OCDs and skin

OCDs occur in 2 percent to 3 percent of the general population - and about 1 percent of children, says Thelda M. Kestenbaum, M.D., associate professor of medicine, division of dermatology, University of Kansas Medical Center, Kansas City, Kan. But in dermatology patients (excluding those with skin cancers) complaining of itching or discomfort, she says, "The prevalence rate increases to 14 percent to 20 percent. So dermatologists are seeing a lot more people who have OCDs."

Furthermore, Dr. Kestenbaum says patients who are overly concerned with body image seek out dermatologists just as they do plastic surgeons.

Patients with OCD can present with skin manifestations such as neurotic excoriations, acne excoriée, recalcitrant eczemas, nail biting or picking and hair pulling (trichotillomania). However, Dr. Kestenbaum adds, such patients rarely admit these problems. "They may say, 'I'm losing my hair,' and it's up to the dermatologists to figure it out."

Similarly, she says excessive concern about any of the following issues might alert physicians to an OCD diagnosis:

"It behooves dermatologists to be aware of these various manifestations, while also looking for other causes" besides OCD, Dr. Kestenbaum says. Unfortunately, she adds, most OCD sufferers are not properly diagnosed for well over 10 years, and only one in five patients is under treatment.

And while body dysmorphic disorder (BDD) - an impairing preoccupation with slight or imagined defects - may or may not be part of the OCD spectrum, Dr. Kestenbaum says, it's wise to identify these patients quickly. Due to their irrational perceptions, she says it can be difficult to accommodate them.

Treatment mainstays for OCDs include behavioral therapy and drug therapy with selective serotonin reuptake inhibitors (SSRIs), Dr. Kestenbaum says. In the latter area, to treat OCD, physicians must work up to the highest dose and maintain therapy for at least three months, she advises. If those drugs prove ineffective, she says some physicians may add one of the newer antipsychotic drugs, such as Zyprexa (olanzapine, Eli Lilly)."

Among tricyclic antidepressants, though, she says that Anafranil (clomipramine, Novartis) is the only tricyclic antidepressant effective in treating OCD. However, "Most people consider SSRIs safer than tricyclic antidepressants, and they're highly effective in most cases when used in high doses for at least three months," Dr. Kestenbaum says.

If one suspects a patient has OCD, Dr. Kestenbaum says it's not necessary to immediately refer to a psychiatrist. "When people come to a dermatologist, they're expecting treatment" rather than a quick referral, she says.

In cases involving neurotic excoriations, for example, she says, "Usually I try some topical medications, but then I suggest that some people can get into a habit or compulsion of picking. The vast majority of patients are willing to listen to that."

And since many patients with OCD already are taking antidepressants (because depression is often associated with OCD), they're usually willing to consider increasing their doses, Dr. Kestenbaum says. In addition to medications, Dr. Kestenbaum says she often tactfully suggests behavioral therapies under the guidance of a mental health professional.