Psychodermatology in the 21st Century
John Koo, MD
The field of mental health is in the midst of exciting
new developments, in both the understanding of the
basic pathophysiology of mental disorders and the
development of more efficacious and more "user-
friendly" psychopharmacologic agents. These devel-
opments, such as the application of brain imaging
techniques, should not only elucidate basic patho-
physiology or psychopathology but also make them
visible to our eyes. They will undoubtedly continue
into the next millennium. As a specialty, we have a
choice to make. We can finally acknowledge that the
management of psychodermatologic disorders is part
of our expertise and our responsibility and incorporate
both scientific and therapeutic advances in the mental
health field into our own armamentarium, or we can
continue to treat psychodermatology as a stepchild of
our specialty and remain ignorant or simply watch
from the sidelines as the progress in mental health
fields unfolds.
Advances in the Understanding of the
Pathophysiology of Mental Disorders
Probably the most exciting advance in the basic sci-
ence of mental disorders is the advent of functional
neuroimaging in psychiatry. It used to be said that der-
matology and psychiatry are like opposites: in one you
can see everything; in the other, you can see nothing.
This dichotomy is no longer valid with the advent of
functional neuroimaging using techniques such as
magnetic resonance spectroscopy, positive emission
tomography (PET), single photon emission computed
tomography, and functional magnetic resonance imag-
ing. These techniques allow psychiatrists and other
mental health professionals to go beyond studying the
anatomy of the brain in a cadaver to the point where
functional parameters, such as cerebral blood flow and
cellular metabolism, can be studied noninvasively in
vivo. With use of a PET scan, patients with obsessive-
compulsive disorder (OCD) clearly show hyperactivity
of the orbital frontal lobes.1 In major depressive disor-
der, most studies show global or focal decreases in
glucose metabolism in blood flow in various parts of
Curr Probl Dermatol, March/Apdl2 0 0 0
the brain, such as the frontal lobes, left anterior cingu-
late gyrus, left dorsolateral prefrontal cortex, and basal
ganglia. 2,3 In schizophrenia, magnetic resonance
imaging results reveal generalized global brain dys-
morphology, such as ventricular enlargement and sul-
cal dilation, that were not appreciated on simple gross
anatomic inspection. Functional magnetic resonance
imaging results reveal decreased metabolism and
blood flow in basal ganglia. 4,5 PET scans of patients
with trichotillomania also showed glucose hyperme-
tabolism as in patients with OCD but with slightly dif-
ferent anatomic distribution in the brain. 6 In the next
millennium, there is a real possibility that these func-
tional, noninvasive brain imaging techniques might be
applied to psychodermatologic conditions such as
delusions of parasitosis.
Advances in Psychopharmacology
The greatest recent advance in psychopharmacology
involves the development of psychopharmacologic
agents with more benign side effect profiles but with
the same, or even enhanced, efficacy. For example, the
use of tricyclic antidepressants is mostly superseded
by the use of nontricylic agents such as fluoxetine
(Prozac), sertraline (Zoloft), and paroxetine (Paxil),
thereby obviating any concern regarding typical tri-
cyclic side effects such as cardiac side effects, ortho-
static hypotension, anticholinergic side effects. The
first antiobsessive-compulsive agent to be approved by
the Food and Drug Administration was the tricyclic
antidepressant clomipramine (Anafranil). However,
with Food and Drug Administration approval of more
user-friendly nontricyclic selective seratonin reuptake
inhibitors, such as fluoxetine, sertraline, and paroxe-
tine, clomipramine is rarely used. With antianxiety
agents, sedation and addiction are the major potential
side effects of benzodiazepine. Once again, with the
introduction of buspirone (BuSpar), the potential for
these serious side effects is eliminated. Last, for
antipsychotic agents, one of the most serious liabilities
involves the potential for the development of extra-
pyramidal (pseudoparkinsonian) side effects. The first
"atypical" antipsychotic agent, clozapine (Clozaril),
93
was associated with a risk of agranulocytosis.
Therefore, even though this agent eliminated the risk
of extrapyramidal side effects 1, the use of this agent
required close monitoring of blood counts. However,
since then, 3 more "atypical" antipsychotic agents
have become available, and none of these was associ-
ated with increased risk of agranulocytosis.7 These are
olanzapine (Zyprexa), quetiapine (Seroquel), and
risperidone (Risperdal). In short, practically every cat-
egory of psychopharmacologic agent has become sig-
nificantly more "user-friendly" in the recent past, and
this type of progress is expected to continue into the
next millennium.
Conclusion
Dermatology as a specialty prides itself on being able
to provide expertise in the management of all aspects of
skin disorders. However, psychodermatology remains
the only unclaimed territory. Unlike the rest of nonpsy-
chiatric medical specialties, such as internal medicine,
family medicine, pediatrics, and general practice, that
routinely make psychiatric diagnoses and prescribe
psychopharmacologic agents, dermatology has
remained uniquely untrained and uninitiated with
respect to the management of the psychologic aspects
of our specialty. In the coming millennium, as advances
take place in the field of mental health, our specialty
can either continue to isolate itself from the practice of
psychopharmacology and shy away from the manage-
ment of psychodermatologic patients who often "fall
between the cracks," or, alternatively, "take the bull by
the horns" and formally take advantage of these diag-
nostic and therapeutic advances. If our specialty were
to take this challenge, the publication of a formal posi-
tion statement or guideline of care by the American
Academy of Dermatology approving the judicious and
knowledgeable use of psychopharmacologic agents by
94
dermatologists would be of great help. In addition, psy-
chiatric differential diagnoses and psychopharmacolo-
gy relevant to our field should be incorporated into our
residency education curriculum and board certification
examination. Dermatology is not an inherently shy or
inhibited profession that would not venture into new
areas of endeavor relevant to the skin. All one has to do
is to appreciate the tremendous expansion our practi-
tioners have made into the area of cosmetic surgery and
laser therapy to appreciate that our specialty is anything
but "conservative" The incorporation of psychiatric
"know-how" and the psychiatric therapeutic armamen-
tarium into our specialty will at last make dermatolo-
gists true comprehensive experts in the management of
skin patients.
REFERENCES
1. Kido DK, Sheline YI. Neuroimaging for neuropsychiatry.
In: Fogel BS, Schiffer RB, Rao SM, editors. Neuropsychia-
try. Baltimore: Williams & Wilkins; 1996. p. 47-63.
2. Bench CKJ, Friston KJ, Brown RG, et al. The anatomy of
melancholia--focal abnormalities of cerebral blood flow in
major depression. Psychol Med 1992;22:607-15.
3. Bench CKJ, Friston KJ, Brown RG, et al. Regional cerebral
blood flow in depression measured by positron emission
topography. The relationship with clinical dimensions. Psychol
Med 1993;23:579-90.
4. Degreef B, Ashtari M, Bogerts B, et al. Volumes of ventric-
ular system subdivisions measured from magnetic resonance
images in first-episode schizophrenic patients. Arch Gen
Psychiatry 1992;49:531-7.
5. Buchsbaum MS, Haier RJ, Potldn SG, et al. Frontostriatal
disorder of cerebral metabolism in never-medicated schizo-
phrenics. Arch Gen Psychiatry 1992;49:935-42.
6. Swedo SE, Rapoport JL, Leonard HL, Schapiro MB, Rapo-
port SI, Grady CL. Regional cerebral glucose metabolism in
women with trichotillomania. Arch Gen Psychiatry 1991;48:
828-33.
7. Meltzer HY. Novel antipsychotic drugs. New York: Raven;
1992.
Curr Probl Dermatol, March/April 2000