- Email: [email protected]
A dermatology-psychiatry liaison clinic
Volume 9 Number 1 July, 1983
Bioavailability of topical clindamycin
4. On" RJ, Lacina NC, Peters LS, Flynn GL: Topical clindamycin for acne. Part 2. Guidelines for extemporaneous compounding. Am Pharm 18:23-26, 1979. 5. Algra RJ, Rosen T, Waisman M: Topical clindarnycin in acne vulgaris: Safety and stability, Arch Dermatol 113:1390-1391, 1977. 6. Stoughton RB: Topical antiobiotics for acne vulgaris. Current usage. Arch Dermatol 115:486-489, 1979. 7. Guin JD: Topical clindamycin: A double blind study comparing clindamycin phosphate with clindamycin hydrochloride, Int J Dermatol 18: 164-166, 1979. 8. Thomsen RJ, Stranieri A, Knutson D, Strauss JS: Topical clindamycin treatment of acne. Arch Dermatol 116: 1031-1034, 1980. 9. Becker LE, Bergstresser PR, Whiting DA, et al: Topical clindamyein therapy for acne vulgaris: A cooperative clinical study. Arch Dermatol 117:482-485, 1981. 10. Barrett CW, Hadgraft JW, Sarkany I: The influence of vehicles on skin penetration. J Pharm Pharmacol 16: 104T- 107T, 1964. 11. Sarkany I, Hadgraft JW, Caron GA, Barrett CW: The role of vehicles in the percutaneous absorption of corticosteroids. Br J Dermatol 77:569-575, 1965. 12. Ostrenga J, Steinmetz C, Poulsen B: Significance of vehicle composition 1. Relationship between topical vehicle composition skin penetrability, and clinical efficacy. J Pharm Sci 60:1175-1179, 1971. 13. Yankell SL: The effects of various vehicles on absorption rates in skin, in Montagna W, Van Scott EJ, Stoughton RB, editors: Advances in biology of skin. New York, 1972, Appleton-Century-Crofts, vol. 12, pp. 511-522. 14. Whitfield M, McKenzie AW: A new formulation of 0.1% hydrocortisone cream with vasoconstrictor activity and clinical effectiveness. Br J Dermatol 92:585-588, 1975. 15. Elfbaum SG, Laden K: The effect of dimethyl sulfoxide
16.
17.
18. 19.
20.
21. 22. 23.
24. 25. 26.
on percutaneous absorption: A mechanistic study. Part 2. J Soc Cos Chem 19:163-172, 1968. Scala J, McOsker DE, Relier HH: The percutaneous absorption of ionic surfactants. J Invest Dermatol 50:371379, 1968. Brown LW: High pressure liquid chromatographic assay for clindamycin, elindamycin phosphate, and clindamycin palmitate. J Pharm Sci 67:1254-1257, 1978. Franz TJ: Percutaneous absorption: On the relevance of in vitro data. J Invest Dermatol 64:190-195, 1975. Sekura DL, Scala J: The percutaneous absorption of alkyl methyl sulfoxides, in Montagna W, Van Scott EJ, Stoughton RB, editors: Advances in biology of skin. New York, 1972, Appleton-Century-Crofts, vol. 12, pp. 257-269. Chowan ZT, Pritchard R: Effect of surfactants on percutaneous absorption of Naproxen. I. Comparisons of rabbit, rat and human excised skin. J Pharm Sci 67: 1272-1274, 1978. Scheuplein RJ, Ross LW: Mechansim of percutaneous absorption. V. Percutaneous absorption of solvent deposited solids. J Invest Dermatol 62:353-360, 1974. Feldmann RJ, Maibach HI: Percutaneous penetration of steroids in man. J Invest Dermatol 52:89-94, I969. Sinha AJW, Shaw SR, Weber DJ: Percutaneous absorption and excretion of tritium-labelled diflorasone diacetate, a new topical corticosteroid in the rat, monkey and man. J Invest Dermatol 71:372-377, 1978. Guin JD, Reynolds R, Gielerak PL: Penetration of topical clindamycin into comedones. J AM ACADDERMATOL 3: 153-156, 1980. Voron DA: Systemic absorption of topical clindamycinl Arch Dermatol 114:798, 1978. (Letter to Editor.) Milstone EB, McDonald AJ, Scholhamer DF Jr: Pseudomembranous colitis after topical application of clindamycin. Arch Dermatol 117:154-155, 1981.
m
A dermatology-psychiatry liaison clinic William M, Gould, M.D., and Thomas M. Gragg, M.D.
Stanford, CA A dermatology-psychiatry liaison clinic at Stanford University is described. The clinic provides an oppommity for dermatology residents to learn about the psychological aspects of the specialty and to witness at first hand technics o f interviewing, strategic questioning, and listening. (J AM ACAO DERMATOL 9:73-77, 1983.)
From the Departments of Dermatology and Psychiatry, Stanford University School of Medicine. Accepted for publication Nov. 24, 1982. Reprint requests to: Dr. William M. Gould, 750 Welch Rd., Suite 218, Palo Alto, CA 94304/415-327-5783.
T h e d e r m a t o l o g y - p s y c h i a t r y l i a i s o n c l i n i c at S t a n f o r d w a s s t a r t e d in 1972. I t g r e w o u t o f a m u t u a l n e e d o n the p a r t o f t h e a u t h o r s , o n e a 73
74
Journal of the American Academy of Dermatology
Gould and Gragg
Table I. Psychiatric diagnoses in sixty consecutive patients* Diagnosis
Number
Depression Anxiety Obsessive-compulsive personality Adjustment reaction Paranoid schizophrenia Psychoneurosis Organic brain syndrome Paranoid personality Psychotic reaction Stress reactor Substance abuse (alcohol, drugs) Conversion reaction Sociopathic personality Total
22 15 8 5 4 3 2 2 2 2 2 1 1 69
*Some patients had more than one diagnosis,
dermatologist (W. M. G.) and one a psychiatrist (T. M. G.), to explore beyond the traditional boundaries of their chosen specialties. The clinic provides dermatology residents with an opportunity to learn at first hand something of the psychological aspects o f dermatology. ORGANIZATION OF THE CLINIC The liaison clinic is held every Friday morning. Only one room of the dermatology outpatient department is used for this purpose, and the regular clinic goes on concurrently. Patients are referred to the liaison clinic by dermatology residents, full-time staff, and at times from private practices. Patients are always told the nature o f the clinic: that it is a special clinic; that they will be seen simultaneously by both a dermatologist and a psychiatrist; and that a dermatology resident will also be present. A typical initial session begins with introductions followed by a review of how the patient happened to be referred. An examination of the skin is carried out and the patient is encouraged to relate his or her history. Although a review of physical and mental conditions is made, there is no set structure to the sessions. The three physicians present are all free to participate, the only proviso being the unstated one of tact. Questions or comments of a dermatologic nature are usually han-
dled by the dermatologist or the resident or both. Psychological issues are most frequently dealt with by the psychiatrist. However, there is an improvisational quality to the sessions, and no absolute boundaries are set up. Our usual practice is to work for a period of several months with one resident whose sole responsibility on Friday morning is to be available for the liaison clinic. In this fashion the assigned resident, over a period of 3 to 6 months, is present at interviews with a variety of patients. The majority of Stanford dermatology residents in training over the last few years have had some exposure to the liaison clinic. It is in this teaching function that the clinic has had its greatest effect. No more than three, and usually only two patients are seen during a given session. While we feel confident that most of these patients have been helped by their coming to the clinic (and this conclusion has been confirmed by survey), we are more impressed with the importance of the exposure it gives our residents to the psychological dimension of dermatologic practice. It is an opportunity for them to see, in a handful of patients, the inseparability of the physical from the mental, and vice versa. STATISTICAL DATA The liaison clinic experience does not lend itself to numerical analysis. A list of cases seen over the years is not the same thing as the experience itself. The latter is a process. It is sitting in the room with the patient who talks about his or her illness. Nevertheless, a sense of the types of patients seen is obtained from Tables I-IH, which represent an analysis of sixty consecutive patients. All sixty have some dermatologic complaint or disorder. Their psychiatric and dermatologic diagnoses fall into three categories: strictly psychiatric disorders; generally accepted psychocutaneous disorders; and other dermatologic conditions. There is overlapping among the categories. For example, a patient with pruritus might also carry a diagnosis of depression. Approximately 40% of the patients were seen for one or two visits. Another 40% were seen for three to six visits. The remaining 20% were seen for more than six visits. A few of these were in the ten- to fifteen-visit range. Many of the
Volume 9 Number 1 July, 1983
Dermatology-psychiatry liaison clinic
Table
I I . Psychocutaneous diagnoses in sixty consecutive patients
Diagnosis Delusion of parasitosis Trichotillomania Neurotic excoriations Factitial dermatosis Bromhidrosophobia Total
[
Table
I I I . Other dermatologic d i a g n o s e s in sixty consecutive patients*
Number
Diagnosis
9 4 3 2 1 19
Dermatitis-eczema Pruritus Acne Psoriasis Prurigo nodularis Burning of the skin or tongue Foll iculitis Seborrheic dermatitis Vitiligo Acne rosacea Alopecia areata Dermatosis papulosa nigra Dyshidrosis Eruptive histiocytoma Hair loss Hyperhidrosis Leukoderma Lymphoma Normal skin Onychomyeosis Pityriasis rosea Scabies Solar elastosis Tongue chewing Urticaria Total
patients were seen b y three or more physicians prior to referral to the liaison clinic, and it is apparent from a review of records that some physicians are unaware o f the potential for psychiatric help. CASE R E P O R T S
Case 1 A mildly mentally retarded 23-year-old woman had scabbed nodular lesions on the hands and forearms. She produced these by striking her hands against hard objects, such as table edges, during times of stress. She expressed feelings of resentment about her situation, and we arranged to meet with members of her family and with the supervisor of the boarding home where she lived. Together with her social worker and with the help of her parents, we made arrangements for certain easy changes to be made. These related to her room at the home, and to her interaction with certain fellow boarders. The patient was also frustrated by her assembly line job in a manufacturing plant, and we arranged a different type of work for her. She stopped banging her hands, and the lesions healed.
75
I
Number 8 7 7 5 4 2 2 2 2 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 55
*The sum of all dennatologic diagnoses made includes patients from Tables II and lII.
A 30-year-old nurse came to the liaison clinic for severe trichotillomania beginning in childhood and continuing unabated. In six sessions we gradually uncovered issues which were bothering her: friction with her parents and difficulties in forming lasting emotional commitments. She agreed to see a psychiatrist in private practice and entered long-term therapy. She still has trichotillomania and wears a wig, but she feels that she is happier and on the way to solving some of her basic problems. In her case the liaison clinic functioned as a transitional mode of help.
sponse to conventional treatment was unusually slow. In five visits to the liaison clinic it became clear that she was depressed. Issues included menopause, a divorce, and friction with her children who had moved away. She worked long hours as the manager of a grocery store and had little time or inclination for relaxation or social activity. During the period we saw her, the patient noted improvement in her skin and in her relationship with her children. She was quite psychologically minded, and we were able to make suggestions about a more efficient use of time so as to allow her opportunities for recreation. She had written poetry as a young woman and began this activity once again. She is typical of many patients who may benefit from short-term psychotherapy which is focused on current, mundane, disturbing issues in their lives.
Case
Case
Case 2
3
A 56-year-old woman had a severe, recurring eczematoid dermatitis over the trunk and limbs. Her re-
4
A 65-year-old Filipino man complained of having an unpleasant odor to his skin of many years' duration. He
76
GouM and Gragg
was certain that people avoided him because of his smell. He interpreted coughs, sneezes, and throat clearing by others to be proof of his offensiveness. He recalled frequent occasions when people on buses or in crowds moved away from him. Examination of this meticulous and fastidious man on numerous visits failed to substantiate his belief. A neurologic examination and electroencephalogram were normal. The patient became more relaxed on thioridazine and seemed to gain significant reassurance through his visits to the clinic. On a number of occasions he said that if someone on a bus or in a crowd were to insult him verbally about his odor, he would be provoked to the point of violence. His eventual goal was to retire in the Philippines as a gentleman farmer raising chickens. The liaison clinic may have helped him work toward that goal. He was able to vent his feelings and to exercise restraint as a result of his visits. When last seen he was improved, but not cured of his symptom. COMMENT We live in an era of some psychological sophistication, and there are few physicians who would deny the profound importance of body-mind and mind-body interactions in their patients. Psychosomatic medicine, far from being a radical discipline on the lunatic fringe, continues to gain validation through continuing advances in psychology, biochemistry, and neuropharmacology, which have begun to build a new framework bridging the gap between physical and behavioral science. Indeed, it is an exciting time. But although there is tacit acceptance of the importance of these interactions, a practical problem has always been how to teach the subject. Medical students learn psychiatry mostly through reading, formal lectures, conferences, rounds on inpatient units, and, if they are very fortunate, through one-to-one psychotherapy, each hour of which is reviewed at a later time by a supervisor. The liaison clinic is a way for dermatology residents to observe at first hand technics of interviewing, strategic questioning, and listening which can be applied to the types of patients they will soon be seeing in their practices. The discussions which follow each interview are based on a review of the issues pertinent to the particular patient, but they are often wide-ranging and always provocative. A
Journal of the American Academy of Dermatology
questionnaire sent to former residents asking their thoughts on the liaison clinic produced uniformly enthusiastic replies and enumerated specific features of the clinic found especially helpful. The residents learned, for example, to begin listening to patients the way psychiatrists are trained to do; to pay attention to things like body language and tone of voice; to look behind the facade of the obvious; to realize that boredom felt by the physician is at least as important in a diagnostic sense as the actual words the patient is producing. The residents also learned to question why they like certain patients and dislike others. They began to attempt an understanding of some of their own motivations in becoming physicians: what they expect from it; what kinds of rewards they cherish; what kinds of anxieties they feel in certain situations and with certain kinds of patients. The clinic is not without its problems and one is a high rate of missed appointments. While regular dermatology visits may take 10 or 15 minutes, a missed appointment in the liaison clinic means that 30 to 50 minutes of the staff's time is wasted. It is perhaps unfortunate, but nonetheless true, that patients with psychiatric problems may exhibit resistance in just this fashion. Another problem is the danger in such a setting of assuming too quickly that every symptom is due to mental stress. The bi-disciplinary approach helps to guard against this, and we are particularly elated that in one patient referred by a very thorough and competent dermatologist for neurodermatitis, Sarcoptes mites were demonstrated in skin scrapings. Another patient with itching thought to be a manifestation of organic brain syndrome was found to have correctable hypothyroidism. Although the confrontation of one patient by three physicians might seem awkward or difficult, in practice this has not been the case. The university setting lends authority and so, in one sense, the team of physicians speaks with one voice. This is the court of last appeal for many patients and, probably for this reason, it often seems more acceptable to them to be told here that all of the laboratory tests have been done and that the investigation has been thorough enough. It makes it possible then to commence some psychological
Volume 9 Number 1 July, 1983
Dermatology-psychiatry liaison clinic
work. Many of the patients whom we see exhibit significant amounts of paranoia. Here, the presence of three physicians serves to diffuse the level of irritation and antagonism in the patient. The liaison clinic works well because it is a joint undertaking and depends on the mutuality of
the effort. It is a shared, noncompetitive enterprise the purpose of which is not to turn every dermatologist into a psychiatrist, but rather to introduce the psychological dimension into the training of residents.
Potassium iodide in erythema nodosum and other erythematous dermatoses Takeshi Horio, M.D., Kiichiro Danno, M.D., Hiroyuki Okamoto, M . D . , Yoshiki Miyachi, M.D., and Sadao Imamura, M.D.
Kyoto, Japan Potassium iodide therapy has a history of more than 150 years. It has been tried in many diseases in the past. However, with the development of modem medications indications for potassium iodide therapy are very limited. It is well known that potassium iodide is the drug of choice for sporotrichosis. Subacute nodular migratory panniculitis and erythema nodosum have also been treated successfully with this drug. (J AM ACADDERMATOL9:77-8 1, 1983.) Erythema nodosum was treated formerly with potassium iodide. However, this modality had long been forgotten by dermatologists until Schulz and Whiting, 1 in 1976, and T6r6k and Sziics, in 1977, 2 reported excellent symptomatic improvement in a substantial number of patients who had erythema nodosum and nodular vasculitis. Their reports stimulated us to try potassium iodide in patients with various erythemateus dermatoses. Fifty-one patients with erythema nodosum, nodular vasculitis, erythema multiforme, or acute febrile neutrophilic dermatosis (Sweet's syndrome) were treated with the drug. All of these disorders responded well and very similarly to potassium iodide. The modem usage of an old drug will be From the Departmentof Dermatology,Facultyof Medicine,Kyoto University,Sakyo,Kyoto606, Japan. Acceptedfor publicationNov. 10, 1982. Reprintrequestto: Dr. TakeshiHorio,Departmentof Dermatology, Facultyof Medicine,KyotoUniversity,Sakyo,Kyoto606,Japan.
presented in this paper. The possible mechanisms of action of potassium iodide and the pathogenesis of erythematous dermatoses will also be discussed. MATERIALS AND METHODS A total of 51 patients were admitted to the trials. There were sixteen patients with erythema nodosum, eleven with nodular vasculitis, sixteen with erythema multiforme, and eight with Sweet's syndrome. Potassium iodide was administered as pills in most cases or as aqueous solution in a few. Each pill contains 100 mg of potassium iodide. After the diagnosis was made, all patients were given only potassium iodide, 300 rag, orally three times a day. Within 1 week usually 3 to 7 days after the initiation of medication, the patients were re-examined. Thereafter, the therapeutic effects of the drug were evaluated once every week or two. When no response was observed on the second examination, the medication was considered ineffective and was discontinued in most patients. 77
Bioavailability of topical clindamycin
4. On" RJ, Lacina NC, Peters LS, Flynn GL: Topical clindamycin for acne. Part 2. Guidelines for extemporaneous compounding. Am Pharm 18:23-26, 1979. 5. Algra RJ, Rosen T, Waisman M: Topical clindarnycin in acne vulgaris: Safety and stability, Arch Dermatol 113:1390-1391, 1977. 6. Stoughton RB: Topical antiobiotics for acne vulgaris. Current usage. Arch Dermatol 115:486-489, 1979. 7. Guin JD: Topical clindamycin: A double blind study comparing clindamycin phosphate with clindamycin hydrochloride, Int J Dermatol 18: 164-166, 1979. 8. Thomsen RJ, Stranieri A, Knutson D, Strauss JS: Topical clindamycin treatment of acne. Arch Dermatol 116: 1031-1034, 1980. 9. Becker LE, Bergstresser PR, Whiting DA, et al: Topical clindamyein therapy for acne vulgaris: A cooperative clinical study. Arch Dermatol 117:482-485, 1981. 10. Barrett CW, Hadgraft JW, Sarkany I: The influence of vehicles on skin penetration. J Pharm Pharmacol 16: 104T- 107T, 1964. 11. Sarkany I, Hadgraft JW, Caron GA, Barrett CW: The role of vehicles in the percutaneous absorption of corticosteroids. Br J Dermatol 77:569-575, 1965. 12. Ostrenga J, Steinmetz C, Poulsen B: Significance of vehicle composition 1. Relationship between topical vehicle composition skin penetrability, and clinical efficacy. J Pharm Sci 60:1175-1179, 1971. 13. Yankell SL: The effects of various vehicles on absorption rates in skin, in Montagna W, Van Scott EJ, Stoughton RB, editors: Advances in biology of skin. New York, 1972, Appleton-Century-Crofts, vol. 12, pp. 511-522. 14. Whitfield M, McKenzie AW: A new formulation of 0.1% hydrocortisone cream with vasoconstrictor activity and clinical effectiveness. Br J Dermatol 92:585-588, 1975. 15. Elfbaum SG, Laden K: The effect of dimethyl sulfoxide
16.
17.
18. 19.
20.
21. 22. 23.
24. 25. 26.
on percutaneous absorption: A mechanistic study. Part 2. J Soc Cos Chem 19:163-172, 1968. Scala J, McOsker DE, Relier HH: The percutaneous absorption of ionic surfactants. J Invest Dermatol 50:371379, 1968. Brown LW: High pressure liquid chromatographic assay for clindamycin, elindamycin phosphate, and clindamycin palmitate. J Pharm Sci 67:1254-1257, 1978. Franz TJ: Percutaneous absorption: On the relevance of in vitro data. J Invest Dermatol 64:190-195, 1975. Sekura DL, Scala J: The percutaneous absorption of alkyl methyl sulfoxides, in Montagna W, Van Scott EJ, Stoughton RB, editors: Advances in biology of skin. New York, 1972, Appleton-Century-Crofts, vol. 12, pp. 257-269. Chowan ZT, Pritchard R: Effect of surfactants on percutaneous absorption of Naproxen. I. Comparisons of rabbit, rat and human excised skin. J Pharm Sci 67: 1272-1274, 1978. Scheuplein RJ, Ross LW: Mechansim of percutaneous absorption. V. Percutaneous absorption of solvent deposited solids. J Invest Dermatol 62:353-360, 1974. Feldmann RJ, Maibach HI: Percutaneous penetration of steroids in man. J Invest Dermatol 52:89-94, I969. Sinha AJW, Shaw SR, Weber DJ: Percutaneous absorption and excretion of tritium-labelled diflorasone diacetate, a new topical corticosteroid in the rat, monkey and man. J Invest Dermatol 71:372-377, 1978. Guin JD, Reynolds R, Gielerak PL: Penetration of topical clindamycin into comedones. J AM ACADDERMATOL 3: 153-156, 1980. Voron DA: Systemic absorption of topical clindamycinl Arch Dermatol 114:798, 1978. (Letter to Editor.) Milstone EB, McDonald AJ, Scholhamer DF Jr: Pseudomembranous colitis after topical application of clindamycin. Arch Dermatol 117:154-155, 1981.
m
A dermatology-psychiatry liaison clinic William M, Gould, M.D., and Thomas M. Gragg, M.D.
Stanford, CA A dermatology-psychiatry liaison clinic at Stanford University is described. The clinic provides an oppommity for dermatology residents to learn about the psychological aspects of the specialty and to witness at first hand technics o f interviewing, strategic questioning, and listening. (J AM ACAO DERMATOL 9:73-77, 1983.)
From the Departments of Dermatology and Psychiatry, Stanford University School of Medicine. Accepted for publication Nov. 24, 1982. Reprint requests to: Dr. William M. Gould, 750 Welch Rd., Suite 218, Palo Alto, CA 94304/415-327-5783.
T h e d e r m a t o l o g y - p s y c h i a t r y l i a i s o n c l i n i c at S t a n f o r d w a s s t a r t e d in 1972. I t g r e w o u t o f a m u t u a l n e e d o n the p a r t o f t h e a u t h o r s , o n e a 73
74
Journal of the American Academy of Dermatology
Gould and Gragg
Table I. Psychiatric diagnoses in sixty consecutive patients* Diagnosis
Number
Depression Anxiety Obsessive-compulsive personality Adjustment reaction Paranoid schizophrenia Psychoneurosis Organic brain syndrome Paranoid personality Psychotic reaction Stress reactor Substance abuse (alcohol, drugs) Conversion reaction Sociopathic personality Total
22 15 8 5 4 3 2 2 2 2 2 1 1 69
*Some patients had more than one diagnosis,
dermatologist (W. M. G.) and one a psychiatrist (T. M. G.), to explore beyond the traditional boundaries of their chosen specialties. The clinic provides dermatology residents with an opportunity to learn at first hand something of the psychological aspects o f dermatology. ORGANIZATION OF THE CLINIC The liaison clinic is held every Friday morning. Only one room of the dermatology outpatient department is used for this purpose, and the regular clinic goes on concurrently. Patients are referred to the liaison clinic by dermatology residents, full-time staff, and at times from private practices. Patients are always told the nature o f the clinic: that it is a special clinic; that they will be seen simultaneously by both a dermatologist and a psychiatrist; and that a dermatology resident will also be present. A typical initial session begins with introductions followed by a review of how the patient happened to be referred. An examination of the skin is carried out and the patient is encouraged to relate his or her history. Although a review of physical and mental conditions is made, there is no set structure to the sessions. The three physicians present are all free to participate, the only proviso being the unstated one of tact. Questions or comments of a dermatologic nature are usually han-
dled by the dermatologist or the resident or both. Psychological issues are most frequently dealt with by the psychiatrist. However, there is an improvisational quality to the sessions, and no absolute boundaries are set up. Our usual practice is to work for a period of several months with one resident whose sole responsibility on Friday morning is to be available for the liaison clinic. In this fashion the assigned resident, over a period of 3 to 6 months, is present at interviews with a variety of patients. The majority of Stanford dermatology residents in training over the last few years have had some exposure to the liaison clinic. It is in this teaching function that the clinic has had its greatest effect. No more than three, and usually only two patients are seen during a given session. While we feel confident that most of these patients have been helped by their coming to the clinic (and this conclusion has been confirmed by survey), we are more impressed with the importance of the exposure it gives our residents to the psychological dimension of dermatologic practice. It is an opportunity for them to see, in a handful of patients, the inseparability of the physical from the mental, and vice versa. STATISTICAL DATA The liaison clinic experience does not lend itself to numerical analysis. A list of cases seen over the years is not the same thing as the experience itself. The latter is a process. It is sitting in the room with the patient who talks about his or her illness. Nevertheless, a sense of the types of patients seen is obtained from Tables I-IH, which represent an analysis of sixty consecutive patients. All sixty have some dermatologic complaint or disorder. Their psychiatric and dermatologic diagnoses fall into three categories: strictly psychiatric disorders; generally accepted psychocutaneous disorders; and other dermatologic conditions. There is overlapping among the categories. For example, a patient with pruritus might also carry a diagnosis of depression. Approximately 40% of the patients were seen for one or two visits. Another 40% were seen for three to six visits. The remaining 20% were seen for more than six visits. A few of these were in the ten- to fifteen-visit range. Many of the
Volume 9 Number 1 July, 1983
Dermatology-psychiatry liaison clinic
Table
I I . Psychocutaneous diagnoses in sixty consecutive patients
Diagnosis Delusion of parasitosis Trichotillomania Neurotic excoriations Factitial dermatosis Bromhidrosophobia Total
[
Table
I I I . Other dermatologic d i a g n o s e s in sixty consecutive patients*
Number
Diagnosis
9 4 3 2 1 19
Dermatitis-eczema Pruritus Acne Psoriasis Prurigo nodularis Burning of the skin or tongue Foll iculitis Seborrheic dermatitis Vitiligo Acne rosacea Alopecia areata Dermatosis papulosa nigra Dyshidrosis Eruptive histiocytoma Hair loss Hyperhidrosis Leukoderma Lymphoma Normal skin Onychomyeosis Pityriasis rosea Scabies Solar elastosis Tongue chewing Urticaria Total
patients were seen b y three or more physicians prior to referral to the liaison clinic, and it is apparent from a review of records that some physicians are unaware o f the potential for psychiatric help. CASE R E P O R T S
Case 1 A mildly mentally retarded 23-year-old woman had scabbed nodular lesions on the hands and forearms. She produced these by striking her hands against hard objects, such as table edges, during times of stress. She expressed feelings of resentment about her situation, and we arranged to meet with members of her family and with the supervisor of the boarding home where she lived. Together with her social worker and with the help of her parents, we made arrangements for certain easy changes to be made. These related to her room at the home, and to her interaction with certain fellow boarders. The patient was also frustrated by her assembly line job in a manufacturing plant, and we arranged a different type of work for her. She stopped banging her hands, and the lesions healed.
75
I
Number 8 7 7 5 4 2 2 2 2 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 55
*The sum of all dennatologic diagnoses made includes patients from Tables II and lII.
A 30-year-old nurse came to the liaison clinic for severe trichotillomania beginning in childhood and continuing unabated. In six sessions we gradually uncovered issues which were bothering her: friction with her parents and difficulties in forming lasting emotional commitments. She agreed to see a psychiatrist in private practice and entered long-term therapy. She still has trichotillomania and wears a wig, but she feels that she is happier and on the way to solving some of her basic problems. In her case the liaison clinic functioned as a transitional mode of help.
sponse to conventional treatment was unusually slow. In five visits to the liaison clinic it became clear that she was depressed. Issues included menopause, a divorce, and friction with her children who had moved away. She worked long hours as the manager of a grocery store and had little time or inclination for relaxation or social activity. During the period we saw her, the patient noted improvement in her skin and in her relationship with her children. She was quite psychologically minded, and we were able to make suggestions about a more efficient use of time so as to allow her opportunities for recreation. She had written poetry as a young woman and began this activity once again. She is typical of many patients who may benefit from short-term psychotherapy which is focused on current, mundane, disturbing issues in their lives.
Case
Case
Case 2
3
A 56-year-old woman had a severe, recurring eczematoid dermatitis over the trunk and limbs. Her re-
4
A 65-year-old Filipino man complained of having an unpleasant odor to his skin of many years' duration. He
76
GouM and Gragg
was certain that people avoided him because of his smell. He interpreted coughs, sneezes, and throat clearing by others to be proof of his offensiveness. He recalled frequent occasions when people on buses or in crowds moved away from him. Examination of this meticulous and fastidious man on numerous visits failed to substantiate his belief. A neurologic examination and electroencephalogram were normal. The patient became more relaxed on thioridazine and seemed to gain significant reassurance through his visits to the clinic. On a number of occasions he said that if someone on a bus or in a crowd were to insult him verbally about his odor, he would be provoked to the point of violence. His eventual goal was to retire in the Philippines as a gentleman farmer raising chickens. The liaison clinic may have helped him work toward that goal. He was able to vent his feelings and to exercise restraint as a result of his visits. When last seen he was improved, but not cured of his symptom. COMMENT We live in an era of some psychological sophistication, and there are few physicians who would deny the profound importance of body-mind and mind-body interactions in their patients. Psychosomatic medicine, far from being a radical discipline on the lunatic fringe, continues to gain validation through continuing advances in psychology, biochemistry, and neuropharmacology, which have begun to build a new framework bridging the gap between physical and behavioral science. Indeed, it is an exciting time. But although there is tacit acceptance of the importance of these interactions, a practical problem has always been how to teach the subject. Medical students learn psychiatry mostly through reading, formal lectures, conferences, rounds on inpatient units, and, if they are very fortunate, through one-to-one psychotherapy, each hour of which is reviewed at a later time by a supervisor. The liaison clinic is a way for dermatology residents to observe at first hand technics of interviewing, strategic questioning, and listening which can be applied to the types of patients they will soon be seeing in their practices. The discussions which follow each interview are based on a review of the issues pertinent to the particular patient, but they are often wide-ranging and always provocative. A
Journal of the American Academy of Dermatology
questionnaire sent to former residents asking their thoughts on the liaison clinic produced uniformly enthusiastic replies and enumerated specific features of the clinic found especially helpful. The residents learned, for example, to begin listening to patients the way psychiatrists are trained to do; to pay attention to things like body language and tone of voice; to look behind the facade of the obvious; to realize that boredom felt by the physician is at least as important in a diagnostic sense as the actual words the patient is producing. The residents also learned to question why they like certain patients and dislike others. They began to attempt an understanding of some of their own motivations in becoming physicians: what they expect from it; what kinds of rewards they cherish; what kinds of anxieties they feel in certain situations and with certain kinds of patients. The clinic is not without its problems and one is a high rate of missed appointments. While regular dermatology visits may take 10 or 15 minutes, a missed appointment in the liaison clinic means that 30 to 50 minutes of the staff's time is wasted. It is perhaps unfortunate, but nonetheless true, that patients with psychiatric problems may exhibit resistance in just this fashion. Another problem is the danger in such a setting of assuming too quickly that every symptom is due to mental stress. The bi-disciplinary approach helps to guard against this, and we are particularly elated that in one patient referred by a very thorough and competent dermatologist for neurodermatitis, Sarcoptes mites were demonstrated in skin scrapings. Another patient with itching thought to be a manifestation of organic brain syndrome was found to have correctable hypothyroidism. Although the confrontation of one patient by three physicians might seem awkward or difficult, in practice this has not been the case. The university setting lends authority and so, in one sense, the team of physicians speaks with one voice. This is the court of last appeal for many patients and, probably for this reason, it often seems more acceptable to them to be told here that all of the laboratory tests have been done and that the investigation has been thorough enough. It makes it possible then to commence some psychological
Volume 9 Number 1 July, 1983
Dermatology-psychiatry liaison clinic
work. Many of the patients whom we see exhibit significant amounts of paranoia. Here, the presence of three physicians serves to diffuse the level of irritation and antagonism in the patient. The liaison clinic works well because it is a joint undertaking and depends on the mutuality of
the effort. It is a shared, noncompetitive enterprise the purpose of which is not to turn every dermatologist into a psychiatrist, but rather to introduce the psychological dimension into the training of residents.
Potassium iodide in erythema nodosum and other erythematous dermatoses Takeshi Horio, M.D., Kiichiro Danno, M.D., Hiroyuki Okamoto, M . D . , Yoshiki Miyachi, M.D., and Sadao Imamura, M.D.
Kyoto, Japan Potassium iodide therapy has a history of more than 150 years. It has been tried in many diseases in the past. However, with the development of modem medications indications for potassium iodide therapy are very limited. It is well known that potassium iodide is the drug of choice for sporotrichosis. Subacute nodular migratory panniculitis and erythema nodosum have also been treated successfully with this drug. (J AM ACADDERMATOL9:77-8 1, 1983.) Erythema nodosum was treated formerly with potassium iodide. However, this modality had long been forgotten by dermatologists until Schulz and Whiting, 1 in 1976, and T6r6k and Sziics, in 1977, 2 reported excellent symptomatic improvement in a substantial number of patients who had erythema nodosum and nodular vasculitis. Their reports stimulated us to try potassium iodide in patients with various erythemateus dermatoses. Fifty-one patients with erythema nodosum, nodular vasculitis, erythema multiforme, or acute febrile neutrophilic dermatosis (Sweet's syndrome) were treated with the drug. All of these disorders responded well and very similarly to potassium iodide. The modem usage of an old drug will be From the Departmentof Dermatology,Facultyof Medicine,Kyoto University,Sakyo,Kyoto606, Japan. Acceptedfor publicationNov. 10, 1982. Reprintrequestto: Dr. TakeshiHorio,Departmentof Dermatology, Facultyof Medicine,KyotoUniversity,Sakyo,Kyoto606,Japan.
presented in this paper. The possible mechanisms of action of potassium iodide and the pathogenesis of erythematous dermatoses will also be discussed. MATERIALS AND METHODS A total of 51 patients were admitted to the trials. There were sixteen patients with erythema nodosum, eleven with nodular vasculitis, sixteen with erythema multiforme, and eight with Sweet's syndrome. Potassium iodide was administered as pills in most cases or as aqueous solution in a few. Each pill contains 100 mg of potassium iodide. After the diagnosis was made, all patients were given only potassium iodide, 300 rag, orally three times a day. Within 1 week usually 3 to 7 days after the initiation of medication, the patients were re-examined. Thereafter, the therapeutic effects of the drug were evaluated once every week or two. When no response was observed on the second examination, the medication was considered ineffective and was discontinued in most patients. 77