Understanding the Pharmacist’s Role in the Treatment of Psychodermatological Disorders
It’s the classic example of a self-perpetuating cycle—skin problems cause psychological distress, while psychological disorders lead to skin conditions. Trying to untangle the two to find the root cause of psychodermatological disorders is a challenge faced by psychiatrists and dermatologists alike. A multidisciplinary approach works best, but that’s not always feasible and it sure isn’t easy to convince patients to see another specialist. That’s where pharmacists can help. Whether you formally join the team or not, your expertise is essential for monitoring medications and encouraging patient adherence.
The Evolving Specialty of Psychodermatological Disorders
Psychodermatology is only now being recognized in the United States, with both psychiatrists and dermatologists calling it a new discipline. The difference between the two fields is that psychiatrists have a good chance of referring a patient to a dermatologist, but it doesn’t work in reverse. Patients who first consult a dermatologist often resist referral to a psychiatrist and may even be offended if the idea is suggested. As a result, dermatologists are encouraged to learn about psychological disorders, treat the whole patient, and discern when a psychiatric consult is needed. Here are a few statistics to give you a sense of the extent of the condition:
- Thirty to 40 percent of patients with a dermatological disorder experience psychological conditions related to their skin problem.1
- Prevalence of skin diseases exacerbated by stress ranges from 50 percent in patients with acne to more than 90 percent in those with rosacea, alopecia areata and neurotic excoriations.2
- Nine to 14 percent of patients visiting a dermatology clinic have body dysmorphic disorder. The suicide rate in this group is 37 percent higher than the general population.3
- Ninety percent of patients with rosacea suffer from low self-esteem, 54 percent experience anxiety, 43 percent feel depressed, and at least half avoid face-to-face contact.
When you interact with these patients, never assume you know how they feel based on the condition of their skin. The severity of the dermatological manifestation doesn’t necessarily correlate with the psychological impact. “I’ve seen people who have nodulocystic acne who aren’t happy but really aren’t psychologically distraught; I’ve also seen patients with one zit on their chin who have attempted suicide,” said dermatologist Rick Fried, MD, PhD during an interview for Monitor on Psychology.4
Common Psychodermatological Conditions and Treatments
Experts are just beginning to understand the complex interplay between the skin, neuroendocrine and immune systems that give rise to psychodermatological disorders. While the most common psychocutaneous disorders are psoriasis, atopic dermatitis, dermatitis artefacta, and trichotillomania, this group includes numerous mental and physical health conditions that are divided into four main categories:
- Psychophysiological disorders: These are true organic skin problems that are affected by stress and other emotions. Patients should have a chronological association between psychological states and skin exacerbations. The brain-skin connection is so strong that the course of the disease changes based on the emotional state of the patient. This group includes acne, atopic dermatitis, psoriasis, alopecia areata, hyperhidrosis, pruritus, rosacea, and lichen simplex.
- Primary psychiatric disorders: All skin lesions in this category are self-inflicted due to underlying psychopathology related to psychotic, delusional, or obsessive psychiatric conditions. Patients typically lack awareness of their condition and refuse to see a psychiatrist. The disorders most often diagnosed include neurotic excoriations, trichotillomania, onychotillomnia, delusions of parasitosis, and factitious disorder.
- Secondary psychiatric disorders: Psychological problems develop due to the impact of a skin condition on the patient’s psyche. Anxiety, depression, and social phobias resulting from psoriasis, alopecia areata, or acne are most common. The psychiatric symptoms usually respond to successful dermatologic therapy.
- Cutaneous sensory disorders: This group includes conditions in which the patient experiences abnormal sensations on the skin, but a clinical workup doesn’t find a diagnosable skin disorder. Patients may feel itching, stinging, crawling, or burning sensations, which can occur anywhere on the body. No skin changes are evident and a psychiatric diagnosis may or may not exist. The cause may be neuropathic.
The best treatments are often multimodal and designed to target the underlying condition, improve functioning, lower physical distress, improve quality of sleep, and manage psychiatric symptoms.
- Pharmacologic treatments include selective serotonin reuptake inhibitors, tricyclic antidepressants, antianxiety agents, antipsychotic drugs, methotrexate, systemic steroids, oral retinoids, antihistamines, and any number of oral medications for skin conditions.
- Topical creams, ointments, and patches containing steroids such as Fluocinonide, capsaicin, and calcineurin inhibitors.
- Nonpharmacologic options that have proven successful include psychotherapy, cognitive behavioral therapy, relaxation therapy, biofeedback, stress management, and guided imagery.
How Pharmacists Can Promote Patient Care
One of most important roles pharmacists perform for any patient is medication therapy management, but this service is vital for patients with psychodermatological disorders. There’s a good chance they will be on several medications and, depending on the psychological diagnosis, may be at a higher risk for noncompliance. In addition to screening for potential drug-drug interactions, teach patients about what they’re taking and the importance of sticking with the regimen. Right at the start, reach out to the physician and establish a collaborative relationship. Talk about your role on the team and how you can monitor for adherence and side effects.
Psychiatric medications often cause skin-related side effects. In addition to alerting the physician, ask the patient whether they’ve noticed any new skin problems every time they refill prescriptions. This is a short list of some of the skin conditions associated with psychotropics:
- Antipsychotics – contact dermatitis, erythema, palmer erythema, purpura, seborrheic dermatitis, urticaria
- Anti-anxiety agents – bullous lesions, erythema nodosum, hyperpigmentation, maculopapular rash, urticarial
- Antidepressants – acne, alopecia, erythema multiforme, toxic epidermal necrolysis
Many patients self-treat before they consider seeing a physician, which offers opportunities for outreach. You can offer to help them choose the best OTC product, then talk to them about other treatment options if their problem doesn’t clear up. Of course, always be prepared to refer them to their primary care physician or a dermatologist.
Forming a Health Care Team Promotes Optimal Outcomes
It’s worth your time to coordinate a health care team for your patients with psychodermatological disorders. It may be the only way they’ll have access to the expertise they need from multiple specialty areas, which improves outcomes and promotes the patient’s health. But the team approach fills another goal—it improves quality of care, which boosts the quality ratings of insurance providers and helps you provide value-based patient care.
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- “Psychodermatology: A Review,” May 2015http://practicaldermatology.com/2015/05/psychodermatology-a-review/ ↩
- “Psychological Problems Impact Skin Disease,” August 2015, http://dermatologytimes.modernmedicine.com/dermatology-times/news/psychological-problems-impact-skin-disease?page=0,0 ↩
- “Dermatologists Should Recognize BDD,” March 2015, http://dermatologytimes.modernmedicine.com/dermatology-times/news/dermatologists-should-recognize-bdd ↩
- “The Link Between Skin and Psychology,” February 2015, http://www.apa.org/monitor/2015/02/cover-skin.aspx ↩