Psychiatric medications: Adverse cutaneous drug reactions
Introduction
Adverse cutaneous drug reactions (ACDRs) are the most frequent adverse events in patients receiving drug therapy, with higher rates being associated with psychotropic medications.1 Compounding the concern is that psychotropic medications are among the most highly prescribed medications in the United States. The most recent National Center for Health Statistics report on prescription drug use found that in 2007 to 2008, antidepressants were the most commonly prescribed drugs used by adults in the United States aged 20 to 59 years, surpassing even analgesics in frequency.2 As these data suggest, the prevalence of psychiatric illness is very high. The most recent National Comorbidity Survey Replication estimated the 12-month prevalence of any Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision disorder to be 26.2% in the general population, with 22.3% of these being classified as serious.3
Although most ACDRs associated with psychotropic medications are benign and easily treated, some can be life-threatening, and particularly those associated with the mood stabilizers. Because it is often necessary to use more than one agent concurrently to obtain remission of severe bipolar mood episodes, this risk is increased in the more severely ill patient who is taking combinations of mood stabilizers.4-12 In addition, cross-sensitivity between these medications has been noted.13., 14., 15.
The decision to discontinue a psychotropic medication vs symptomatic treatment of a less serious ACDR can be difficult for the dermatologist, because the severity of a patient’s psychiatric illness and risk of relapse may not be immediately apparent. With severe ACDRs, the appropriate options for the dermatologist to consider with drug discontinuation can also be challenging, particularly in a patient with a severe mental illness. The decision to remove a possibly offending agent should be weighed carefully, because relapse of mania or severe depression poses a serious risk of morbidity and even mortality. In this contribution, the most common, serious, and general ACDRs associated with antidepressants, mood stabilizers, and antipsychotics will be discussed. Advice concerning when and how to safely discontinue a psychotropic medication will also be presented.
Section snippets
Special questions and considerations when discontinuing a psychiatric medication secondary to an ACDR
Any time a medication is discontinued secondary to an ADCR, the decision is based on the severity of the skin reaction vs the risk of relapse or exacerbation of the original condition for which the medication was prescribed. When the offending medication is a psychotropic, however, this process can be even more difficult than with other classes of medications. In a busy dermatology practice, it can be time consuming, and perhaps overwhelming, to evaluate a patient’s current mental stability to
Pruritus
Pruritus usually occurs secondary to another drug reaction, but it can be a common primary adverse effect of any of the antidepressants, mood stabilizers, or antipsychotics.17 Pruritus alone would rarely be a cause of discontinuation of a psychotropic medication when considering the risk of relapse of the patient’s disorder. Although pruritus can occur with any psychotropic agent, see Table 1, Table 2, Table 3 for specific drugs more frequently associated with pruritus.
Exanthematous reactions
Exanthematous reactions
Erythema multiforme
Although rare with antidepressants and antipsychotics, fluoxetine,79 paroxetine,25 bupropion,26 clozapine,25 and risperidone,25 have been associated with erythema multiformelike eruptions. Erythema multiformelike eruptions have also been found in patients being treated with carbamazepine,49 valproic acid,25 lamotrigine,25 gabapentin,25 and oxcarbazepine.25
Treatment must include immediate discontinuation of the offending drug with inpatient psychiatric or medical hospitalization determined by
Acneiform eruptions
Acneiform eruptions have been associated with almost all antidepressants. Lithium,17 topiramate, lamotrigine, gabapentin, and oxcarbazepine are the mood stabilizers that are associated with acne, and the antipsychotics of note are quetiapine and haloperidol.66 Typically occurring on the face, chest, and upper back, the eruption consists of folliculocentric pustules, usually without comedones. Discontinuation of the agent will lead to improvement, but is not necessary as antibiotics with topical
Conclusions
Although ACDRs are frequent with psychotropic medications, most of the skin lesions are benign and easily managed. When serious ACDRs occur, care must be taken to assess safety before withdrawal of the medication. In addition, consideration of the potential for severe morbidity when a drug is withdrawn should not be underestimated. Because many patients with debilitating psychiatric illnesses have almost always had numerous medication trials before an effective regimen is found, a thorough
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