Branka Vujcic

Increased frequency of Attention Deficit Hyperactivity Disorder (ADHD) in acne versus dermatologic controls: analysis of an epidemiologic database from the US

Introduction: Acne can be associated with psychiatric morbidity and suicide, which have sometimes been considered an adverse reaction to some acne therapies such as isotretinoin. A recent population-based study reports that suicide in acne is related to the psychosocial burden of substantial acne, rather than medication effects. As suicidality is not always directly related to acne severity, factors other than acnes direct psychosocial burden also likely contribute to the suicide risk. Attention Deficit Hyperactivity Disorder (ADHD) is a disorder of childhood and adolescence that is associated with increased suicidality. We examined the frequency of ADHD in acne versus all other dermatology-related patient visits, after controlling for age and other factors. Methods: Retrospective cross-sectional study of epidemiologic databases (NAMCS and NHAMCS) representing 55 825 dermatology outpatient visits from 1995 to 2009. Results: In comparison to other dermatologic disorders, acne was over two times more likely to be associated with ADHD (odds ratio = 2.34, 95%CI 1.06–5.14) after controlling for the possible confounding effects of age, sex, stimulant medications, comorbid anxiety or depressive disorders, and atopic dermatitis, a condition previously associated with ADHD. Discussion: Our preliminary findings suggest a significant association of acne with ADHD, which could contribute to the increased psychological morbidity and suicidality in some acne patients.

Use of opioid analgesics in skin disorders: Results from a nationally representative US sample

Abstract Introduction: Increasing and inappropriate use of opioid analgesics (OA) have been declared a public health concern in the United States. There are no epidemiologic studies of OA use in skin disorders. We examined OA use in a nationally representative sample of US patient visits with only physician-diagnosed skin disorders. Methods: Retrospective cross-sectional study of 56 751 patient visits from 1995 to 2010 (International Classification of Diseases, 9th Revision, Clinical Modification codes 680–709 denoting “Diseases of the Skin and Subcutaneous Tissue”; 172, 173, 216 and 232 denoting malignant and benign skin neoplasms). Results: An estimated 3.1% ± 0.2% of skin disorders visits were associated with OA use; 52.7% ± 5.4% were Schedule III opioids; 11.4% ± 1.4% of OA visits involved skin neoplasms and 45.4% ± 2.3% cellulitis and abscess. OA use increased from 1995 to 2010 (adjusted OR = 1.82, 95% CI: 1.49–2.22), even after controlling for increase in the frequency of skin infections from 1995 to 2010. Discussion: The most frequent use OA for cellulitis and abscess is entirely consistent with their Food and Drug Administration (FDA)-approved indications for pain management. The almost two-fold increase in OA use in skin disorders from 1995 to 2010 may suggest that OA are being considered for pain management earlier in therapy. Conclusions: Only a minority of patient visits with OA had primary dermatologic disease. OA are being used in dermatology primarily for FDA-approved indications.

Obstructive sleep apnea and dermatologic disorders

Obstructive sleep apnea (OSA) is present in at least 2% of women and 4% of men, and its prevalence is increasing, because a major predisposing factor for OSA is a high body mass index. Psoriasis has the most strongly substantiated link with OSA, where the relationship may be bidirectional. Dermatologic disorders may be comorbid with OSA due to several factors: (i) the heightened proinflammatory state in OSA, which can occur independent of body mass index, and may exacerbate inflammatory dermatoses; (ii) intermittent hypoxemia may promote neovascularization and tumor growth in certain cancers, such as melanoma; (iii) obesity, present in majority of OSA patients, can be associated with a heightened proinflammatory state; (iv) upper airway obstruction due to local tumors or soft tissue swelling due to physical urticaria or angioedema; (v) acute nasal congestion in the atopic patient with allergic rhinitis; (vi) dermatologic disorders associated with other OSA risk factors (eg, acanthosis nigricans and metabolic syndrome); and (vii) a high sympathetic tone (eg, in atopic dermatitis) and resultant sleep fragmentation contributing to upper airway instability during sleep. In many instances, the dermatology patient with OSA may have other medical and psychiatric comorbidities that are also associated with increased OSA risk.

Dissociation and conversion symptoms in dermatology

Dissociation and conversion (defined as the somatic component of dissociation) can play an important mediating role in the exacerbation of the stress-reactive dermatoses (eg, psoriasis, idiopathic urticaria, atopic dermatitis), dermatoses that are exacerbated by excessive scratching (eg, lichen simplex chronicus, prurigo nodularis) and koebnerization, and the self-induced dermatoses (dermatitis artefacta, acne excoriée, skin picking disorder, trichotillomania, onychotillomania/onychophagia). Dissociative symptoms often coexist with obsessive-compulsive symptoms in the more severe cases of the self-induced dermatoses. Dissociation can play an important role in cutaneous sensory disorder (eg, scalp dysesthesia syndrome, stomatodynia/glossodynia, vulvodynia/scrotodynia, medically unexplained anesthesia). Dissociation typically occurs in the context of extreme psychosocial stress and a history of severe abuse/neglect during early life. Dissociative patients may experience a sense of detachment from their body and present in a state of extreme self-neglect, including denial of serious skin disorders. Amnesia is one of the core symptoms of dissociation; therefore, patients, who self-induce their skin lesions during a dissociative episode often deny self-inducing their lesions; it is important to recognize that this is distinct from malingering, and the lesions are not intentionally induced. Dissociation and conversion symptoms are typically present in the complex dermatology patient and should be assessed using a comprehensive biopsychosocial approach.

Higher frequency of psychiatric morbidity in patients with bacterial infection of the skin and subcutaneous tissue versus cutaneous neoplasms: results from a nationally representative sample from the United States.

Background: Poor hygiene and nutrition and resultant compromised immune status in some psychiatric patients can increase susceptibility to bacterial skin infections. Objective: We examined the frequency of ICD9-CM psychiatric disorders (codes 290–319) in bacterial skin infections (ICD9-CM codes 680–686) (N = 18,734) versus malignant and benign cutaneous neoplasms (ICD9-CM codes 172, 173, 232, 216) (N = 8,376), conditions that would be expected to cause psychological distress for the patient. Methods: Logistic regression analysis was conducted controlling for age, sex, race, diabetes, obesity, and the use of antineoplastic and immunosuppressant medications. Results: Skin infections were more commonly (odds ratio = 3.03, 95% CI 1.58–5.82) associated with a psychiatric disorder; the most frequent diagnoses were substance dependence and abuse (19.5%), depressive disorder (19.0%), attention-deficit disorder (14.4%), and anxiety disorders (11.6%). Conclusion: In contrast to cutaneous neoplasms, bacterial skin infections were three times as likely to be associated with a psychiatric disorder. Psychiatric comorbidity should be ruled out as a factor in patients with intractable skin infections.

Use of Antiepileptic Mood Stabilizers in Dermatology

Several antiepileptic drugs (AEDs) are approved by the US Food and Drug Administration for the treatment of bipolar disorder (valproic acid, divalproex, lamotrigine, carbamazepine) and some cutaneous neuropathic pain syndromes (carbamazepine, gabapentin, pregabalin). The AEDs may be effective in the management of (1) chronic pruritus, including pruritus due systemic disease, including uremia, neuropathic pain, neuropathic pruritus, and complex cutaneous sensory syndromes, especially where central nervous system (CNS) sensitization plays a role; (2) management of emotional dysregulation and the resultant repetitive self-excoriation or other cutaneous self-injury in patients who repetitively stimulate or manipulate their integument to regulate emotions (prurigo nodularis, lichen simplex chronicus, skin picking disorder, trichotillomania); (3) management of dermatologic clinical manifestations associated with autonomic nervous system activation (hyperhidrosis, urticaria, flushing; these often occur in conjunction with psychiatric disorders with prominent autonomic activation and dysregulation, eg, social anxiety disorder, posttraumatic stress disorder); and (4) when certain anticonvulsants have a direct therapeutic effect (eg, in psoriasis); currently the use of AEDs for such cases is largely experimental. Gabapentin (dosage range 300-3600 mg daily) is the most widely studied AED mood stabilizer in dermatology and is especially effective in situations where CNS sensitization is a mediating factor. Further larger-scale controlled studies of AEDs in dermatology are necessary.

Use of Antipsychotic Drugs in Dermatology

Antipsychotic drugs can be beneficial in dermatology because of their both central nervous system and peripheral effects. All antipsychotic drugs have a central postsynaptic dopamine D2 receptor blocking effect, which underlies their antipsychotic action. The antipsychotic drugs have varying degrees of histamine H1-receptor, cholinergic muscarinic receptor, and α1-adrenergic receptor blocking effects, which can affect cutaneous perception and the autonomic reactivity of the skin and can be potentially beneficial in the management of certain histamine or sympathetically mediated dermatologic manifestations (eg, urticaria, pruritus, hyperhidrosis). In addition to their antipsychotic effect, antipsychotic drugs also have a general anxiolytic effect related in part to their α1-adrenergic receptor blocking action, which can be of benefit in many dermatologic conditions, including pruritus. The antipsychotic drugs are most commonly used in dermatology for the management of a delusional disorder, somatic type, manifesting as delusional infestation, and as monotherapy or as augmentation therapy of selective serotonin reuptake inhibitor (SSRI) antidepressants, and for management of trichotillomania and skin-picking or excoriation disorder. There is earlier literature (1) on the possible beneficial effect of the phenothiazine antipsychotics in a wide range of pruritic dermatoses, and (2) the efficacy of pimozide as adjunctive therapy for metastatic melanoma, which both warrant further investigation.