Management of Psychodermatologic Disorders

Philip D. Shenefelt, MD, MS


Dermatology Nursing 

In This Article

Management Options

Standard Pharmacologic Psychocutaneous Therapies

To obtain the most current information on specific products, see the current Physicians' Desk Reference (PDR) (PDR Staff, 2009), package inserts, or other appropriate information source to check dosages, indications and usage, review pharmacokinetics, and note contraindications, warnings, precautions, drug interactions, and adverse reactions. Many psychotropic drugs should be started at a low dose and progressively increased to therapeutic range, then tapered as appropriate (Lee & Koo, 2003).


SSRIs are used for depression, anxiety, and obsessive-compulsive spectrum disorders. Side effects include nausea, diarrhea, insomnia, or sedation (Lee & Koo, 2003). They should be started at low dose and titrated upward. Response to SSRIs is slow, usually taking 3–6 weeks (see Table 3). Lower initial dosages are recommended in the elderly.

Tricylics are also used for depression and obsessive-compulsive spectrum disorders. They should be started at low dose and titrated upward. Commonly used tricyclics are amitriptyline (Elavil®), clomipramine (Anafranil®), imipramine (Tofranil®), nortriptyline (Pamelor®), protriptyline (Vivactil®), trimipramine (Surmontil®). The most commonly prescribed tricyclic by dermatologists, including the author, is doxepin, which is dosed at 25–300 mg daily and also has antihistamine and antipruritic actions. The norepinephrine and dopamine reuptake inhibitor bupropion (Well butrin®), is an aminoketone antidepressant.


Typical (dopamine receptor antagonists) antipsychotics such as haloperidol (Haldol®) and pimozide (Orap®) are used in dermatology for delusional psychoses such as delusions of parasitosis and delusions of bromhidrosis. Atypical (serotonin-dopamine antagonists) such as olanzapine (Zyprexa®), risperidone, and ziprasidone (Geodon®) are used in dermatology often as a second agent in addition to SSRIs for treatment of resistant cases of obsessive-compulsive spectrum disorders (see Table 3).


Gamma aminobutyric acid (GABA) elevators such as gabapentin (Neurontin®) and pregabalin (Lyrica®) are used in dermatology for relief of pain, itching, or paraesthesias in peripheral neuropathies including postherpetic neuralgia (see Table 3).


Benzodiazapines are Schedule IV controlled substances due to potential abuse and addictive dependence. They tend to be sedating. They are used in dermatology for pre-procedure anxiety. Alazopram (Xanax®) and lorazepam (Ativan®) are short acting (half-life less than a day) while diazepam (Valium®) is long acting (see Table 3). The serotonin agonist buspirone (Buspar®) is an azaperone. It has the advantage of not being a controlled substance and being non-sedating. Its disadvantage is that it has a delayed onset of action.


Antihistamines that are sedating are used extensively in dermatology for pruritus. They are also used for urticaria , angioedema, and dermatographism (see Table 3).


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