Dermatologists should be on the lookout for OCD 'red flags'

National report - The prevalence of obsessive-compulsive disorder (OCD) in certain dermatologic settings outside of skin cancer - such as itchy dermatosis - can be as high as 14 percent to 20 percent, compared to a prevalence of 2 percent to 3 percent in the general population.

Dermatologists should see OCD "red flags" when they diagnose neurotic excoriations, trichotillomania and even nail biting and picking, among other things, says Thelda M. Kestenbaum, M.D., an associate professor of medicine in the division of dermatology at the University of Kansas Medical Center, Kansas City, Kan.

"Many of these people have OCD," she says.

"You can't just refer these patients to a psychologist. If you recommend during the first visit that they see a therapist, they're going to be put off. Another important point is that there is a high comorbidity of OCD with other psychological problems - especially depression. So a lot of these patients may already be in treatment for depression," she says.

Making the connection

After being involved in the study of OCD and dermatology for 10 years, Dr. Kestenbaum says she is amazed at the number of people who are not treated as well as they could be because primary care physicians often overlook the connection.

"(Patients are) given creams when what they really need is to be listened to so that the root of the problem can be found," she says. "If I suspect OCD and I want a patient to 'open up,' I'll often say, 'A lot of people do this and they don't even realize they're doing it,' whether it's picking their skin or pulling their hair or whatever, and that gives them a chance to open up," she says.

The behavior isn't always extreme. Patients who present with recalcitrant hand eczema often suffer from OCD.

"Dermatologists should ask these patients how many times a day they wash their hands. They may suffer some degree of OCD that's often overlooked if their hand-washing behavior is not questioned," she says. Most people who wash their hands excessively because of an irrational fear of germs do not mention the behavior to their physician because they don't think it's pertinent or they're embarrassed.

"While people in some professions should be washing their hands numerous times throughout the day, for others it's clearly unnecessary," she says. "It behooves the physician to broach the topic in a nonthreatening, nonjudgmental way so that people will feel free to open up and not worry that they'll be judged as unbalanced."

Treatment options

A combination of drug treatment and behavioral therapy is optimal, according to Dr. Kestenbaum.

"In these cases, in order to treat the skin you have to treat the brain," she says. "Selective serotonin reuptake inhibitors (SSRI), such as Prozac, Paxil, Lexapro and Zoloft, among others, seem to be beneficial when they are given at a high dose for at least three months. If a patient who is on Prozac 20 milligrams for two weeks doesn't make progress, I wouldn't call that a treatment failure. They have to be on long-term and at a high dose - higher than the typical dose recommended for the treatment of depression."

Clomipramine, a tricyclic antidepressant, is also effective, and Dr. Kestenbaum notes that it was the first drug approved by the Food and Drug Administration for the treatment of OCD.