In 2018, almost one in six adults were prescribed antidepressants,1 with the number of prescriptions for antidepressants in England nearly doubling in the past decade.2 Antidepressants treat a range of conditions and, for the majority, the benefits far outweigh the potential side effects.
However, for a few, this medication can affect their skin and bodies in unexpected ways. It is estimated that skin reactions caused by psychotropic drugs are twice as frequent as those caused by other drugs.3 For these patients, it can be particularly troublesome because they are already feeling low in themselves. It is also important to consider body dysmorphic disorder (BDD) patients who are frequently prescribed antidepressants and likely to be severely impacted by any such side effect.4 As such, it is important for aesthetic practitioners to be aware of the best ways to assess and treat patients on antidepressants who may present with skin concerns.
Skin complications
Adverse cutaneous drug reactions (ACDRs) are usually mild, although life-threatening reactions can also occur. Factors such as female gender, increased age, African- American ethnicity, use of multiple medications, and the presence of a serious illness can all increase the risk of an ACDRs.5
Mild skin complications linked to antidepressants are dry skin, acne, urticaria and itching. Severe skin complications associated with antidepressant use, which are rare, include photosensitivity, erythema multiforme, Stevens-Johnson syndrome, Lyell’s Syndrome, acute generalised exanthematous pustulosis and drug-induced hypersensitivity syndrome.4 These severe skin conditions may result in prolonged hospitalisation, substantial disability, and even death.6
The most common conditions experienced are dry skin and acne. Antidepressants, particularly tricyclic antidepressants, have a strong anticholinergic effect.7 In blocking acetylcholine, it can lead to general dehydration, making the mouth, lips and skin cry out for moisture. There is very little literature which details precisely how acne is caused by antidepressants. Most articles focus primarily on selective serotonin reuptake inhibitors (SSRIs) as being a drug of cause.8,9 It is suggested that acne may be related to induced high activity in the serotonergic system at the dermal and epidermo-dermal junction area.8,9
Examination
When considering the best treatment for skin complications caused by antidepressants, it is imperative to carry out a thorough examination to determine severity in the first instance. Treatment of ACDRs should be symptomatic as long as the patient shows no other significant signs of a reaction. Any of the severe skin complications mentioned above would usually require a change in the offending medication and continued observation or referral to a dermatologist.5
When thinking about the treatment of mild ACDRs due to antidepressants, three key Features should be considered:
1. Distribution: Determine if the dry skin or acne is limited to areas of the face or more widespread across the body.
2. Severity: Most medical professionals use their clinical judgement to define the severity, but in terms of dry skin, the specific symptom sum score (SRRC) is a moderately reliable tool,10 and acne may be classed as mild, moderate or severe according to the number of comedones and lesions.11
3. Complications: Whilst dry skin is usually harmless, when not treated, it can lead to atopic dermatitis and/or infections.11 With acne, scarring and pigmentation can occur in those with deep lesions, who delay treatment or who pick and squeeze their spots.
Treatments
It is important to take a holistic approach to treatment, as often, the resolution can be found with non-prescriptive and nonpharmacological interventions. If medical intervention is required, topical therapies are generally the preferred treatment option for mild ACDRs of antidepressants, whilst oral therapy may be necessary for severe cases.
Treatment for dry skin
• Bathing and showering practices: Long showers or baths and hot water remove the natural sebum oils from the skin. I always advise my patients to limit their shower or bath to five to 10 minutes and use warm, not hot, water. Avoid harsh soaps, i.e. those containing detergents, fragrance, sodium lauryl sulfate and have a high pH, which dry the skin. Instead use those which have added oils and fats, which will leave a protective barrier on the skin to help moisturise.12 I also advise patting the skin dry. Letting the water evaporate from the skin will cause a higher loss of transepidermal water, so it is recommended to apply moisturiser shortly after bathing or showering to lock in the moisture.12,13
• Cleanser: It is essential to understand the importance of using a cleanser over an exfoliator. Whilst exfoliators have a role in removing old and dead skin, they also effect the skin barrier, leaving it dry and unprotected. Using a premium cosmeceutical cleanser should be at the heart of any skincare routine. These cleansers are well designed to rid the skin of the days’ build-up of makeup, bacteria, dead skin cells, dirt and excess oil without stripping it of those essential oils and keeping the skin hydrated. Avoid those containing the same ingredients found in harsh soaps.
• Moisturiser: Different moisturisers have different ingredients, and each may have a different mode of action. A well-designed moisturising product for damaged and dehydrated skin will contain a combination of occlusives, humectants and emollients.14 The use of a moisturiser is pivotal and systematic use will reduce the need for corticosteroid creams.
• Topical steroids: Topical steroids are usually introduced in the treatment regime after lesions do not respond to good skincare and regular use of moisturisers as monotherapy.13 The choice of topical steroid will depend on the person’s age, how severe it is and which area of the body is affected. It is important to remember that when using a topical steroid cream, advise the patient to use a moisturiser or emollient 15 minutes prior, and if using a topical steroid ointment, then to apply the ointment 15 minutes after a moisturiser or emollient.13
Treatment of acne
• Non-pharmacotherapy: It is important to advise patients to avoid over-cleaning the skin (which may cause dryness and irritation), as the acne is not caused by poor hygiene. They should avoid picking and squeezing spots as this increases the risk of scarring and pigmentation.15
• Phototherapy: The use of light in the treatment of acne is increasing, as these modalities are safe, effective and associated with no or minimal complications when appropriately used.16 It is also reported that light therapy can affect brain chemicals linked to mood and sleep, therefore easing symptoms of various type of depression.17 Therefore, serious consideration should be given to phototherapy in ACDRs from antidepressants, as it can have a positive impact on both the cause and reaction.
• Benzoyl peroxide (BPO): BPO is the most widely used topical acne treatment with significant antibacterial, antikeratolytic and comedolytic activity. Unlike antibiotics, no bacterial resistance has been noted.18
• Retinoids (topical): Topical retinoids such as tretinoin and adapalene work by causing the skin cells to turn over and die. This increase in skin cell turnover creates exfoliation, helping the pores stay clear and removing dead skin cells from the surface of the skin, preventing them from building up within hair follicles.19,20 It can also help reduce oily skin and pigmentation.
• Azelaic acid 20%: Azelaic acid has antimicrobial and anti-inflammatory properties. It can also help to reduce pigmentation, so it is particularly useful for darker-skinned patients for whom acne spots can leave persistent brown marks.21
• Oral therapy: Before starting systemic therapy, a discussion of risk vs. benefit should always be taken with the individual. As acne caused by antidepressants is thought to be linked to increased activity of the serotonergic system and found to subside following discontinuation of the antidepressant, it may be more prudent to consider changing the antidepressant.8
• Oral antibiotics: Tetracyclines are considered first line. Macrolides should generally be avoided due to high levels of resistance, but can be used if tetracyclines are contraindicated, for example, in pregnancy.15
• Oral retinoids: Oral retinoids have the same benefits as topical retinoids. They should only be considered if the patient has not responded to two different courses of antibiotics, or if they are starting to scar. Refer to a dermatologist for initiation.15
Review
I always like to arrange a follow-up with patients four to six weeks after starting treatment. It allows for a review on how the treatment is progressing, ensures the patient is tolerating the treatment plan, ensures adherence and gives the patient the opportunity to feedback and ask questions. Following this, follow-ups are arranged according to the patient’s response and outcomes.
Benefits
All that said, it should be noted that antidepressant agents can play an essential positive role in the management of a wide range of dermatologic disorders.22 Some of the psychiatric disorders that are usually comorbid with dermatological disorders and respond to antidepressants include major depressive disorder, obsessive compulsive disorder, body dysmorphic disorder and social phobia. In such cases, cutaneous symptoms may be the feature of a primary psychiatric disorder, such as cutaneous body image problems, or may be comorbid with a primary dermatological disorder, such as social phobia with psoriasis.23
SSRIs are also effective in some cases of body dysmorphic disorder, often seen in patients with cutaneous concerns, and posttraumatic stress disorder, which underlies some self-induced dermatose.22
Conclusion
Presenting complaints such as dry skin and acne are common with antidepressant use, and whilst treatment is symptomatic, it is always important to take a full medical history and take time to get to know and understand your patient. In doing so, it can help establish the best possible treatment plan, taking into consideration both pharmacological and nonpharmacological options and advice.
Patients presenting with aesthetic concerns are experiencing some degree of psychological impact, and in those taking antidepressants, it can make the treatment plan that bit more challenging.
