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Industry: Email Alert RSS FeedPsychodermatology: The Mind and Skin Connection
American Family Physician, Dec 1, 2001 by John Koo, Andrew Lebwohl
The use of doxepin requires the usual precautions taken with older tricyclic antidepressants. This includes carefully limiting the amount of medication that may be dispensed at one time to minimize the risk of suicide. A detailed description is beyond the space available in this article; however, it should be mentioned that if the patient is truly depressed, adequate dosages of antidepressants are required to prevent undertreatment of the patient. Elderly patients may respond to lower dosages. SSRIs may also be used.(15)
TRICHOTILLOMANIA
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Trichotillomania, according to the dermatologic use of the word, is a condition in which a person pulls out his or her own hair. The psychiatric definition of trichotillomania requires the presence of "impulsivity."(16) However, using the less specific dermatologic definition, the physician once again must ascertain the nature of the underlying psychopathology to select the most appropriate treatment.
The most common underlying psychopathology is obsessive-compulsive behavior, whether or not it formally meets the criteria of the Diagnostic and Statistical Manual of Mental Disorders, 4th ed., for obsessive-compulsive disorder.(17) The other possible underlying psychiatric diagnoses include simple habit disorder, reaction to situational stress, mental retardation, depression and anxiety, as well as extremely rare cases of delusion in which the patient pulls out his or her hair based on a delusional belief that something in the roots needs to be "dug out" so the hair can grow normally. This latter, rare condition is called "trichophobia." The differential diagnosis of trichotillomania includes pseudopelade, alopecia areata, syphilis and tinea capitis.
Trichotillomania is one of the rare conditions in which pathologic examination of the skin can be diagnostic. The hair root undergoes a unique change called trichomalacia, which only occurs in patients with trichotillomania.(18) Thus, if the patient continues to deny pulling his or her own hair, a skin biopsy can be helpful in determining the diagnosis.
As with other conditions, the treatment of trichotillomania is based on the nature of the underlying psychopathology. Because the most commonly encountered underlying psychopathogy is obsessive-compulsive tendency, medications such as fluoxetine (Prozac), paroxetine (Paxil), sertraline (Zoloft), fluvoxamine (Luvox) and clomipramine (Anafranil), in dosages appropriate for the treatment of obsessive-compulsive disorder, can be helpful in the pharmacologic management of trichotillomania.(19) It should be noted that the anti-obsessive-compulsive dosage for any of these medications tends to be higher than the antidepressant dosage. The nonpharmacologic approach includes psychotherapy, which may be useful if the patient has a definable issue that can be discussed. Behavior therapy is another treatment modality.
Secondary Psychiatric Disorders
Although skin conditions are usually not life-threatening, because of their visibility they can be "life-ruining." Persons with disfigurement frequently feel psychologically and socially devastated as a result (Figure 6). Moreover, persons with skin disorders have trouble getting jobs in which appearance is important.(20) It is also well documented that persons with visible disfigurement face discrimination, especially if the condition is perceived to be contagious.(21)
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