Aug 29, 2019
Psychiatric disease is seen in 30%-60% of dermatology patients.
In this special resident takeover of the podcast, three dermatology
residents – Dr. Elisabeth Tracey, Dr. Julie Croley, and Dr. Daniel
Mazori – talk about the challenges of treating patients with both
psychiatric and dermatologic disease. “In some instances, although
ideally, we would like to refer [patients to a mental health
professional], we do have to develop good skills during our
training to be well equipped to handle these cases,” explains Dr.
Croley. Beginning at 4:29, they discuss common psychiatric
disorders seen by dermatologists, appropriate therapies, and
strategies for building a strong rapport with these patients prior
to referral.
We also bring you the latest dermatology news and research.
-
Recent progress in vitiligo treatment might be heading to vitiligo
cure
Clinical trials are now actively being planned to target
interleukin-15, a cytokine thought to be essential for maintaining
memory T cells. In murine models, this approach led to rapid and
durable repigmentation without apparent adverse effects.
-
Dermatologists lack training about skin of color
The results of a small survey argue for enhanced training in
treating patients with skin of color, an emphasis on culturally
sensitive and competent care, and greater diversity in the
dermatology workforce.
Things you will learn in this episode:
- Dermatologists often see psychiatric disease in two forms: a
condition that is primary and drives a cutaneous disease or a
condition that is comorbid or secondary to a dermatologic
disorder.
- Delusional infestation (also known as delusions of parasitosis)
is a common primary condition in dermatology. Patients with
delusional infestation have a fixed false belief that an organism
or other nonliving matter is present in or under the skin, which
they may bring to the office in a matchbox as proof of infestation
(known as the matchbox sign). Dr. Mazori adds, “Now that about 80%
of Americans own smartphones, instead of the matchbox sign, I’ve
seen patients increasingly present with photos of the
specimens.”
- Obsessive-compulsive disorder and other related disorders
represent a broad category of primary conditions, including body
dysmorphic disorder (BDD), olfactory reference syndrome,
excoriation disorder, trichotillomania, and trichophagia.
- An estimated 12% of dermatology patients have BDD, which
presents more commonly in cosmetic dermatology. In the general
dermatology population, BDD occurs at the substantial rate of
7%.
- In patients with dermatitis artefacta, a condition in which the
individual has deliberately self-afflicted skin lesions, the motive
for the behavior is unconscious. This illness should be
distinguished from malingering, in which patients have a conscious
goal of secondary fame.
- Useful treatment modalities for primary neurodermatoses include
antidepressants, antipsychotics, and cognitive-behavioral
therapy.
- Selective serotonin reuptake inhibitors (SSRIs) are a
first-line treatment of BDD and also may be useful for olfactory
reference syndrome.
- The antipsychotics risperidone and olanzapine have achieved
full or partial remission in two-thirds of delusional infestation
cases.
- A mental health referral is warranted for patients who have a
psychiatric condition secondary to or comorbid with a skin
disorder.
- Avoid referring patients in the first visit. Build a strong
therapeutic alliance or rapport to gain their trust before making a
referral.
- Consider focusing on symptomatic treatments for patients. For
patients with delusions of parasitosis, offer strategies to reduce
skin picking.
- If a patient brings a sample of a parasite, examine it and then
review the results in a matter-of-fact way. “Always try to be
sympathetic,” advises Dr. Mazori. “Even though we shouldn’t confirm
their delusions, we can still acknowledge that they’re experiencing
symptoms that are real.”
- For pediatric patients, interview parents/guardians to elicit
history and perhaps an underlying cause of a psychiatric
component.
- A psychiatry-dermatology multidisciplinary clinic can help
destigmatize referral to a mental health professional. “The
dermatologist sees a patient with a psychiatrist,” explains Dr.
Tracey. “The patient feels like they are coming to see the
dermatologist. Then we tell the patient [that] everyone in this
clinic sees both of these providers and that’s the way we are able
to help these patients see a psychiatrist.”
If you know someone in crisis, call the National Suicide Prevention
Lifeline at 1-800-273-8255.
Hosts: Nick Andrews, Carol Nicotera-Ward
Guests: Elisabeth (Libby) Tracey, MD (Cleveland Clinic
Foundation, Ohio); Julie Ann Amthor Croley, MD (The University of
Texas Medical Branch at Galveston); Daniel R. Mazori, MD (State
University of New York, Brooklyn).
Show notes by Jason Orszt, Melissa Sears, Kathy Scarbeck
You can find more of our podcasts at
http://www.mdedge.com/podcasts.
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