Dermatologist links skin with psyche

For starters, recent controversies involving drugs such as isotretinoin and selective seratonin reuptake inhibitors (SSRIs) have frightened many dermatologists and patients.

"There's so much misinformation out there about isotretinoin," says Richard G. Fried, M.D., Ph.D. "Dermatology is in a real quagmire right now in the sense that we've got data saying that every single thing we put in our patients' mouths may be inappropriate." A board-certified dermatologist and clinical psychologist, he is clinical director of Yardley Dermatology and Yardley Skin Enhancement and Wellness Center, Yardley, Pa.

"There's a study out there right now that says benzoyl peroxide works just as well as oral antibiotics," he says. "There's also the backdrop of litigation for idiosyncratic side effects from any agent. We've got this huge population of people with recalcitrant nodulocystic acne who have failed oral antibiotics and topical therapy. They need isotretinoin, but we've got Web site after Web site of lawyers advertising that if you've had any side effect from isotretinoin, you may be entitled to a settlement."

Realities So what are the realities behind the psychological impact of isotretinoin?

"The data remains very robust that the psychiatric risk of not prescribing isotretinoin far outweighs any idiosyncratic psychiatric effects that are associated with taking the medicine," Dr. Fried says. "A very small percentage of people idiosyncratically experience depression with isotretinoin. But does it exceed the expected rate of depression in the age-matched general population? There still is no data to suggest that it does.

"More importantly, the data is crystal clear that untreated acne leads to higher incidences of depression, suicide, anxiety disorders, unemployment and sexual dysfunction," Dr. Fried says. "For untreated acne, there are protean implications for disruptions in every way we define psychiatric impairment (Koo J, Lee CS, eds. Psychocutaneous Medicine. New York, NY: Marcel Dekker; 2003. Gupta MA, Gupta AK. Am J Clin Dermatol. 2003;4(12):833-842. Review.)"

Psychiatric medications Dr. Fried takes a similar position regarding psychiatric medications.

"The data is clear that they can help patients to feel better, cope better and do better," Dr. Fried says. "Any dermatologist who claims they're not a psychodermatologist is a liar. Our everyday interactions with patients are emotionally therapeutic. Even Benadryl (diphenhydramine, Warner-Lambert) is a psychoactive medicine. There are documented cognitive and motor impairments with diphenhydramine. It functions as an anxiolytic, as does Atarax (hydroxyzine, Pfizer)," he says.

Similarly, most dermatologists prescribe doxepin, a tricyclic antidepressant, for chronic itching.

"If we're prescribing psychoactive medicines anyway," Dr. Fried says, "the question all of us must ask is where do we draw that line that says, 'This is how much I will write in terms of a psychoactive medicine'?"

Answer lies with patient For Dr. Fried, the answer lies in whether dermatology patients are damaging their own skin through picking, rubbing or otherwise manipulating it, in some cases to compulsive levels.

"Failing to write a psychotropic medicine for a patient who is doing irreparable harm to the skin can be viewed by some as malpractice," he says.