Psychopharmacology in Dermatology

Abstract

Psychodermatology encompasses the complex relationship between psychiatric disorders and dermatologic conditions, focusing on their bidirectional effects. This review delves into the role of psychopharmacology in managing dermatologic diseases and their associated psychiatric comorbidities, specifically investigating how psychotropic medications, such as antidepressants, anxiolytics, and antipsychotics, are used to treat dermatologic conditions with psychiatric comorbidities and their impact on both skin health and psychiatric symptoms. A narrative review was conducted, synthesizing studies published between 2019 and 2024 that included studies focused on psychopharmacological interventions in psychocutaneous disorders. Relevant literature was analyzed to evaluate the efficacy of psychotropic medications in improving both dermatologic and psychiatric symptoms. The present review highlighted that psychotropic medications, particularly antidepressants, anxiolytics, and antipsychotics, offer significant benefits in managing psychodermatologic conditions. Across the literature, antidepressants were shown to reduce inflammation and immune dysregulation in conditions such as psoriasis and hidradenitis suppurativa. Furthermore, psychotropic drugs were shown to alleviate psychiatric symptoms associated with dermatologic diseases, such as anxiety, compulsive behaviors, and delusional thoughts. Although the literature has demonstrated the efficacy of psychotropic medication in treating dermatologic diseases, psychiatric referrals and psychopharmacological treatments remain underutilized in clinical practice. Psychopharmacology plays a crucial role in managing psychodermatologic conditions by addressing both skin and psychiatric symptoms. Despite growing evidence of the importance and utility of psychodermatology, there is a need for greater awareness and incorporation of multidisciplinary psychiatric evaluation and treatment in dermatologic care. Future research should focus on larger, longitudinal studies to assess the long-term efficacy and safety of psychotropic medications in dermatology.

Introduction

Psychodermatology explores the complex interplay between psychiatry and skin disease, highlighting the bidirectional influences of dermatologic conditions on mental health. The utility of psychopharmacology in treating dermatologic conditions and their associated comorbidities continues to be explored in research throughout the field.

The efficacy of psychotropic medications in dermatology lies in their ability to modulate the complex interactions between the skin and the central nervous system. The hypothalamic–pituitary–adrenal (HPA) axis, for example, is central to the skin’s response to stress through the release of cortisol and other neurohormones.[1] Chronic stress can disrupt this axis, worsening inflammatory skin conditions, including psoriasis, hidradenitis suppurativa, and acne.[2,3] Such responses are regulated by neurotransmitters such as serotonin and dopamine, which directly affect sensations of itch and pain secondary to skin inflammation.[4] Hence, psychotropic medications may aid in the management of chronic stress and sensory disturbance in dermatologic conditions by targeting the interconnected nervous system pathways.

Beyond the central nervous system, many psychodermatologic diseases involve the immune response, during which the immune system releases neuropeptides such as substance P and calcitonin gene-related peptide, cytokines, and endocrine neurotransmitter hormones.[5] Psychopharmacologic medications, such as antidepressants, have been shown to influence the immune system by reducing the levels of pro-inflammatory cytokines and increasing the production of anti-inflammatory cytokines.[6]

Although it is estimated that over one-third of dermatology patients may have comorbid psychiatric disturbance, the knowledge of psychotropic medications remains limited within the community.[7,8] Moreover, psychiatric referrals and multidisciplinary approaches remain underutilized, further limiting comprehensive care for patients with psychodermatologic conditions.

This narrative review aims to explore the most current applications of psychopharmacology in dermatology, including studies published between 2019 and 2024, focusing on both primary psychiatric disorders (e.g., body dysmorphic disorder, trichotillomania, delusional parasitosis) and dermatologic conditions that can lead to secondary psychiatric morbidities (e.g., psoriasis, atopic dermatitis, acne). By doing so, we aim to support greater awareness, education, and collaboration within dermatology to optimize treatment outcomes in psychodermatologic disorders.

Common Psychotropic Medications Used in Dermatology

Antidepressants, anti-anxiety medications, and antipsychotics are commonly prescribed by healthcare providers to treat various psychodermatological conditions. The following section provides an overview of the most frequently prescribed psychotropic drugs in dermatological practice. Subsequent sections of this narrative review will discuss primary and secondary psychiatric disorders, along with their specific psychopharmacologic treatments. A consolidated summary of the commonly used psychotropic medications in dermatology, including their classes, doses, indications, and side effect profiles, is provided in Table 1.

Table 1.

Common Psychotropic Medications in Dermatology

Medication(s)	Class	Starting Dose	Dermatologic Indications	Monitoring Parameters/ Common Side-effects
Fluoxetine Sertraline Paroxetine	SSRI	10–50 mg/day Not specified	Trichotillomania, chronic pruritus, delusional infestation, neurotic excoriation, body dysmorphic disorder	Gastrointestinal upset, weight changes, sleep disturbances, sexual dysfunction, avoid with MAOIs
Duloxetine	SNRI	Not specified	Psoriasis, atopic dermatitis, and neurogenic rosacea	Not specified
Amitriptyline Mirtazapine	TCA/ Atypical antidepressant	10–25 mg/day (amitriptyline) 7.5–15 mg/day (mirtazapine)	Chronic pruritus, neurogenic pain	Anticholinergic effects, sedation, cardiac arrhythmias
Lorazepam Clonazepam	Benzodiazepines	0.25–0.5 mg/day	Neurotic excoriations, acute anxiety	Sedation, cognitive impairment, dependency risk; use with caution in the elderly
Buspirone	Anxiolytic	15 mg/day	Chronic anxiety in psychodermatology	Nausea, dizziness
Pimozide	Typical antipsychotic	0.5–1 mg/day	Delusions of parasitosis	QT prolongation, EPS, ECG monitoring
Risperidone Olanzapine	Atypical antipsychotics	0.5–5 mg/day	Delusions of parasitosis, trichotillomania	Weight gain, sedation, EPS

ECG: Electrocardiogram. EPS: Extrapyramidal Symptoms. MAOI: Monoamine Oxidase Inhibitor. QT: Interval from start of Q wave to end of T wave on ECG (cardiac repolarization measurement). SNRI: Serotonin–Norepinephrine Reuptake Inhibitor. SSRI: Selective Serotonin Reuptake Inhibitor. TCA: Tricyclic Antidepressant

Antidepressants

Antidepressants, particularly selective serotonin reuptake inhibitors (SSRIs), are among the most commonly prescribed psychopharmacological agents in dermatology due to their high efficacy and comparatively low side effect profile.[9] SSRIs function by inhibiting the reuptake of serotonin, thereby enhancing serotonin availability in the synaptic cleft, which is believed to contribute to their therapeutic effects. This mechanism makes SSRIs particularly effective in addressing psychodermatologic conditions where serotonin dysregulation plays a role.

Commonly prescribed SSRIs, including citalopram, escitalopram, fluoxetine, fluvoxamine, paroxetine, and sertraline, have demonstrated efficacy in treating a range of conditions such as neurotic excoriation, dysmorphophobia, trichotillomania, delusions of parasitosis (DOP), and chronic pruritus. These medications not only alleviate the psychological distress contributing to these conditions but may also improve the associated dermatologic symptoms by reducing compulsive behaviors and anxiety levels.[9,10] For example, paroxetine may be useful in DOP and chronic itch, while other common agents such as fluoxetine and sertraline may be preferred for comorbid depression and pruritus.

Other classes of antidepressants, while less frequently utilized in dermatology, also play a role in treatment. Serotonin–norepinephrine reuptake inhibitors (SNRIs), such as venlafaxine and duloxetine, have shown promise in patients with conditions like psoriasis and atopic dermatitis, where comorbid depression or anxiety may exacerbate symptoms. Duloxetine has also been proven beneficial in neurogenic rosacea.[11]

Tricyclic antidepressants (TCAs), such as amitriptyline and doxepin, are particularly effective for conditions involving chronic pruritus or pain due to their antihistamine and analgesic properties. Atypical antidepressants, including bupropion and mirtazapine, are also used in specific cases, offering additional options for patients who may not respond to or tolerate SSRIs or SNRIs.[9,10]

Antidepressants should be initiated at low doses (e.g., sertraline 25–50 mg/day, fluoxetine 10–20 mg/day) with gradual titration every 1–2 weeks depending on dose response. Common side effects of antidepressants include gastrointestinal upset, weight changes, sleep disturbances, and sexual dysfunction. TCAs may also exert anticholinergic action, leading to symptoms like dry mouth and constipation. Contraindications for these agents include concurrent use with monoamine oxidase inhibitors (MAOIs), linezolid, or other psychotropic medications. These medications should be avoided in those with known hypersensitivities. TCAs, specifically, are contraindicated in patients with uncontrolled cardiac arrhythmias, and bupropion in those with seizure disorders.[12] The following sections will delve deeper into the conditions treated with these medications and the evidence supporting their use in dermatological practice.

Anxiolytics

Benzodiazepines and 5-hydroxytryptamine 1A (5-HT1A)/serotonin 1A partial agonists, such as buspirone, have been widely utilized in the management of psychodermatologic conditions, particularly those associated with acute anxiety.[10] Benzodiazepines, due to their rapid onset of action, are especially effective in providing immediate relief for anxiety-related exacerbations of dermatologic conditions such as chronic urticaria, pruritus, and neurotic excoriations. Commonly prescribed agents such as lorazepam, clonazepam, and diazepam can be considered. However, their use is often limited to short-term treatment due to the potential for dependency and tolerance. With this in mind, benzodiazepines should always be initiated at their lowest effective dose (e.g., lorazepam 0.5 mg or clonazepam 0.25 mg). Titration should be exercised with caution, based on symptom control and tolerability, with duration of treatment not exceeding one month.[13]

Buspirone, a non-benzodiazepine anxiolytic, offers a favorable alternative for long-term management as it has a lower risk of dependency and fewer sedative effects. By addressing the underlying anxiety, these medications can significantly improve both dermatologic symptoms and the overall quality of life for affected patients.[9] This medication is usually initiated at 15 mg/day with gradual titration.[14]

Side effects of anxiolytics are imperative to consider. Those of benzodiazepines include sedation, dizziness, and cognitive impairment. Buspirone use may result in nausea, dizziness, and headaches. Benzodiazepines are contraindicated in patients with myasthenia gravis, respiratory insufficiency, and acute narrow-angle glaucoma. Use in elderly populations and those with a history of substance use disorder should be cautioned.[13]

Antipsychotics

Both first-generation and second-generation antipsychotics have been utilized in the treatment of psychodermatologic conditions characterized by repetitive skin-picking behaviors, such as trichotillomania, and delusional disorders, including DOP.[10] These medications primarily exert their effects by inhibiting dopamine D2 receptors in the brain, which helps regulate the dopamine pathways implicated in these conditions. By addressing the underlying psychiatric components of these disorders, antipsychotics not only alleviate delusional or repetitive behaviors but also help improve dermatologic outcomes and overall quality of life for patients.

First-generation antipsychotics, also known as typical antipsychotics, include agents such as pimozide, which has been particularly noted for its efficacy in treating DOP.[9] Pimozide not only addresses the core delusional symptoms but also reduces the associated compulsive behaviors that can exacerbate skin damage. Its use, however, may be limited by potential side effects such as extrapyramidal symptoms or QT prolongation, requiring careful monitoring during treatment.[15] It is typically initiated at 0.5–1 mg/day with gradual titration and frequent electrocardiogram monitoring.[16]

Second-generation antipsychotics, such as risperidone and olanzapine, offer a broader spectrum of action by targeting additional neurotransmitter systems, such as serotonin receptors, which may contribute to improved efficacy and a more favorable side effect profile compared to first-generation agents. Risperidone and olanzapine are favored for conditions like DOP and trichotillomania. They are typically started at 0.5–1 mg/day and 2.5–5 mg/day, respectively. Doses should be titrated every 5–7 days based on tolerability.[16]

Common side effects include drowsiness and sedation, movement disorders (e.g., tardive dyskinesia), cognitive impairment, metabolic syndrome (e.g., weight gain), orthostatic hypotension, and hormonal imbalances. Extrapyramidal symptoms, such as movement disorders, are more common with first-generation agents. Serious risks include neuroleptic malignant syndrome and QT prolongation, and use should be avoided in patients with a history of these disorders. Other contraindications are concurrent use with central nervous system depressants and anticholinergic medications. Providers should exercise caution in the elderly, pregnant women, and women who are breastfeeding.[16]

Applications in Primary Psychiatric Disorders

Delusions of parasitosis

Delusions of parasitosis (DOP) is a psychodermatologic condition characterized by a false belief of infestation with parasites, despite the absence of medical evidence supporting such claims. It has been postulated that dysregulation of dopamine synthesis is a key pathological mechanism underlying delusional disorders, and antipsychotic medications, which exert their effects through dopamine blockade, have demonstrated efficacy in their management.[17] Similar to other delusional disorders, DOP has been shown to respond to antipsychotic treatment.[18] For instance, studies have demonstrated the effectiveness of risperidone in achieving remission in patients with DOP.[18,19,20,21] Similarly, other atypical antipsychotics, such as olanzapine, have proven successful in treating DOP.[21,22] Aripiprazole has also shown promise, with evidence of complete remission in patients after six months of treatment.[23]

In addition to antipsychotics, SSRIs, such as paroxetine and sertraline, have been effective in managing DOP, particularly in patients who either refused antipsychotic treatment or did not respond well to it.[18,24] It is crucial to note that individuals with primary DOP, as opposed to secondary DOP caused by substance use, are more challenging to treat due to their delusional baseline. These patients often exhibit lower rates of medication adherence, which further complicates management.[19,21]

Applications in Secondary Psychiatric Disorders

Psoriasis

Psoriasis, a common psychophysiological inflammatory skin disease, is thought to possess a bidirectional relationship with psychiatric disease onset, both due to dysregulated immune processes and as a trigger for secondary psychiatric morbidities. Elevated pro-inflammatory cytokine levels have been implicated in both psoriasis and major depressive disorder (MDD).[25,26,27] Individuals with MDD are thought to have an exaggerated inflammatory response, and therapies targeting inflammatory mediators have been reported to improve depressive symptoms in those with inflammatory diseases.[27,28] MDD has since been identified as an independent risk factor for psoriasis, and vice versa, strengthening their two-way interaction.[29,30]

Preliminary studies investigating the effects of antidepressants on psoriasis and its associated psychiatric ailments have been conducted. Tzeng et al.[31] revealed that antidepressant users with MDD had a significantly lower risk of psoriasis than nonusers, particularly with SSRIs. These findings support a previous Swedish cohort study reporting that SSRI use decreased the need for systemic psoriasis treatments.[32] It is suggested that antidepressants reduce inflammatory biomarker levels, likely explaining their protective effects in psoriasis.[31] Specifically, SSRIs have been shown to decrease levels of multiple pro-inflammatory cytokines central to psoriasis, including IL-6, IL-1β, TNF-α, and IL-10.[33] Hence, the bidirectional relationship between psoriasis and MDD, driven by dysregulated immune processes, underscores the potential therapeutic applications of antidepressants.

Hidradenitis suppurativa

Hidradenitis suppurativa (HS) is a chronic skin condition of the intertriginous areas with established risk of anxiety and depression likely secondary to disturbed body image and impairment of daily activities.[34,35] As discussed previously, it is postulated that the pathogenesis linking HS and psychiatric disorders relies on increased levels of pro-inflammatory cytokines, specifically TNF-α, IL-1β, and IL-10.[36] Additionally, both HS and depression are frequently associated with obesity and metabolic disorders, sharing pathological processes related to the stress response and metabolic disruptions.[34]

In a prospective cohort study conducted in Denmark, depression was identified as one of the earliest comorbidities to manifest in patients with HS, providing additional evidence of the significant relationship between the two.[37] The majority of participants in this cohort with established depression received antidepressant prescriptions for their psychiatric symptoms, highlighting the need for recognition and treatment of psychiatric comorbidities in HS management. Antidepressant efficacy may be attributed to decrease in inflammatory mediator levels, as seen in other inflammatory disorders like psoriasis.

Chronic pruritic conditions

Chronic pruritus (CP) can have a variety of causes, including cutaneous, neurologic, autoimmune, and systemic disorders, and may lead to psychiatric disturbances if not treated.[38] The pathogenesis of CP is heterogeneous, thought to consist of signaling between non-histaminergic pathways and the immune system.[39,40] This underlying complexity renders management challenging, with conventional therapy consisting mainly of topical treatments.[39] Antidepressants and gabapentin may be considered for patients who are unresponsive to standard treatment options. Their efficacy may be due to their influence on serotonin and histamine levels.

According to an observational cohort study in the Netherlands, symptoms of pruritus and overall quality of life improved following gabapentin treatment (900–1800 mg/day for 4 weeks).[41] The effect of antidepressants was variable, with the highest response after initiation of amitriptyline and nortriptyline or mirtazapine (10–25 mg/day and 7.5–15 mg/day, respectively, for 4 weeks). The utility of other oral antidepressants, including SSRIs and combination antidepressants, has also been documented.[42,43] SSRIs may be particularly useful in pruritus secondary to malignancies, cholestasis, chronic kidney disease, or uremia.[41]

In a case series reported by Szymanski et al.,[44] researchers analyzed five female patients with a prolonged course of nodular pemphigoid (NP) to evaluate their clinical and immunological characteristics and treatment outcomes. The patients met both clinical and immunological criteria for NP. Despite being treated with various medications, the study found that the combination of clobetasol propionate applied over the entire body and antidepressants provided the most effective disease control.[44]

Vitiligo

Vitiligo is a chronic autoimmune skin condition characterized by the progressive loss of skin pigmentation, resulting in depigmented patches on the skin. Although the exact cause of vitiligo remains unclear, its pathogenesis is believed to involve a combination of environmental and autoimmune factors.[45] Beyond its physical manifestations, vitiligo has been shown to have a profound psychosocial impact, as visible skin changes can lead to stigma, reduced self-esteem, and diminished quality of life, particularly in those with darker skin color.[46,47]

A growing body of research highlights the psychological comorbidities associated with vitiligo, such as MDD.[47] For example, a cohort study examined this bidirectional relationship using data from the Health Improvement Network (THIN) database of the UK, which included patients aged 10–90 years.[48] The study found that individuals with MDD had a 64% increased risk of developing vitiligo compared to those without MDD. Conversely, patients with vitiligo were also at higher risk of developing MDD. Importantly, the study noted that patients with MDD who used antidepressants had a lower risk of developing vitiligo than those who did not.[48] Given vitiligo’s proposed pathophysiology, which involves an immune response, antidepressants may exert their effects by reducing pro-inflammatory cytokines, such as IFN-γ, TNF-α, and IL-6, while increasing anti-inflammatory cytokines, such as IL-10. This may potentially reduce the risk of vitiligo development.[6]

Rosacea

Neurogenic rosacea is a newly recognized subtype of rosacea characterized by severe, persistent facial erythema accompanied by dysesthesia out of proportion to the clinical features of flushing and inflammation.[49] Unlike typical rosacea, this subtype is often refractory to conventional rosacea treatments, including oral doxycycline, oral minocycline, topical metronidazole, and calcineurin inhibitors.[50] Due to its novelty, neurogenic rosacea has become the subject of research aimed at understanding its underlying mechanisms and exploring effective treatment strategies.

A Korean multicenter retrospective case-control study identified 17 patients with neurogenic rosacea who exhibited severe erythema localized to the cheeks and mandibular area and were resistant to conventional treatments.[50] Notably, the majority of the patients were female (94.1%), and heat stimuli (58.8%) and psychological stress (52.9%) were the primary aggravating factors, highlighting the complex interplay between external triggers and psychological stressors in neurogenic rosacea. In this study, novel therapeutic approaches involving anticonvulsants, such as gabapentin and pregabalin, and antidepressants such as tianeptine, diazepam, and duloxetine, were given to the treatment-resistant patients. A remarkable 82.3% of patients reported improvements in both clinical symptoms and visible cutaneous signs following treatment with these medications.[50] These findings suggest that targeting the neurogenic and psychological components of the condition may offer a more effective therapeutic pathway for patients unresponsive to conventional therapies.

Neuropathic pain syndromes: Postherpetic neuralgia and burning mouth syndrome

Neuropathic pain syndromes result from peripheral nerve damage, often secondary to disease or injury. Patients may feel constant or intermittent pain, itching, burning, or tingling. Postherpetic neuralgia (PHN) is a painful complication of the herpes zoster. PHN treatment often involves TCAs, SSRIs, and gabapentinoids.[51] These medications interfere with pain-processing pathways in the spinal cord; moreover, antidepressants’ regulation of the immune response could contribute to pain alleviation.[52] A randomized controlled trial aimed to compare the efficacy and safety of pregabalin and nortriptyline in patients with postherpetic neuralgia.[52] The study found that both medications were effective in alleviating PHN symptoms, but pregabalin demonstrated superior outcomes at the 8-week mark. The results of this study highlight the efficacy of utilizing antidepressants in the treatment of PNH.

In addition to PHN, psychotropic medication has been seen to be effective in the treatment of other neuropathic pain syndromes, such as burning mouth syndrome (BMS). In a retrospective study, Le Bris et al.[53] evaluated the outcomes of psychiatric interventions for patients with primary BMS. Of the 38 patients, 18.4% reported complete pain resolution, while 21.1% and 28.9% experienced pain reductions greater than 50% and between 30% and 50%, respectively. Following psychiatric intervention, the proportion of patients requiring antidepressant treatment decreased from 63.2% to 36.8%. Among the 26 patients (68.4%) undergoing psychotropic treatment, antidepressants were commonly prescribed, with SSRIs being the most frequent. Eleven patients (28.9%) did not receive any psychotropic treatment. These findings suggest that psychiatric interventions provide meaningful and sustained therapeutic benefits for managing BMS, with similar pathophysiological underpinnings as other neuropathic pain disorders.

Conclusion and Future Directions

This narrative review highlights the diverse applications of psychotropic medications in dermatology, addressing both primary and secondary psychiatric disorders. Antidepressants were the most commonly prescribed medications for the diseases discussed. Their versatility may stem from their ability to modulate neuronal and immune responses, contributing to the inflammation and pain commonly seen in various dermatologic conditions. Further examination of these agents would not only allow for the optimization of management guidelines but also a deeper exploration of the connections between dermatology and psychiatry.

Utilization of psychiatric evaluation and pharmacology in dermatology practice remains limited, despite growing evidence of mental health impacts from dermatologic disease. Based on the presented data, we suggest consideration of psychotropic medications to alleviate psychiatric comorbidities of dermatologic conditions, and in some cases, to address primary dermatologic symptomatology. These medications should be prescribed in collaboration with a psychiatrist or primary care team. Patients’ medical and psychiatric history, current medications, and potential adverse side effects should be reviewed. When considering the discontinuation or tapering of these medications, careful assessment should consider the chronicity and severity of both psychiatric and dermatologic symptoms. As with any medication, psychotropic agents should be tapered or discontinued if severe adverse reactions occur. Once dermatologic symptoms have resolved, factors to consider when tapering include symptom stability, resolution of the underlying dermatologic condition, potential psychosocial stressors that could trigger a relapse, and the presence of psychiatric comorbidities. Specific tapering recommendations should follow current clinical guidelines for each respective medication class to ensure safe and effective discontinuation. Moreover, routine follow-up is necessary when prescribing psychotropics. In light of these considerations, dermatologists should feel empowered to suggest these options in cases of mild to moderate psychiatric disturbances. However, if severe psychiatric symptoms, complex patient histories, or diagnostic uncertainty are present, prompt referral to psychiatry is warranted.

This review has several limitations, including reliance on a limited body of available literature, much of which consists of small case series. Therefore, the findings may not be generalizable to broader populations. Additionally, this review did not address all potential applications of psychotropic medications, including their use in conditions such as trichotillomania, body dysmorphic disorder, dermatillomania, and atopic dermatitis.

Future research should incorporate longitudinal designs, larger patient cohorts, and more diverse populations to better evaluate the long-term benefits and risks associated with psychotropic medications in dermatologic care.

Authors’ contributions

The manuscript has been read and approved by all authors. All authors meet authorship criteria, and the manuscript represents honest work.

Conflicts of interest

There are no conflicts of interest.

Use of artificial intelligence (AI)

We have not used artificial intelligence.

Funding Statement

Nil.