Cutaneous effects of the most commonly used antidepressant medication, the selective serotonin reuptake inhibitors

Cutaneous toxicity induced by antidepressants and second-generation antipsychotics in the United States food and drug administration adverse event reporting system

BACKGROUND

Adverse cutaneous drug reactions have been reported with most drugs, including antidepressants (ADs) and second-generation antipsychotics (SGAs). The lack of extensive research on the relationship between ADs and SGAs, and cutaneous toxicity remains troubling. Our study aimed to assess the cutaneous toxicity of ADs and SGAs and provide valuable insights for clinical applications and scientific investigations.

RESEARCH DESIGN AND METHODS

We conduct a pharmacovigilance study based of the United States Food and Drug Administration Adverse Event Reporting System (FAERS) database to analysis the relationship of ADs and SGAs and cutaneous adverse events. Reporting odds ratios (ROR) and information components (IC) were presented using statistical shrinkage transformation.

RESULTS

Comparing ACDRs to other ADRs, each AD (fluoxetine (ROR025 = 1.49), fluvoxamine (ROR025 = 1.14), paroxetine (ROR025 = 1.49), escitalopram (ROR025 = 1.79), sertraline (ROR025 = 1.44), venlafaxine (ROR025 = 1.46) and duloxetine (ROR025 = 1.69)) showed significantly more cases. There was no association between SGA and cutaneous toxicity. The spectrum displayed strong signals in duloxetine-induced genital ulceration (IC025 = 2.75) and amisulpride-induced conjunctivitis (IC025 = 2.56).

DISCUSSION

This study provides a valuable foundation for clinical practice and medication monitoring by thoroughly analyzing, methodically evaluating, and quantifying the potential dermal toxicity of ADs and SGAs.

An Unusual Presentation with Facial Hyperpigmentation on Escalation of the Dose of Sertraline

Background

Hyperpigmentation is a common side effect of different drugs with many of these having a well-explained mechanism and some even having a characteristic distribution. However, it is a rare side effect of sertraline, a selective serotonin reuptake inhibitor (SSRI), with only a few reported cases. In addition, there are no specific characteristics of the lesions or the risk factors. Case Summary. This is a case report of a 24-year-old male with panic disorder, who developed hyperpigmentation over the face after 5 days of increasing the dosage of sertraline to 100 mg/day. There were no other significant findings from the physical examination or investigations. The patient was treated as a case of sertraline-induced hyperpigmentation, and the dose was reduced to 75 mg/day and maintained at 50 mg/day after 1 week along with tablet propranolol 20 mg/day. He was also prescribed tablet tranexamic acid 500 mg/day and sunscreen with sun protection factor 50. The hyperpigmentation disappeared within 2 months, and the medication was gradually tapered after 7 months of treatment.

Conclusion

Hyperpigmentation is a rare but distressing side effect of sertraline. It is a potentially curable side effect if recognized early. Early recognition and intervention can decrease unnecessary investigations and treatment. There are limited studies highlighting this unusual adverse effect of this commonly used SSRI. Hence, further studies are needed to better understand various aspects of this condition including the characteristics, patients at risk, and possible management. The development of diagnostic and treatment guidelines would decrease the dilemma of identification and management.

Cutaneous Small-Vessel Vasculitis Induced by Escitalopram: A Case-Based Brief Review of the Literature

A 65-year-old male with multiple comorbidities and recently diagnosed with diabetic kidney disease developed upper and lower extremity rash following escitalopram initiation for his depressive mood. Clinical assessment and skin biopsy confirmed cutaneous small-vessel vasculitis (CSVV), prompting drug discontinuation and oral methylprednisolone therapy. The resolution of the rash was achieved within a week. This rare case of CSVV induced by escitalopram highlights the importance of timely recognition and management of drug-induced CSVV and adds to the limited literature on selective serotonin reuptake inhibitor-associated CSVV.

Assessing the effect of Alpinia galanga extract on the treatment of SSRI-induced erectile dysfunction: A randomized triple-blind clinical trial

Objective

SSRIs are considered the first line in the medical treatment of depression and anxiety disorders. One of their most common side effects, sexual dysfunction, has led many patients to discontinuing their medication and treatment course. Alpinia galanga, a plant from the ginger family, has been shown to enhance androgenic activity and sexual function. This study aimed to assess whether the addition of Alpinia galanga extract to the treatment regimen of adult males consuming SSRIs can improve SSRI-induced erectile dysfunction.

Materials and methods

This triple-blind randomized clinical trial was conducted on 60 adult males who were being treated with SSRIs at the time of the study. The participants were divided into two groups, a group of 30 people receiving 500 mg of Alpinia galanga extract and a group of 30 subjects receiving placebo. The population were re-assessed on week 2 and week 4 of the study using the international index of erectile function (IIEF), the Beck Depression Inventory, and the Beck Anxiety Inventory. In all the tests, a p-value of 0.05 was considered as the cut-off for significance.

Results

At the beginning of the study, the IIEF scores of the placebo group and the intervention group were 10.6 ± 3.8 and 11.2 ± 4.8, respectively, which were not significantly different (p-value = 0.577). By week 4 of the study, the IIEF scores of the control group and the Alpinia galanga group had increased to 13.7 ± 4.3 and 17.4 ± 3.7 respectively, which demonstrates a remarkably larger increase in the group receiving Alpinia galanga extract in comparison to the placebo group (p-value < 0.001).

Conclusion

In this study, the effect of the addition of Alpinia galanga extract to the treatment regimen of male patients using SSRIs on the sexual dysfunction experienced by this group has been promising. Similar results, if proven, can aid both patients and clinicians in making and following better treatment plans with more pleasant outcomes.

Clinical trial registration

[https://clinicaltrials.gov/], identifier [IRCT20101130005280N41].

Treatment Options for Troublesome Itch

Itch (or pruritus) is an unpleasant sensation, inducing the desire to scratch. It is also a major and distressing symptom of many skin and systemic diseases. The involvement of histamine, which is a major itch mediator, has been extensively examined. Recent studies suggest that histamine-independent pathways may play roles in chronic itch. Therefore, antihistamines are not always effective in the treatment of patients with chronic itch. The development of biologics and κ-opioid receptor (KOR) agonists has contributed to advances in the treatment of itch; however, since biologics are expensive for patients to purchase, some patients may limit or discontinue their use of these agents. Furthermore, KOR agonists need to be prescribed with caution due to risks of side effects in the central nervous system. Janus kinase (JAK) inhibitors are sometimes associated with side effects, such as infection. In this review, we summarize antidepressants, antineuralgics, cyclosporine A, antibiotics, crotamiton, phosphodiesterase 4 inhibitor, botulinum toxin type A, herbal medicines, phototherapy, and acupuncture therapy as itch treatment options other than antihistamines, biologics, opioids, and JAK inhibitors; we also explain their underlying mechanisms of action.

Alopecia associated with the use of selective serotonin reuptake inhibitors: Systematic review

We aimed to systematically review published cases of alopecia (hair loss) associated with selective serotonin reuptake inhibitors (SSRIs). Four electronic databases were searched up to November 16, 2021. Thirty-eight publications describing 71 patients with a total of 81 episodes of alopecia met inclusion criteria. Patients' age ranged from 7 to 85 years and 80.3% were female. Alopecia most commonly affected scalp (98.6%). Reported time to onset ranged from 3 days to 5 years (median: 8.6 weeks). Discontinuation of the suspected SSRI led to recovery in 63.0% of episodes. Clinicians should be aware of this possible adverse effect of SSRIs.

Selective serotonin reuptake inhibitor and serotonin-norepinephrine reuptake inhibitor associated cutaneous adverse drug reactions: A systematic review of case reports and case series

Anecdotal evidence suggests that selective serotonin reuptake inhibitors (SSRIs) and serotonin and norepinephrine reuptake inhibitors (SNRIs) cause cutaneous adverse drug reactions (CADRs). However, there is limited information on the factors associated with these occurrences. In this study, we aimed to describe the demographic, clinical and pharmacological characteristics associated with CADRs encountered by patients administered SSRIs and/or SNRIs for psychiatric diagnoses and to compare the differences in these factors between severe and non-severe CADRs. A protocol was developed a priori (PROSPERO: CRD42020204830) in line with the PRISMA guidelines. We searched PubMed/Medline, PsycINFO and SCOPUS from inception to October 2020 to identify case reports and/or case series of SSRI and SNRI associated CADRs. Additional cases were obtained from the retrieved articles' bibliography. A total of 141 articles were included in the study, documenting 173 CADRs. Females accounted for 128 (74.0%) of the analysed CADRs. The median age of the cases was 42 IQR (27; 53) with no statistically significant differences in age between males and females (P = 0.542). A total of 157 (90.8%) of the reported CADRs were associated with SSRIs, particularly fluoxetine 68 (39.5%), sertraline 30 (17.4%) and paroxetine 25 (14.5%). Non-severe CADRs and severe CADRs accounted for 23 (13.4%) and 149 (86.6%) reports respectively. No statistically significant differences were observed for gender (P = 0.616), age at onset (P = 0.493) and time to onset (P = 0.105) between non-severe CADRs and SCARs. In conclusion, CADRs following SSRIs and SNRIs disproportionately affect females in the reproductive age group compared to males and are mostly associated with SSRIs.

Psychological Aspects of Hair Disorders: Consideration for Dermatologists, Cosmetologists, Aesthetic, and Plastic Surgeons

Hair loss disorders may cause considerable distress to patients. Although many do not pose a significant medical risk, the sociocultural importance of hair is substantial. Often the extent of hair loss does not correlate to the impact on psychosocial function, thus necessitating an individualized approach. Hair loss disorders are interrelated with mental health and at times exert significant psychological percussions, and therefore, providers should address both medical and psychological aspects of treatment. This review contains a discussion of the impact on quality of life of common hair loss disorders and the psychological approaches that providers may utilize to improve care. The incorporation of psychodermatology and psychotrichology in dermatology and psychiatry residency programs is of vital importance. Dermatology and psychiatry liaison clinics may prove useful in the treatment of these patients.

Selective Serotonin Reuptake Inhibitors and Adverse Effects: A Narrative Review

Depression is the most prevalent psychiatric disorder in the world, affecting 4.4% of the global population. Despite an array of treatment modalities, depressive disorders remain difficult to manage due to many factors. Beginning with the introduction of fluoxetine to the United States in 1988, selective serotonin reuptake inhibitors (SSRIs) quickly became a mainstay of treatment for a variety of psychiatric disorders. The primary mechanism of action of SSRIs is to inhibit presynaptic reuptake of serotonin at the serotonin transporter, subsequently increasing serotonin at the postsynaptic membrane in the serotonergic synapse. The six major SSRIs that are marketed in the USA today, fluoxetine, citalopram, escitalopram, paroxetine, sertraline, and fluvoxamine, are a group of structurally unrelated molecules that share a similar mechanism of action. While their primary mechanism of action is similar, each SSRI has unique pharmacokinetics, pharmacodynamics, and side effect profile. One of the more controversial adverse effects of SSRIs is the black box warning for increased risk of suicidality in children and young adults aged 18–24. There is a lack of understanding of the complexities and interactions between SSRIs in the developing brain of a young person with depression. Adults, who do not have certain risk factors, which could be confounding factors, do not seem to carry this increased risk of suicidality. Ultimately, when prescribing SSRIs to any patient, a risk–benefit analysis must factor in the potential treatment effects, adverse effects, and dangers of the illness to be treated. The aim of this review is to educate clinicians on potential adverse effects of SSRIs.

2020 guidelines for the diagnosis and treatment of prurigo

Prurigo is a treatment-resistant skin disease characterized by multiple isolated papules/nodules that cause severe itch. Prurigo papules/nodules occur either as primary lesions or as secondary lesions due to persistent scratching. The fundamental concepts and classifications of prurigo have not been sufficiently established, and considerable confusion remains regarding this topic. Clinical guidelines for chronic prurigo in Japan were published in 2012 in an attempt to reduce confusion regarding the concepts of prurigo and to standardize laboratory tests and treatments. However, the diagnostic terms for prurigo and associated concepts have changed over time, and new forms of treatment are under development. We have, thus, updated and revised the guidelines to classify prurigo based on clinical forms and causes, and disease name classifications based on the clinical form have been further simplified, such as prurigo nodularis, prurigo chronica multiformis, and prurigo (not otherwise specified). Expressions for acute, subacute, and chronic forms are not used. These guidelines outline the current concepts and specify treatments for prurigo.

2020 guidelines for the diagnosis and treatment of cutaneous pruritus

The mechanisms underlying itch are not fully understood. Physicians usually encounter difficulty controlling itch in generalized pruritus. Since only a small percentage of patients with generalized pruritus respond to antihistamines (H₁ receptor antagonists), a variety of itch mediators and mechanisms other than histaminergic signals are considered to be involved in itch for these non-responsive patients. In 2012, we created guidelines for generalized pruritus. Those guidelines have been updated and revised to make some of the definitions, diagnostic terms, and classifications more applicable to daily clinical practice. Cutaneous pruritus as designated in these guidelines is a disease characterized by itch without an observable rash. Generalized pruritus (without skin inflammation) is defined as the presence of itch over a wide area, and not localized to a specific part of the body. This entity includes idiopathic pruritus, pruritus in the elderly, symptomatic pruritus, pregnancy-associated pruritus, drug-induced pruritus, and psychogenic pruritus. Localized pruritus (without skin inflammation) represents fixed itch localized to a specific part of the body, and includes anogenital pruritus, scalp pruritus, notalgia paresthetica, and brachioradial pruritus. These guidelines outline the current concepts and specify the diagnostic methods/treatments for cutaneous pruritus.

Kisspeptin and RF9 prevent paroxetine-induced changes in some parameters of seminal vesicle fluid in the male rats

The aim of the study was to examine possible impacts of paroxetine and agomelatine on the levels of some components that constitute the seminal vesicle fluid. As a second purpose, it was also aimed to examine how possible negative effects induced by paroxetine on seminal vesicle fluid components were affected by kisspeptin and RF9 (an RFamide-related peptide antagonist, RFRP). Forty-two male rats, aged 21 days, divided into six groups; control, sham, paroxetine, agomelatine, paroxetine + kisspeptin and paroxetine + RF9. Paroxetine (3.6 mg/kg) and agomelatine (10 mg/kg) were administrated by oral gavage. Kisspeptin (1 nmol) and RF9 (20 nmol) were administered intracerebroventricular (i.c.v). The experiments were ended on post-natal 120 days; fructose, vitamin E, sodium, potassium and magnesium levels were measured in seminal vesicle fluid. Fructose, vitamin E, magnesium and potassium levels were significantly decreased in seminal vesicle fluid from the rats treated with paroxetine but did not show significant differences following agomelatine administration. The co-administration of kisspeptin or RF9 with paroxetine prevented the paroxetine-induced negative effects on seminal vesicle fluid components. These results suggest that reduction in sperm fertilising ability caused by changes in seminal vesicle fluid can be seen in long-term antidepressant use. RF-9 and kisspeptin might have positive effects on long-term antidepressant use-induced infertility.

Ankle edema after administration of selective serotonin reuptake inhibitors

Clinical manifestations of drug-induced skin reactions include a wide range of symptoms, from mild drug-induced exanthemas to dangerous and life-threatening generalized systematic reactions. Drug-induced skin reactions to psychotropic medication are usually associated with antiepileptic drugs. However, a significant role can be assigned to selective serotonin reuptake inhibitors. We report a case of a female patient, who after approximately one month therapy with escitalopram developed a bilateral ankle edema, which resolved completely within the first week following its discontinuation. Although serious complications are rare, clinicians should be aware of severe skin complications in patients treated with antidepressants, which necessitate careful clinical monitoring and management. Individualization of pharmacotherapy is crucial, together with regular evaluation of safety and tolerance of the treatment.

Angiotensin-converting Enzyme Inhibitor and Other Drug-associated Angioedema

Nonsteroidal antiinflammatory agents, β-lactam antibiotics, non-β lactam antibiotics, and angiotensin-converting enzyme inhibitors are the most common classes of drugs that cause angioedema. Drug-induced angioedema is known to occur via mechanisms mediated by histamine, bradykinin, or leukotriene, and an understanding of these mechanisms is crucial in guiding therapeutic decisions. Nonallergic angioedema occurs in patients with genetic variants that affect metabolism or synthesis of bradykinin, substance P, prostaglandins, or leukotrienes, or when patients are taking drugs that have synergistic mechanisms. The mainstay in treatment of nonallergic drug-induced angioedema is cessation of the offending agents.

Spontaneous extracranial hemorrhagic phenomena in primary headache disorders: A systematic review of published cases

Background Head pain is a cardinal feature of primary headache disorders (PHDs) and is often accompanied by autonomic and vasomotor symptoms and/or signs. Spontaneous extracranial hemorrhagic phenomena (SEHP), including epistaxis, ecchymosis, and hematohidrosis (a disorder of bleeding through sweat glands), are poorly characterized features of PHDs. Aim To critically appraise the association between SEHP and PHDs by systematically reviewing and pooling all reports of SEHP associated with headaches. Methods Advanced searches using the PubMed/MEDLINE, Web of Science, Cochrane Library, Google Scholar, and ResearchGate databases were carried out for clinical studies by combining the terms "headache AND ecchymosis", "headache AND epistaxis", and "headache AND hematohidrosis" spanning all medical literature prior to October 10, 2015. Preferred Reporting Items for Systematic Reviews and Meta-analyses and Meta-analysis of Observational Studies in Epidemiology guidelines were applied. Results A total of 105 cases of SEHP associated with PHDs (83% migraine and 17% trigeminal autonomic cephalgias) were identified (median age 27 years, male to female ratio 1:2.3); 63% had epistaxis, 33% ecchymosis, and 4% hematohidrosis. Eighty-three percent of studies applied the International Classification of Headache Disorders diagnostic criteria. Eighty percent of the reported headaches were episodic and 20% were chronic. Twenty-four percent of studies reported recurrent episodes of SEHP. Conclusions Our results suggest that SEHP may be rare features of PHDs. Future studies would benefit from the systematic characterization of these phenomena.

Risk of Spontaneous Bruising with Concomitant Use of Nonsteroidal Antiinflammatory Drugs and Citalopram

Objective:

To report a case of spontaneous bruising with concomitant use of nonsteroidal antiinflammatory drugs (NSAIDs) and citalopram.

Case Summary:

A 34-year-old white woman with a history of chronic thrombocytopenia (baseline platelet count 120–130 × 103/μL) presented to the emergency department (ED) after noticing an increase in bruising on her upper and lower extremities. When the patient was interviewed, it was found that her dose of citalopram had been recently increased from 20 to 40 mg/day and she had started ibuprofen (dose unknown) on her own to manage rib pain approximately 1 month after the citalopram dosage increase. The patient was advised to discontinue ibuprofen and was discharged. Shortly thereafter, she was started on oxaprozin 600 mg twice daily for management of trochanteric bursitis. She returned to the ED stating that bruising occurred 1 week after she was given oxaprozin. At this visit, the patient was told to discontinue oxaprozin and naproxen 440 mg twice daily was prescribed. One week later, the patient again returned to the ED with complaints of spontaneous bruising. At this point citalopram and naproxen were discontinued and she was started on acetaminophen (dose not documented) and buspirone 10 mg twice daily. No other episodes of ecchymosis have occurred in the 8 months since this change to her drug regimen.

Discussion:

Medications that increase the risk of bleeding should be carefully administered in patients who have a low platelet count. This patient experienced bruising when her dose of citalopram was increased and an increase in bruising when she combined an NSAID with citalopram. Selective serotonin reuptake inhibitors (SSRIs) may increase antiplatelet activity of NSAIDs and could therefore increase the risk of bruising. Use of the Horn Drug Interaction Probability Scale indicated a possible interaction with concomitant use of NSAIDs and citalopram.

Conclusions:

Patients who experience NSAID- and/or SSRI-related bruising should consult their providers and alternative treatments should be considered.

Citalopram-induced subacute cutaneous lupus erythematosus -- first case and review concerning photosensitivity in selective serotonin reuptake inhibitors

OBJECTIVE

This report describes a case of subacute cutaneous lupus erythematosus (SCLE) in a patient treated with citalopram and discusses evidence linking selective serotonin reuptake inhibitors (SSRIs) to the induction of photosensitivity.

METHOD

Case report and review of published literature.

RESULTS

A 71-year-old woman with major depression developed 2 days after intake of 20 mg citalopram a strongly itching and largely dimensioned confluencing erythema with infiltrations and blisters all over the trunk with fever and malaise. Histological and laboratory investigations were consistent with the diagnosis of SCLE. After stopping citalopram intake, dermatologic symptoms significantly improved within 2 weeks. SSRIs have been associated with 14 cases of adverse cutaneous events as a result of SSRI-induced photosensitivity. No case of SSRI-induced SCLE has been described.

CONCLUSION

In clinical practice, indication and dosage of citalopram and other SSRIs should be carefully monitored. In the case of a SSRI-induced photosensitivity, medication can be switched to an antidepressant from another class.

Sibutramine (reductil®)-induced cutaneous leukocytoclastic vasculitis: a case report

A 24-year old woman presented with hemorrhagic vesicles on her legs. She had taken sibutramine (Reductil®, Abbott Labs., Seoul, South Korea) for 3 months and developed skin lesions the week before. A skin biopsy showed leukocytoclastic vasculitis with conspicuous eosinophilic infiltration of the tissue. These lesions showed improvement after discontinuation of sibutramine. However, 3 months later the skin lesions recurred on other sites on the lower extremities when the patient was rechallenged with the same drug for 2 weeks. Herein, we report the first case of necrotizing vasculitis induced by sibutramine.

Using electronic patient records to discover disease correlations and stratify patient cohorts

Electronic patient records remain a rather unexplored, but potentially rich data source for discovering correlations between diseases. We describe a general approach for gathering phenotypic descriptions of patients from medical records in a systematic and non-cohort dependent manner. By extracting phenotype information from the free-text in such records we demonstrate that we can extend the information contained in the structured record data, and use it for producing fine-grained patient stratification and disease co-occurrence statistics. The approach uses a dictionary based on the International Classification of Disease ontology and is therefore in principle language independent. As a use case we show how records from a Danish psychiatric hospital lead to the identification of disease correlations, which subsequently can be mapped to systems biology frameworks.

Text mining and information extraction can be seen as the challenge of converting information hidden in text into manageable data. We have used text mining to automatically extract clinically relevant terms from 5543 psychiatric patient records and map these to disease codes in the International Classification of Disease ontology (ICD10). Mined codes were supplemented by existing coded data. For each patient we constructed a phenotypic profile of associated ICD10 codes. This allowed us to cluster patients together based on the similarity of their profiles. The result is a patient stratification based on more complete profiles than the primary diagnosis, which is typically used. Similarly we investigated comorbidities by looking for pairs of disease codes cooccuring in patients more often than expected. Our high ranking pairs were manually curated by a medical doctor who flagged 93 candidates as interesting. For a number of these we were able to find genes/proteins known to be associated with the diseases using the OMIM database. The disease-associated proteins allowed us to construct protein networks suspected to be involved in each of the phenotypes. Shared proteins between two associated diseases might provide insight to the disease comorbidity.

Chronic pruritus in the absence of specific skin disease: an update on pathophysiology, diagnosis, and therapy

Chronic pruritus is a major and distressing symptom of many cutaneous and systemic diseases and can significantly impair the patient's quality of life. Pruritus perception is the final result of a complex network involving dedicated nerve pathways and brain areas, and an increasing number of peripheral and central mediators are thought to be involved. Itch is associated with most cutaneous disorders and, in these circumstances, its management overlaps with that of the skin disease. Itch can also occur without associated skin diseases or primary skin lesions, but only with nonspecific lesions secondary to rubbing or scratching. Chronic itch with no or minimal skin changes can be secondary to important diseases, such as neurologic disorders, chronic renal failure, cholestasis, systemic infections, malignancies, and endocrine disorders, and may also result from exposure to some drugs. The search for the cause of pruritus usually requires a meticulous step-by-step assessment involving careful history taking as well as clinical examination and laboratory investigations. Few evidence-based treatments for pruritus are available. Topical therapy, oral histamine H(1) receptor antagonists, and phototherapy with UV radiation can target pruritus elicitation in the skin, whereas antiepileptic drugs, opioid receptor antagonists, and antidepressants can block signal processing in the CNS.

Stevens-Johnson syndrome caused by combined use of lamotrigine and fluoxetine and review of the literature

Stevens-Johnson syndrome (SJS) is a rare, life-threatening acute allergic drug reaction presenting with target lesions and blebs of epidermis. Although a variety of etiologies such as infections and underlying malignancies have been implicated as potential causes of SJS, drugs remain the predominant inciting agent. This report presents a SJS case due to combined use of lamotrigine and fluoxetine. A 41-year-old man was admitted to our clinic with fever, skin eruptions (especially on the face and trunk) and lesions around the mouth. The patient’s history revealed lamotrigine and fluoxetine use during the previous three weeks for major depression. Dermatological examination revealed a typical clinical picture of SJS; his psychotropic medications were all stopped. While topical and ocular prednisolone (1mg/kg/day) cares were initiated, steroid dosage was reduced within 15 days. The condition of patient rapidly improved through this treatment. Effective management of SJS begins with prompt recognition of the entity, combined with attention to each of the major organs that may be affected, potential comorbidities and withdrawal of all potentially causative drugs. Clinicians should bear in mind the possibility that drugs with potential risk in developing SJS must be used carefully.

Bilateral ankle oedema in a patient taking escitalopram

Escitalopram (ESC) is the S-isomer of the racemic compound citalopram, and has been shown to be an efficacious treatment for major depressive disorder. Several studies or case reports are available describing its side effects, none of which however refer to its potential to induce ankle oedema. We report the case of a 69-year-old female depressed patient who, after approximately 1 month of therapy with ESC, progressively titrated up to 30 mg/day, developed a bilateral ankle oedema, which resolved completely within the first week following its discontinuation.

Aripiprazole-induced acneiform eruption

Drug-induced acneiform eruptions are inflammatory follicular reactions that resemble acne vulgaris both in morphology and distribution, which manifest clinically as papulopustules and occasionally as comedones. We report a case of a patient who developed acneiform eruptions while being treated with aripiprazole which resolved after discontinuation of aripiprazole and application of topical retinoic acid. The acneiform eruption could be explained on the basis of Type III allergic mechanism in an already sensitized individual.

The skin as a mirror of the soul: exploring the possible roles of serotonin

Serotonin (5-hydroxytryptamine; 5-HT) is an important mediator of bidirectional interactions between the neuroendocrine system and the skin. The rate of synthesis of 5-HT from l-tryptophan can be enhanced by brain-derived neuronal growth factor, cytokines, exposure to ultraviolet light and steroids. The major source of 5-HT in the skin are platelets, which, upon aggregation, release this biogenic amine. Moreover, the epidermal and dermal skin express the enzymes required for the transformation of tryptophan to 5-HT, and certain skin cells, such as melanocytes, have been demonstrated to produce 5-HT. In addition, rodent mast cells produce 5-HT, but human mast cells have not yet been fully examined in this respect. Skin cells express functionally active, membrane-bound receptors for 5-HT, as well as proteins that transport 5-HT. The interactions of 5-HT with these various proteins determines the nature, magnitude and duration of serotonergic responses. The immune and vasculature systems in the skin are traditional targets for bioregulation by 5-HT. Moreover, recent findings indicate that keratinocytes, melanocytes and dermal fibroblasts also respond to this amine in various ways. Thus, mammalian skin is both a site for the production of and a target for bioregulation by 5-HT. This indicates that agonists and antagonists directed towards specific 5-HT receptors could be useful in connection with treatment of skin diseases. Based on our increasing knowledge concerning these receptors and their plasticity, future research will focus on the development of serotonergic drugs that exert metabotrophic effects on the cells of the skin without affecting the central nervous system.