Abstract
Psoriasis is a chronic, persistant, T-cell mediated inflammatory skin disease caused by multifactorial etiology. Psychosocial factors have roles in the onsets and exacerbations. The patient was presented to outpatient department with complaints of lack of will and interest, depressed mood, fatigue, lack of energy, excessive sleeping, loss of apetite and feelings of worthlessness. She has had bipolar disorder I for 30 and psoriasis for 20 years. She had nacre-coloured, pruritic and excoriated plaques in flexor and extensor sites of the extremities, scalp and the whole body. We learned that she had 5 manic and 8 depressive episodes. She was prescribed with depressive episode. Dermatology consultation was demanded as she has not been using any medications for her lesions for a year. The patient refused the drugs advised by dermatology with the reason that those drugs exacerbate the psychiatric condition. On follow-up twenty days later, she referred to the clinic with hypomania. Lesions had recovered dramatically despite not taking any medication. Fluoksetin stopped. Valproic acid dose was increased to 1500 mg and quetiapine XR 600 mg. In the control visit, she was in remission. No worsening was monitorized in the lesions. With this case we tried to show that treating the underlying psychiatric problems would make the treatment of dermatologic diseases easier. The cooperation of dermatology and psychiatry would increase the treatment success.
Keywords :
Bipolar Disorders
, Psoriasis
Turkish Abstract
Psoriasis multifaktöriyel etiyolojili, kronik, tekrarlayıcı, T hücre aracılı inflamatuvar bir deri hastalığıdır. Hastalığın başlamasında ve alevlenmesinde psikososyal nedenlerin aşikar rolü vardır. Son altı aydır mevcut olan ilgi-istek kaybı, depresif duygudurum, yorgunluk, enerji azlığı, çok uyuma, iştah kaybı, değersizlik düşünceleri gibi şikayetleri olan hasta, yakını tarafından polikliniğimize getirildi. Özgeçmişinde, yaklaşık 30 yıldır bipolar bozukluk I ve 20 yıldır psoriasis öyküsü mevcuttu. Ekstremitelerin fleksör ve extansör yüzeylerinde belirgin olmak üzere saç, saçlı deri dahil tüm vücutta yaygın ekskoriye, sedef renginde ve plak şeklinde kaşıntılı lezyonları mevcuttu. Öyküsüden 5 manik, 9 depresif epizod geçirdiği anlaşılmaktaydı. Bipolar bozukluk depresif epizod tanısıyla tedavisi düzenlendi. Deri lezyonları için 1 yıldır sistemik veya topikal herhangi bir ilaç kullanmadığını ifade eden hastaya dermatoloji konsultasyonu istendi. Dermatoloji tarafından önerilen ilaçların psikiyatrik hastalığını ağırlaştırdığını bu nedenle kullanmak istemediklerini söylediler. Hasta 20 gün sonra polikliniğe hipomani semptomları ile geldi. Cildindeki lezyonlar herhangi bir dermatolojik ilaç almamasına rağmen dramatik bir şekilde iyileşmişti. Hastanın kullandığı fluoksetin kesildi. Valproik asit 1500 mg, ketiyapin XR 600 mg olarak düzenlendi. 15 gün sonraki kontrol muayenesinde remisyonda olarak değerlendirildi. Cilt lezyonlarında herhangi bir artma ve kötüleşme olmamıştı. Bu hastada altta yatan psikiyatrik sorunun çözülmesi dermatolojik hastalığın tedavisini kolaylaştırmıştır. Psikiyatri ve dermatoloji branşlarının işbirliği içerisinde olması hastalıkların tedavi başarısını arttıracaktır.
Turkish Keywords :
, Bipolar bozukluk
, Psoriasis
Introduction
Psoriasis is a chronic, persistant and T-cell mediated inflammatory skin disease of multifactorial etiology 1. Stress and psychosocial factors have prominent role in both onset and exacerbations of the disease 2. Therefore, psoriasis patients because of skin lesions usually have psychiatric disorders such as depression and anxiety 3. In this case report, we aim to show the relationship between bipolar cyclicity and psoriasis lesions? exacerbation and remission episodes. Skin lesions occur in depressive episodes, dramatically decrease in hypomania and remission.
Case Report
A 52-year-old, married, primary school graduated female patient was admitted to our outpatient clinic by a relative with complaints of lack of will and interest, depressive mood, fatigue, lack of energy, excessive sleeping, loss of appetite and feelings of worthlessness. Her medical history was remarkable for bipolar disorder I for 30 years and psoriasis for 20 years. It was determined that she had low self-care and psychomotor retardation. She had pruritic and excoriated psoriatic plaques mainly on the extensor sites of the extremities, scalp and the whole body (Figure-1.A).
In mental examination, she was in a sad and depressive mood and was anhedonic. Speed of her speech was slow, tone was low and the number of words she used while talking were few. Content of thinking was depressive but no suicide idea, delusions or obsessions. No perceptual and thought disturbances were determined. Her sleep requirement was increased, appetite was decreased. There were 5 manic and 9 depressive episodes in her history. Blood cell count and all biochemical parameters including vitamin-B12,folic acid, electrolytes, renal and liver function tests and thyroid function tests were within normal range. Her treatment was regulated as fluoxetine 20 mg per day, valproic acid 1000 mg per day and quetiapine XR (extended release) with the diagnosis of depressive episode. Dermatology consultation was required for skin lessions. As the dermatology medication exacerbated her psychiatric condition, both the patient and her husband refused to use the drugs recommended by the dermatologist. The patient was admitted to our clinic with hypomanic symptoms 20 days after her first visit. However, the skin lesions had recovered dramatically without taking any medication. (Figure-1.B).
Fluoksetin treatment was stopped. Valproic acid dose was increased to 1500 mg per day and quetiapine XR dose to 600 mg per day. After 15 days in the control visit her psychiatric symptoms were in remission. No augmentation or worsening was monitorized in the skin lesions.
Discussion
Psoriasis is a chronic, persistant, T-cell mediated inflammatory skin disease of multifactorial etiology which affects %1-2 of the community 4. Bipolar disorder has courses of mania and depression and affects nearly % 1 of the community 5. There are some limitations with regard to treatment when these two conditions coexist. Lamotrigine is an anticonvulsant drug and may be used to prevent depressive episodes of bipolar disorder 6. Skin rash is seen frequently with mono or combined therapy of lamotrigine 7. In literature lithium-induced psoriasis cases are mentioned frequently 8,9. Consequently, valproic acid is preferred as mood stabilizer. Psoriasis have a multidirectional relationship with mood disorders and treatments. It is reported that skin eruptions and psychiatric symptom severity are positively correlated 10. Depressive state may ease perception of itching by lowering sensual threshold 11. Psychological stress substantially affects psoriasis patients? response to treatment 12. In a study comparing 50 psoriasis patients with 50 controls, it was reported that depression and discharge of physical way were higher in the patient group and risk for psoriasis development was higher in medium-severe depression group. They also stated that there was a relationship between symptom severity, difficulty to express emotions and high Beck Depression Scale scores. As a result, these findings may indicate that there may be an association between psoriasis and psycological problems 13. Compatible with the literature, our patient?s lesions worsened in depressive period and diminished with treatment.
In patients applying to dermatology clinics, psychiatric disorders may also exist. Also, drugs used in psychiatry have adverse effects on skin. While some of these side effects regress with treatment, some may have fatal course. Treatment of underlying psychiatric problems will enhance compliance of medication. Especially for medication-resistive skin diseases, psychiatric consultation should be taken into account. Collaboration of dermatology and psychiatry clinics will improve the success of treatment.
References
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Information Presentation
Bu olgu 6. Uluslararası Psikofarmakoloji Kongresi ve 2. Uluslararası Çocuk ve Ergen Psikofarmakolojisi Sempozyumu?nda poster bildirisi olarak sunulmuştur.
16-20 Nisan 2014 Antalya
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