A control study of the cutaneous side effects of chronic lithium therapy

Self-care methods use for acne treatment among health science students

Introduction

The use of self-care methods, such as over-the-counter (OTC) products and complementary and alternative medicine (CAM), is common along the acne care pathway. This study aimed to explore self-care methods for acne and assess their associations with acne severity.

Methods

This cross-sectional study was conducted among university students in health programs. Convenience sampling was used to invite participants to complete a survey containing sociodemographic, clinical, and self-care-related questions. Acne diagnosis and severity were evaluated by a physician via the Global Acne Grading System (GAGS). A multivariate regression model was used to analyze the associations between variables.

Results

The final sample comprised 190 participants, with 24.2 % males and 70.8 % females. Most participants had mild acne (77.4 %) and reported positive family histories (82.1 %). Approximately one-third used OTC products (31.1 %), and nearly two-thirds used CAM (62.6 %). The most frequently used OTC products were facial cleansers (48.2 %), followed by creams and moisturizers (30.7 %) and cleansing soap (21.1 %). A lack of acne severity was the primary reason for the use of CAM. Social media (46.7 %) and the internet (46.2 %) were the most frequently reported sources of information. Acne severity was associated with OTC product use (p = 0.009) and the duration of acne (p < 0.001). Furthermore, OTC product use was associated with receiving a professional diagnosis (p < 0.001).

Conclusions

This study identified the most common OTC products and CAM used in acne and demonstrated an association between OTC product use and acne severity. Future studies should explore discussions on self-care methods in clinical consultations and the timing of using these methods throughout the care pathway. Integrating shared decision-making in clinical practice and tailoring educational interventions to patient preferences and communication channels may encourage the safe and effective use of self-care methods.

Bipolar disorder in patients with psoriasis and the impact of lithium therapy on psoriasis

There is a significant amount of research examining the link between psoriasis and common mental health disorders; however, studies on less common psychiatric disorders, such as bipolar disorder (BD), remain limited. We conducted a systematic review of studies in the PubMed and Cochrane databases that explored the relationship between BD and psoriasis. In addition, we evaluated the impact of lithium on psoriasis in patients with BD and included a quality assessment of all the studies. This review covers five studies that addressed the connection between psoriasis and psychiatric disorders, three studies on medical conditions in patients with BD, and four studies examining the effects of lithium intake on psoriasis in BD patients. We found substantial evidence supporting a link between psoriasis and BD, suggesting that psoriasis is an independent risk factor for BD. Patients with psoriasis are also more likely to use psychotropic medications. A limited number of studies indicate that lithium therapy may trigger or worsen psoriasis. We also explore the mechanisms of lithium-induced or lithium-aggravated psoriasis, highlighting the intricate interplay between lithium treatment, inositol depletion, and psoriasis in patients with BD. In a placebo-controlled, randomized study, inositol supplementation could mitigate psoriasis in patients taking lithium. Additional research is needed to evaluate the efficacy of inositol supplementation for patients with psoriasis who need to continue lithium treatment for their BD.

Efficacy and safety of drugs for psoriasis patients with mental disorders: A systematic review

BACKGROUND

The emergence of biological agents and small molecule drugs has revolutionized the treatment landscape for psoriasis, yet there remains a lack of systematic reviews elucidating the efficacy and safety of drugs for patients with psoriasis and mental disorders (MDs). The aim was to systemically evaluate the efficacy and safety of FDA-approved psoriasis drugs on MD symptoms and MD drugs on psoriasis symptoms.

METHODS

We conducted comprehensive literature searches of the PubMed, Embase, and Cochrane Library from inception to March 24, 2024, identifying 116 relevant studies for inclusion.

RESULTS

Our review encompasses 62 clinical trials and 54 case reports/series. Analyses of clinical trials revealed a positive impact of psoriasis drugs on MD, with notable exceptions including lithium and benzodiazepine receptor agonists, which exhibited adverse effects on psoriasis. Furthermore, analysis of case reports/series highlighted the efficacy of drugs such as apremilast, etanercept, infliximab, and secukinumab in ameliorating MD symptoms, contrasting with detrimental effects observed with methotrexate (MTX), cyclosporine, adalimumab, and secukinumab. Notably, tumor necrosis factor alpha (TNF-α) inhibitors and interleukin inhibitors demonstrated superior efficacy compared to conventional treatments. In the anxiety group, secukinumab showed the largest effective size as assessed by the Hospital Anxiety and Depression Scale - Anxiety (HADS-A) index; In the depression group, ixekizumab showed the largest effective size assessed by the 16-item Quick Inventory of Depressive Symptomology - Self-Report (QIDS-SR16) index.

LIMITATIONS

The extracted data cannot be meta-analyzed, as the measurement scale is not uniform.

CONCLUSIONS

This systematic review provides robust evidence regarding treatment options for individuals with psoriasis and MD, emphasizing the potential benefits of specific drugs in managing both conditions concurrently.

A Rare Phenomenon of Lithium-Associated Acne Inversa: A Case Series and Literature Review

Lithium use has been associated with dermatological issues, including psoriasis, folliculitis, and acneiform outbreaks. The lithium dosage and the therapeutic range of serum lithium levels are closely correlated with the frequency of cutaneous adverse effects. Lithium-induced acne inversa is a less well-known adverse effect, causing significant morbidity. Acne inversa (hidradenitis suppurativa) is a chronic inflammatory illness of the skin seen in the folds of the skin and face and distinguished by the presence of painful nodules and fistulas, as well as a propensity for tissue fibrosis. We report two cases of bipolar affective disorder who received long-term lithium treatment and experienced acne inversa during treatment, which subsided once the lithium was withdrawn.

The role of xenobiotics in triggering psoriasis

Psoriasis is a common inflammatory skin disease affecting approximately 2% of the world population. A complex interplay of genetic predisposition and risk factors contributes to the risk of its onset. Several xenobiotics have been implicated in the pathogenesis of psoriasis. Drugs are among the most investigated trigger factors; strong association with disease induction or exacerbation has been reported for β-blockers, lithium, NSAIDs and ACE inhibitors, all of which are commonly used in the management of various comorbidities in psoriasis patients. Furthermore, inhibitors of TNF have a well-documented potential for triggering new-onset psoriasis when used for other indications (e.g. Crohn's disease or rheumatoid arthritis), while post-marketing data have revealed the same association for ustekinumab. Several other drugs have been connected with psoriasis, but the evidence is less compelling. Smoking and alcohol have been reported to increase the risk for occurrence of psoriasis, but can also affect unfavorably the course of the disease and its response to treatment. Furthermore, exposure to secondhand smoke, especially in childhood, also mediates the risk. Emerging data now suggest that air pollution also has a detrimental effect on skin disease, including psoriasis, but this association needs further investigation. Understanding of the toxic effect of xenobiotics on the initiation and clinical course of psoriasis can contribute to its better control, as it can help with the avoidance of triggering factors and, in some cases, influence the success of pharmacological treatment. It, therefore, has an important place in the comprehensive management of psoriasis.

The Role of WNT Signaling in Mature T Cells: T Cell Factor Is Coming Home

T cell factor, the effector transcription factor of the WNT signaling pathway, was so named because of the primary observation that it is indispensable for T cell development in the thymus. Since this discovery, the role of this signaling pathway has been extensively studied in T cell development, hematopoiesis, and stem cells; however, its functional role in mature T cells has remained relatively underinvestigated. Over the last few years, various studies have demonstrated that T cell factor can directly influence T cell function and the differentiation of Th1, Th2, Th17, regulatory T cell, follicular helper CD4⁺ T cell subsets, and CD8⁺ memory T cells. In this paper, we discuss the molecular mechanisms underlying these observations and place them in the general context of immune responses. Furthermore, we explore the implications and limitations of these findings for WNT manipulation as a therapeutic approach for treating immune-related diseases.

Diagnostic and therapeutic guidelines for plaque psoriasis - Brazilian Society of Dermatology

Psoriasis is a chronic inflammatory disease that affects 1.3% of the Brazilian population. The most common clinical manifestations are erythematous, scaling lesions that affect both genders and can occur on any anatomical site, preferentially involving the knees, elbows, scalp and genitals. Besides the impact on the quality of life, the systemic nature of the disease makes psoriasis an independent risk factor for cardiovascular disease, especially in young patients with severe disease. By an initiative of the Brazilian Society of Dermatology, dermatologists with renowned clinical experience in the management of psoriasis were invited to form a work group that, in a partnership with the Brazilian Medical Association, dedicated themselves to create the Plaque Psoriasis Diagnostic and Treatment Guidelines. The relevant issues for the diagnosis (evaluation of severity and comorbidities) and treatment of plaque psoriasis were defined. The issues generated a search strategy in the Medline-PubMed database up to July 2018. Subsequently, the answers to the questions of the recommendations were devised, and each reference selected presented the respective level of recommendation and strength of scientific evidence. The final recommendations for making up the final text were worded by the coordinators.

Prevalence and Sociodemographic Profile of Lithium-induced Cutaneous Side Effects in Bipolar Affective Disorder Patients: A 1-year Prospective Observational Study in South India

OBJECTIVES

Objective in our study is i) To assess the prevalence and sociodemographic profile of cutaneous side effects in bipolar affective disorder patients (BPAD) on lithium. ii) To assess the course of pre-existing skin reactions, when patient is initiated on lithium therapy.

METHODS

Lithium induced cutaneous side effects were assessed at baseline and monthly for 6 months followed by every 2 months over a year. Dermatologist opinion obtained to diagnose and treat for each patient who developed cutaneous side effects. Data were analyzed in percentage.

RESULTS

The prevalence of lithium induced cutaneous side effects in our study is 38.46%. On analyzing the individual subtype of cutaneous lesions, acneiform eruption and hairfall were most common. The cutaneous adverse reactions on lithium are more common in early adulthood than in the late adulthood and geriatric age group and among the subtypes of skin lesion acneiform eruptions are more common among males than in females. On analyzing the course of pre-existing lesions, severe alopecia developed with pre-existing systemic lupus erythematosis.

CONCLUSION

These novel finding indicate that prevalence of lithium induced cutaneous side effects continues to be high. Hence, clinician should educate the patients before initiating lithium to improve attrition rate.

Is lithium biologically an important or toxic element to living organisms? An overview

Industrialized world is exposing living organisms to different chemicals and metals such as lithium (Li). Due to their use in common household items to industrial applications, it is imperative to examine their bioavailability. Lithium belongs to the group IA and also has wider uses such as in batteries, air conditioners to atomic reactors. Lithium occurs naturally in soil and water, mostly at low concentrations, and enters the food chain. It is not one of the essential minerals though various studies indicate that low levels of Li have beneficial effects on living organisms, whereas high levels expose them to toxicity and related detrimental effects. This review suggests that Li could be biologically important to living organism depending upon its concentration/exposure. Little is known about its biological importance and molecular understanding of its accumulation and mode of action, which might have future implications for Li's long-term effects on living organisms.

Lithium side effects and toxicity: prevalence and management strategies

Despite its virtually universal acceptance as the gold standard in treating bipolar disorder, prescription rates for lithium have been decreasing recently. Although this observation is multifactorial, one obvious potential contributor is the side effect and toxicity burden associated with lithium. Additionally, side effect concerns assuredly play some role in lithium nonadherence. This paper summarizes the knowledge base on side effects and toxicity and suggests optimal management of these problems. Thirst and excessive urination, nausea and diarrhea and tremor are rather common side effects that are typically no more than annoying even though they are rather prevalent. A simple set of management strategies that involve the timing of the lithium dose, minimizing lithium levels within the therapeutic range and, in some situations, the prescription of side effect antidotes will minimize the side effect burden for patients. In contrast, weight gain and cognitive impairment from lithium tend to be more distressing to patients, more difficult to manage and more likely to be associated with lithium nonadherence. Lithium has adverse effects on the kidneys, thyroid gland and parathyroid glands, necessitating monitoring of these organ functions through periodic blood tests. In most cases, lithium-associated renal effects are relatively mild. A small but measurable percentage of lithium-treated patients will show progressive renal impairment. Infrequently, lithium will need to be discontinued because of the progressive renal insufficiency. Lithium-induced hypothyroidism is relatively common but easily diagnosed and treated. Hyperparathyroidism from lithium is a relatively more recently recognized phenomenon.

Distressing cutaneous lesion among bipolar affective disorder patients on lithium therapy: A retrospective cross-sectional study

AIM

To assess the incidence of cutaneous lesion in bipolar affective disorder (BPAD) patients on lithium therapy. To evaluate the relationship between duration of lithium therapy, dosage of lithium, serum lithium level, and cutaneous lesions. To assess whether reduction/stoppage of dose of lithium has any change in the course of cutaneous side effects. To look for a relationship between addition of isotretinoin and the course of mood disorder.

METHODOLOGY

We retrospectively collected hospital case records of 125 consecutive BPAD patients initiated lithium therapy, assessed with inclusion and exclusion criteria. We follow up them for 2½ years for the assessment of above said aims.

RESULTS

The prevalence of skin reaction in BPAD patients with lithium therapy was 19.8%. Among patients on lithium therapy, cutaneous lesion emerged in initial 6 months and later after 1 year of treatment. Nearly 55% of patients on higher doses of lithium (1200 mg) had a cutaneous lesion. Patient on therapeutic serum level of lithium had a higher incidence of skin lesion. Out of six patients in whom dosage of lithium was reduced, three of them had reduced lesions (P = 0.6), in two patients, skin lesion increased, and one patient had no change. Among 11 patients treated with isotretinoin, only two patients had emergence of depressive symptoms.

CONCLUSION

Lithium continues to increase the incidence of multiple cutaneous lesions among BPAD patients on lithium therapy. Incidence of cutaneous side effects directly correlates with the dose of lithium and therapeutic range of serum lithium level. Altering the dose of lithium does not statistically influence the cutaneous lesion.

Relevant issues in pharmacotherapy of psycho-cutaneous disorders

Psychiatric disorders frequently co-occur with dermatological conditions and psychotropic agents may be indicated in treating the underlying psychiatric symptoms. Use of psychotropics can be associated with significant cutaneous adverse effects as well as drug interactions with pharmacological agents used in treatment of the dermatological conditions. Knowledge of indication, contraindication, side effects, and interactions of psycho-tropics is essential for the practicing dermatologist in managing psycho-dermatological conditions. This review aims at discussing relevant issues in pharmacological management of psycho-cutaneous disorders.

Endocrine disturbances related to the use of lithium

Despite recent advances in pharmacological treatment of psychiatric disorders, lithium salts remain frequently used, as they are effective and inexpensive alternatives, especially in the treatment of bipolar disorders. Their use is commonly associated with various endocrine disorders, mainly in thyroid and parathyroid function, and in mineral metabolism. This article aims at reviewing these potential endocrinopathies related to the use of lithium to make health care professionals aware and familiar with these possible complications when they follow up patients using this drug, and to make them able to monitor, identify and institute early and appropriate treatment.

A decision analysis of long-term lithium treatment and the risk of renal failure

OBJECTIVE

To establish whether lithium or anticonvulsant should be used for maintenance treatment for bipolar affective disorder (BPAD) if the risks of suicide and relapse were traded off against the risk of end-stage renal disease (ESRD).

METHOD

Decision analysis based on a systematic literature review with two main decisions: (1) use of lithium or at treatment initiation and (2) the potential discontinuation of lithium in patients with chronic kidney disease (CKD) after 20 years of lithium treatment. The final endpoint was 30 years of treatment with five outcomes to consider: death from suicide, alive with stable or unstable BPAD, alive with or without ESRD.

RESULTS

At the start of treatment, the model identified lithium as the treatment of choice. The risks of developing CKD or ESRD were not relevant at the starting point. Twenty years into treatment, lithium still remained treatment of choice. If CKD had occurred at this point, stopping lithium would only be an option if the likelihood of progression to ESRD exceeded 41.3% or if anticonvulsants always outperformed lithium regarding relapse prevention.

CONCLUSION

At the current state of knowledge, lithium initiation and continuation even in the presence of long-term adverse renal effects should be recommended in most cases.

Lithium and psoriasis: what primary care and family physicians should know

OBJECTIVE

This review focuses on the association of lithium treatment and psoriasis. The mechanism of action of lithium in causing psoriasis and the clinical presentation of psoriasis secondary to lithium treatment are considered.

DATA SOURCES

A search of the literature from 1949 to 2007 was performed using MEDLINE, with the following search terms: lithium, psoriasis, skin, dermatology, and psychodermatology.

DATA SYNTHESIS

Lithium is involved in a variety of cutaneous reactions including psoriasis, which may present as exacerbation of preexisting psoriasis, induction of de novo psoriasis, pustular psoriasis, nail changes, and psoriatic arthropathy. The appearance of psoriatic lesions may occur at normal therapeutic serum lithium levels. The refractory period for the development of psoriatic lesions is variable and generally longer in induction and shorter in exacerbation of psoriasis. Lithium-induced psoriasis is often resistant to conventional treatment modalities, and some cases may require dose reduction or discontinuation of lithium treatment.

CONCLUSION

Lithium is the mainstay of treatment in bipolar disorder and is associated with a variety of cutaneous side effects including psoriasis. Primary care providers and family physicians should be knowledgeable about the association of lithium and its dermatologic side effects. Early recognition and management could be beneficial in avoiding the issues of noncompliance and further deterioration of mood symptoms secondary to obviously disfiguring skin appearance. Primary care, psychiatry, and dermatology liaison services will prove helpful in managing these patients.

Psychiatric reactions to isotretinoin in patients with bipolar disorder

BACKGROUND

Isotretinoin (Accutane(R)) has been available for the treatment of severe cystic acne for about twenty-five years. There have been several reports of adverse psychiatric reactions to isotretinoin, including depressive symptoms and suicide. However, there have been only three case reports of patients with bipolar disorder (BD) who experienced an untoward psychiatric side effect while receiving isotretinoin treatment. In this study, the psychiatric side effects from isotretinoin were assessed in a larger group of BD patients than has previously been reported.

METHODS

A retrospective chart review of 300 BD outpatients identified ten patients treated with isotretinoin.

RESULTS

Nine of these ten patients experienced a significant worsening of mood symptoms, and three developed suicidal ideation. Eight experienced a reversal of the relapsed mood symptoms when the isotretinoin was discontinued, whether prematurely or after a full course.

LIMITATIONS

The limitations of this study include small sample size, retrospective data collection, absence of double-blind controlled design, and inability to control for spontaneous mood episodes in patients with BD.

CONCLUSIONS

These results indicate that BD patients treated with isotretinoin for acne are at risk for clinically significant exacerbation of mood symptoms, including suicidal ideation, even with concurrent use of psychiatric medicines for BD. The clinical implications of this study are especially relevant to the treatment of patients with BD because acne usually occurs during adolescence, which is often the age of onset of BD and because a common side effect of lithium (a standard treatment for BD) is acne.

Acne and systemic disease

Acne is the most common disease of the skin. It affects 85% of teenagers, 42.5% of men, and 50.9% of women between the ages of 20 and 30 years.96,97 The role of hormones, particularly as a trigger of sebum production and sebaceous growth and differentiation, is well known. Excess production of hormones, specifically androgens, GH, IGF-1, insulin, CRH, and glucocorticoids, is associated with increased rates of acne development. Acne may be a feature in many endocrine disorders, including polycystic ovary disease, Cushing syndrome, CAH, androgen-secreting tumors, and acromegaly. Other nonendocrine diseases associated with acne include Apert syndrome, SAPHO syndrome, Behçet syndrome and PAPA syndrome. Acne medicamentosa is the development of acne vulgaris or an acneiform eruption with the use of certain medications. These medications include testosterone, progesterone,steroids, lithium, phenytoin, isoniazid, vitamins B2, B6, and B12, halogens, and epidermal growth factor inhibitors. Management of acne medicamentosa includes standard acne therapy. Discontinuation of the offending drug may be necessary in recalcitrant cases. Basic therapeutic interventions for acne include topical therapy, systemic antibiotics,hormonal agents, isotretinoin, and physical treatments. Generally, the severity of acne lesions determines the type of acne regimen necessary. The emergence of drug-resistant P acnes and adverse side effects are current limitations to effective acne management.

Mood stabilizer therapy and pravastatin: higher risk for adverse skin reactions?

We report on a serious side effect in a severely depressed 55-year-old woman, who presented an erythematous pigmented skin rash on the whole body under combination treatment with antidepressants, atypical antipsychotic drugs, the mood stabilizer lithium and the lipid-lowering drug pravastatin. The skin rash effect was most probably due, in first line, to olanzapine, but the cutaneous skin condition was triggered and aggravated by pravastatin, a 3-hydoxy-3-methylglutaryl-coenzyme A-(HMG-CoA)-reductase inhibitor, and lithium medication. The allergic reaction started to develop after co-administration of pravastatin. Therefore, the combination of atypical antipsychotics with statins should be carefully monitored and the benefits and disadvantages should be balanced.

Drug-Induced Psoriasis: An Evidence-Based Overview and the Introduction of Psoriatic Drug Eruption Probability Score

Psoriasis is a common skin disorder that needs a long-term management, not only because, of its prevalence but also because of the profound impact it can have on patients quality of life. Drugs may result in exacerbation of a preexisting psoriasis, in induction of psoriatic lesions on clinically uninvolved skin in patients with psoriasis, or in precipitation of the disease in persons without family history of psoriasis or in predisposed individuals. The knowledge of the drugs that may induce, trigger, or exacerbate the disease is of primary importance in clinical practice. By reviewing the literature, there are many reports on drug-induced psoriasis, but the data are not univocal. We propose, when possible, the use of a probability score from the authors to obtain a better classification and further understanding of drug-induced psoriasis.

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.

Psychodermatology: a guide to understanding common psychocutaneous disorders

OBJECTIVE

This review focuses on classification and description of and current treatment recommendations for psychocutaneous disorders. Medication side effects of both psychotropic and dermatologic drugs are also considered.

DATA SOURCES

A search of the literature from 1951 to 2004 was performed using the MEDLINE search engine. English-language articles were identified using the following search terms: skin and psyche, psychiatry and dermatology, mind and skin, psychocutaneous, and stress and skin.

DATA SYNTHESIS

The psychotropic agents most frequently used in patients with psychocutaneous disorders are those that target anxiety, depression, and psychosis. Psychiatric side effects of dermatologic drugs can be significant but can occur less frequently than the cutaneous side effects of psychiatric medications. In a majority of patients presenting to dermatologists, effective management of skin conditions requires consideration of associated psychosocial factors. For some dermatologic conditions, there are specific demographic and personality features that commonly associate with disease onset or exacerbation.

CONCLUSIONS

More than just a cosmetic disfigurement, dermatologic disorders are associated with a variety of psychopathologic problems that can affect the patient, his or her family, and society together. Increased understanding of biopsychosocial approaches and liaison among primary care physicians, psychiatrists, and dermatologists could be very useful and highly beneficial.

Effects of lithium carbonate on rat seminiferous tubules: an ultrastructural study

Lithium salts are commonly used for treatment of bipolar disorder but prolonged treatment with therapeutic doses induces substantial toxic effects. In the present study we examined the effects of lithium carbonate on the ultrastructure of rat seminiferous tubules. Rats were exposed to lithium carbonate at doses of 35 mg/kg/day for 21 days. After lithium treatment, the tunica propria widened and folded together with convolutions of the basement membrane, myoid cells and lymphatic endothelium. In the seminiferous epithelium loss of germ cell attachment and appearance of expanded intercellular spaces between spermatogenic cells were observed. Early stages of spermatogenic cells showed nuclear protrusions or swellings because of an extensive enlargement of the outer nuclear membrane. Round spermatids exhibited abnormally shaped acrosomes and dilation of the subacrosomal space. Many abnormal, degenerated late spermatids with random orientation were seen towards the basal and adluminal compartments of the seminiferous epithelium. In addition, spermatids exhibited alteration in F-actin bundle ectoplasmic specialization and contained many mitochondria-associated granular bodies.

Canadian Network for Mood and Anxiety Treatments (CANMAT) guidelines for the management of patients with bipolar disorder: consensus and controversies

Since the previous publication of Canadian Network for Mood and Anxiety Treatments (CANMAT) guidelines in 1997, there has been a substantial increase in evidence-based treatment options for bipolar disorder. The present guidelines review the new evidence and use criteria to rate strength of evidence and incorporate effectiveness, safety, and tolerability data to determine global clinical recommendations for treatment of various phases of bipolar disorder. The guidelines suggest that although pharmacotherapy forms the cornerstone of management, utilization of adjunctive psychosocial treatments and incorporation of chronic disease management model involving a healthcare team are required in providing optimal management for patients with bipolar disorder. Lithium, valproate and several atypical antipsychotics are first-line treatments for acute mania. Bipolar depression and mixed states are frequently associated with suicidal acts; therefore assessment for suicide should always be an integral part of managing any bipolar patient. Lithium, lamotrigine or various combinations of antidepressant and mood-stabilizing agents are first-line treatments for bipolar depression. First-line options in the maintenance treatment of bipolar disorder are lithium, lamotrigine, valproate and olanzapine. Historical and symptom profiles help with treatment selection. With the growing recognition of bipolar II disorders, it is anticipated that a larger body of evidence will become available to guide treatment of this common and disabling condition. These guidelines also discuss issues related to bipolar disorder in women and those with comorbidity and include a section on safety and monitoring.

Psychiatric morbidity in psoriasis: A review

Psoriasis is a common condition, affecting 1.5-2% of the population of industrialized countries. It is important for clinicians to be aware that psoriasis can have a substantial emotional impact on an individual, which is not necessarily related to the extent of skin disease. This review examines current literature addressing the psychological and emotional aspects of psoriasis. A literature search of the MEDLINE (1966-2002) and PsycINFO (1984-2002) computer databases and bibliographies was carried out. Papers selected for the review included English language reviews and all original research relevant to the topic, in the form of randomized controlled trials, cohort studies, case-control studies, cross-over and uncontrolled clinical trials, patient surveys, quality-of-life studies, case series and case reports. Despite significant shortcomings, the available prevalence studies showed uniformly high rates of psychopathology among psoriasis sufferers. The few intervention studies available are summarized and critically discussed. Psoriasis is associated with a variety of psychological problems, including poor self esteem, sexual dysfunction, anxiety, depression and suicidal ideation. The clinical severity of the psoriasis may not reflect the degree of emotional impact of the disease. A number of psychological interventions have shown promise in recent trials. It is important that clinicians consider the psychosocial aspects of this illness.

Dermatologic drug reactions

Cutaneous drug reactions have a variety of clinical presentations. This review focuses on the most common or severe cutaneous reaction patterns. Knowledge of the clinical morphology and the most commonly associated medication aids in rapid diagnosis and institution of the appropriate therapy.

Lithium

The mode of action of the cation lithium is not well known. It is at present used as a topical drug in dermatology. Lithium inhibits many enzymes: Na/K ATPase, adenylcyclase, enzymes of the prostaglandines E1 synthesis, inositol-1-phosphatase. It is active on neutrophils et T lymphocytes, explaining in part its anti-inflammatory activity. It has a dose-dependent action on levures. It has possibly a direct inhibitory activity on DNA synthesis of herpes viruses. Lithium has a good local safety. Percutaneous penetration is weak and plasma concentrations are very much lower than that observed after oral intake. Lithium has been studied in seborrhoeic dermatitis. Its efficacy was primarily observed in psychotic patients. An assay with oral lithium did not confirmed the first observations. Topical lithium was found more efficient. Topical lithium succinate associated with zinc sulfate and lithium gluconate had a greater efficacy than placebo. Comparison with topical ketoconazole showed a non inferiority of lithium gluconate. Oral lithium also showed a reduction of symptoms' duration of herpes simplex. Cutaneous side-effects of oral lithium are frequent and numerous. Some of them may be explained by a lithium pharmacological cell activity (such as psoriasis). Teratogenicity is observed in mice and rats. Drug interactions are not expected after topical application. Irritants side effects are mainly observed after topical application; they are moderate and transitory. Lithium gluconate treatment of seborrhoeic dermatitis is a bid application during at least 8 weeks. It may be used in renal insufficiency. It is not recommended in the first trimester of pregnancy.

Cutaneous adverse effects of lithium: epidemiology and management

Acneiform eruption, psoriasis, folliculitis, and maculopapular eruption have been described as adverse reactions to lithium therapy. In controlled studies, patients treated with lithium developed more cutaneous reactions, particularly acne and psoriasis, than patients receiving other psychotropics, with a prevalence in lithium-treated patients as high as 45%. Male patients taking lithium are more susceptible to developing cutaneous reactions than their female counterparts. Lithium tends to worsen or precipitate cutaneous conditions that are characterized by the pathological findings of neutrophilic infiltration. As lithium-related cutaneous adverse effects can be distressing to patients and may affect medication compliance, attention should be paid to skin problems in patients receiving lithium therapy. Management without cessation of lithium therapy is usually feasible except in some patients with psoriasis that is resistant to treatment. Paradoxically, therapeutic effects of topically applied lithium have been noted in seborrheic dermatitis and recurrent herpes infections.

Optimizing lithium treatment in bipolar disorder: a review of the literature and clinical recommendations

While the past decade has witnessed a major proliferation of putative treatments for bipolar disorder, one medication--lithium--has proven its effectiveness through 50 years of clinical experience and scientific scrutiny. Unfortunately, because the generic compound, lithium, lacks the financial support of its newer, patented comparators, it is often neglected by clinicians who are exposed to continuing medical education (CME) and residency training programs that are heavily weighted towards the newer treatments. This article critically examines the medical literature on lithium's efficacy, anti-suicidal properties, and adverse effects. The authors present research-based recommendations for maximizing lithium's benefits and minimizing adverse effects associated with lithium in patients with bipolar disorder.