A 26 y/o female patient presents to the pharmacy window with a prescription for an SSRI (serotonin selective reuptake inhibitor). This is not completely unusual until you notice that the prescription is from a dermatologist and the directions say take one tablet daily for hair loss. You try to consult with the patient but she's left the pharmacy window immediately after dropping off the prescription to use the ladies room to "wash her hands".

Your original thought is that this is outside the provider's normal scope of practice and the dermatologist should not be writing for this kind of drug. Being wiser than the average bear, you decide to check it out before calling the physician.

What could this physician possibly be treating? Is he just doing a favor for the patient, maybe a 'while I'm here' refill? Is there a legitimate medical reason for the dermatologist to be using an antidepressant (SSRI)?

*** THANKS to TEAM Pan for the case and Major select (Dr.) Libby Schindler for her help with the discussion and pharmacotherapy of this Case ***

Dermatologists may use SSRIs or other psychotropic meds to treat a condition called trichotillomania. Stedman's medical dictionary describes the condition as a "compulsion to pull out one's own hair." This usually is scalp hair but can include facial hair, eye brows/lashes, leg and pubic hair (ouch). DSM-IV defines this as an 'impulse control' disorder related to obsessive compulsive disorder (OCD). The disorder is characterized by heightened tension prior to the behavior, inability to resist the impulse, and the gratification immediately after the act. (FYI - The hand washing comment above was to hint at OCD. Hand washing is the most common compulsion.)

Trichotillomania is a complex disorder with a variety of possible components including familial, psychiatric, physical, emotional, developmental, and medical components. Triggers for the disorder may include abuse or emotional deprivation. Iron deficiency and increased oxytocin have been postulated as possible triggers. Estimates of the incidence of this disorder range from 0.6% to 10%. Females are affected more often than males but the incidence in males may be underestimated since male baldness is socially accepted. Average age of onset is usually in the second decade of life (about 13 y/o) but can start as early as 6 years. The later in life it occurs the poorer the prognosis and the more chronic it appears to be. Family history may include tics, habits and OCD symptoms. Patients may hide this disorder for years. It can be difficult to diagnose. Sometimes a biopsy is necessary to differentiate trichotillomania and either alopecia areata or tinea capitis. Other possible causes (skin infections, lice, iron deficiency, pruritis) must be ruled out as causes. Patients usually present with patchy bald areas but may have complete alopecia. Some patients may consume the hair when removed. Trichobezoars (hairballs) can occur after hair ingestion. These can be a serious medical condition.

Treatment may include behavioral therapy or drug therapy or both in combination. While results of placebo-controlled, double-blind studies are mixed, there are a number of case reports and open studies of serotonergic agents showing efficacy.  Fluoxetine, citalopram, sertraline, paroxetine, trazodone, clomipramine look good, Pimozide as augmentation to one of these agents may be beneficial, TCAs, MAO-Is, buspirone, clonazepam and levonorgestrel all have efficacy in case reports in the literature. SSRIs show good efficacy in the treatment of OCD so their efficacy in this disorder is expected. Clomipramine has the most evidence supporting the drug's efficacy in this disorder. While both treatments may be effective initially, some studies show decreasing efficacy over time.

REFERENCES:

- Raj Kumar, in Skin Pharmacology 1997;10:191-199. (estimates that dermatologists play a role 30-40% of dermatological manifestations of psychiatric and psychological disorders)

FROM MICROmedex:, Vol 110, 2001

This Pearl is meant for academic and educational purposes only. This Pearl is meant to raise important points regarding the safe and cost-effective pharmacotherapy of patients. It is not meant to be the definitive reference for the treatment or prophylaxis of various diseases. Although every effort is taken to ensure this Pearl is correct and factual, errors may occur. The Pharmacoeconomic Center assumes no liability for incorrect information or harm that may occur from the use of the information included in this Pearl.