Considerable controversy exists regarding the degree to which psychologic factors can adversely affect the skin. But even those who doubt the etiologic effect of psychic disability recognize that the presence of skin disease often results in the development of anxiety or depression. Whether cause or effect, these psychologic factors can often be handled by a simple, common sense approach: warmth, a willingness to listen, and support. When more than this is needed, the clinician must be ready either to treat the patient with psychotropic medication or to offer appropriate referral.
Benzodiazepines such as chlordiazepoxide (Librium), diazepam (Valium), and the shorter acting agent alprazolam (Xanax) are useful adjuncts in the treatment of associated anxiety. They are particularly helpful in the control of pruritus and will often work in situations where antihistamines alone have failed. As in the case with antihistamines, the usefulness of the benzodiazepines, particularly Librium and Valium, is often limited by the side effect of drowsiness. This can be partially circumvented by the administration of chlordiazepoxide (10 to 25 mg) or diazepam (5 to 10 mg) at suppertime and, if necessary, again at bedtime. These medications are particularly helpful in the control of the nighttime scratching that is so characteristically present in patients with atopic dermatitis. They are also worth trying in chronic urticaria unresponsive to conventional antihistamine therapy. Habituation, of course, is a problem of considerable importance. This risk can be lessened by avoiding the use of these agents in people with past drug-dependency problems, by limiting the number of pills prescribed, and by sharp restriction on refills.
Phenothiazines such as chlorpromazine (Thorazine) and trifluoperazine (Stelazine) are at least as effective as the benzodiazepines. They are used less often because of a greater frequency of side effects and because of a widespread belief that they are too potent to be used by clinicians other than psychiatrists. The phenothiazines have a chemical structure that is very close to that of some of the antihistamines. It is possible that the efficacy of both groups of drugs depends on their mixed antihistaminic and tranquilizing effect.
Recently, a new, nonsedating, non habituating anxiolytic agent (buspirone, Buspar) has become available. It differs from the above agents inasmuch as it acts on serotonin receptors rather than on y-aminobutyric acid (GABA) receptors. In my experience it is somewhat less effective than the benzodiazepines, but I use it fairly frequently because of its excellent safety profile. I generally start with a dose of 5 mg b.i.d. and increase to a final dose of 10 mg b.i.d.
Depression is a problem that is overlooked to an even greater degree than anxiety. I believe that it is present in at least 10% to 20% of patients with serious dermatologic disease. Mild depression often improves as the skin disease clears and, of course, requires no specific therapy. Depression of greater severity deserves greater attention. Patients should be offered the opportunity for psychotherapy or medical treatment or both. Endogenous depression is thought to be more amenable to treatment with medication than are other forms of depression, but many clinicians believe that a therapeutic trial is worthwhile regardless of diagnosis.
The tricyclics amitriptyline (Elavil) or doxepin (Sinequan, Adapin) given in a single daily dose at bedtime are used most often. The usual starting dose with either is 25 mg, but this can gradually be increased to 150 mg as necessary. The tricyclics are extraordinarily effective antihistamines and appear to be particularly effective in the treatment of resistan t chronic urticaria. Imipramine (Tofranil) is also effective and may be somewhat less sedating. Both physician and patient need to remember that the maximum effect of these medications is not apparent until they have been taken for 3 weeks. Side effects of drowsiness and confusion are fairly common, but other more serious cardiovascular and CNS side effects are only rarely seen.
Toxicity associated with the use of tricyclics often leads to a low level of patient acceptance. Several other alternative drugs are available and are well worth trying in certain circumstances. Alprazolam (Xanax) has antidepressant effects as well as the anxiolytic effects. Trazodone (Desyrel) is chemically unrelated to the tricyclics and appears to function as a serotonin antagonist. Fluoxetine (Prozac) is another serotonin antagonist that produces very little drowsiness. Recently, some concerns have been raised about its ability to potentiate suicidal ideation, but most doubt that this occurs. I have used it very effectively in a dosage of 20 mg each morning. Clomipramine (Clozaril) may have particularly good effect on obsessive-compulsive disorders such as trichotillomania, but high cost and concerns about safety have kept it from more widespread use.
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