approach. The medication should be presented as a "therapeutic trial," and any contentious argument regarding the pathogenesis of the disorder or the mechanism of action of pimozide should be purposely avoided. Encouragement suggesting that pimozide may "help one focus less on the skin and more on enjoying life" may help. Because the FDA-labeled use of pimozide in the United States is for treatment of Tourette's syndrome and not psychosis, there is less stigma attached to this medication than other antipsychotic agents.

NEUROTIC EXCORIATIONS, FACTITIAL DERMATITIS AND SKIN LESIONS IN RESPONSE TO A DELUSIONAL BELIEF

The terms "neurotic excoriations" and "psychologic excoriations" are used when patients self-inflict excoriations (scratch marks) with their fingernails. Factitial dermatitis (dermatitis artefacta) generally refers to a condition in which the patient uses something more elaborate than the fingernails, such as burning cigarettes, chemicals or sharp instruments, to damage his or her own skin.(13)

The most common underlying psychopathologies are major depressive episodes, anxiety and obsessive-compulsive disorders. Rarely, patients excoriate their skin in response to delusional ideation; in such cases, the appropriate diagnosis would be psychosis. Patients with neurotic excoriations usually have depression or anxiety, whereas those with factitial dermatitis often have other psychiatric illnesses. Borderline personality disorder is just one of the more serious diagnoses associated with factitial dermatitis.

If the patient has underlying depression that results in neurotic excoriations, one antidepressant frequently used by dermatologists is doxepin (Sinequan). Doxepin is a tricyclic antidepressant with one of the most powerful anti-itch and antihistaminic effects, as well as sedative/tranquilizing effects. Because many people with depression who excoriate their skin are agitated (i.e., have "agitated depression"), the sedative and tranquilizing effects of doxepin frequently prove to be therapeutic.(14) Moreover, the profound antipruritic effect of this drug is an added benefit. Although these patients create their own skin lesions as they continue to pick at their skin, not allowing it to heal, the "itch-scratch cycle" may create intensely itchy patches that can benefit from the antipruritic effect of doxepin (Figures 3, 4 and 5).

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Psychodermatology: The Mind and Skin Connection

American Family Physician, Dec 1, 2001 by John Koo, Andrew Lebwohl

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