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Background:
Distribution of dermatological diseases in inpatient patients with mental
disorders has been seldom studied.
Purpose: To
study the distribution of dermatological diseases in inpatient patients with
mental disorders.
Materials
and Methods One hundred and sixty nine patients with
dermatologic diseases (male: female = 90: 79, age 23-101 years-old, mean 66.4
years-old) in mental inpatient clinics were studied. The distributions were
compared with the prevalence of dermatological diseases in Japan.
Results: The
distributions of miscellaneous eczema in schizophrenia (41.0%), dementia
(27.8%), geriatric psychiatric disease (53.8%) and organic mental disorder
(83.3%) were significantly elevated compared with those without dermatological
disease patients (4.3%, 0%, 0%, 0%) (P<0.01, P<0.05, P<0.05,
P<0.05), respectively. The distributions of pressure ulcer in schizophrenia
(12.8%), dementia (33.3%) and geriatric psychiatric disease (38.5%) were
significantly elevated compared with those without dermatological disease
patients (P<0.05, P<0.05, P<0.05), respectively. In addition, the
distributions of pressure ulcer in dementia (33.3%) and geriatric psychiatric
disease (38.5%) were significantly elevated compared with those with
schizophrenia (12.8%) (P<0.05, P<0.05), respectively.
Conclusion:
Increased distribution of dermatitis and pressure ulcer in schizophrenia and
other mental disorders was found. These dermatological diseases should be kept
in mind in medical practice in inpatient patients with mental disorders..
Keywords: Dermatological
disease, Mental disorder, Dermatitis, Pressure ulcer.
INTRODUCTION
Psychodermatology includes primary dermatological diseases associated with psychosocial comorbidities and primary psychiatric disease presenting to dermatologists such as delusional infestation, body dystrophic disorder and dermatitis artifacts [1]. It is clear that patients with primary psychiatric disease presenting to dermatologists are fairly common, and that patients with chronic skin disease who experience psychosocial comorbidities are extremely common. The provision of care for such patients is sporadic across the UK and Europe, and probably globally. Dermatological disease is ubiquitous and can affect patients’ live in various ways. Dermatological diseases can have a major impact on patients’ lives in terms of psychological well-being, social functioning and everyday activities [2]. Dermatological diseases are considered to be often distributed also in patients with mental disorders. These distributions can affect not only on social functioning and everyday activities, but also on psychological well-being in these patients. However, these distribution and its effect on psychological well-being have seldom studied. The present study was undertaken to know the distribution of dermatological diseases both in inpatient clinic patients with mental disorders.
MATERIALS
AND METHODS
Methods
From 2013 January to December, patients with mental disorders in
inpatient clinics were consulted to Dermatology clinic for their dermatological
diseases. Clinical dermatological diagnoses were made by their history,
subjective complaints and cutaneous eruptions, and the patients were treated
for their dermatological diseases. All the clinical dermatological diagnoses
were made with the existence of specific cutaneous eruptions. Patients
suspicious for other diseases in each dermatological disease were excluded. All
the patients were Japanese. All of this information was described and analyzed
statistically. Age, sex, diagnoses of mental disorders, cutaneous eruptions,
disease duration, treatment for the dermatological diseases, laboratory
findings, and changes of eruptions after treatment were described every week in
each patient. Specialists for mental disorders excluded patients not suitable
for examination in dermatology clinic. Ethical committee in International
University of Health and Welfare Hospital approved this study.
The dermatological diseases were categorized as dermatitis, cutaneous
infectious diseases, cutaneous tumors, cutaneous inflammatory diseases and
exogenous cutaneous diseases. Cutaneous infectious diseases were composed of
bacterial, viral, fungal and insect infections on the skin. Cutaneous
inflammatory diseases were composed of inflammatory diseases not contained in
dermatitis and/or cutaneous infectious diseases. Exogenous cutaneous diseases
were composed of cutaneous diseases derived from exogenous artificial causes.
The distributions of these disease category in patients with mental diseases
were analyzed comparing with the prevalence of dermatological disorders in
Japan [3]. The study revealed the distribution of skin diseases among
dermatology patients in Japan, a nationwide, cross-sectional, seasonal,
multicenter study conducted in 69 university hospitals, 45 district-based
pivotal hospitals, and 56 private clinics (170 clinics in total). In each
clinic, information was collected on the diagnosis, age, and gender of all
outpatients and inpatients that visited the clinic on any one day of the second
week in each of May, August, and November 2007 and February 2008. Miscellaneous
eczema was composed of dermatitis not included in atopic dermatitis, hand
eczema, contact dermatitis and seborrheic dermatitis. Miscellaneous bacterial
infection was composed of cutaneous bacterial infection not included in acne,
impetigo contagiosum, folliculitis, erysipelas and cellulitis. Miscellaneous
nail disorders were composed of nail disorder not included in ingrown nail and
tinea unguim.
Subjects
The psychiatric hospital studied in this study had 282 beds. Hospital
wards were composed of 2 psychiatric general wards, 2 psychiatric sanatorium
and 1 ward for dementia. The hospital also had psychiatric outpatient clinic
and psychiatric daycare group home. The psychiatric hospital was composed of 9
psychiatric medical specialists. One hundred and sixty nine patients with
dermatologic diseases in inpatient clinics were as follows; male: female = 90:
79, age 23-101 years-old, mean 66.4 years-old (Table 1). The patients with mental disorders were composed of 117
schizophrenia (69.1%), 18 dementia including Alzheimer disease (10.7%), 13
geriatric mental disorder (7.7%), 7 depression (4.1%), 6 organic psychotic
disease (3.6%), 5 epilepsy (3.0%), 2 psychogenic reaction (1.2%) and one
psychosomatic disease (0.6%). More than 2 psychiatric medical specialists made
these diagnoses in these patients.
Statistical analysis
Chi-square
test with Yates’ correction was used to evaluate the difference of occurrence
rate between 2 groups.
RESULTS
The distribution of dermatological diseases
in patients with inpatient mental disorders
The
distributions of dermatological diseases in inpatient clinic were studied (Table 2). Of
eczema / dermatitis, the distribution of miscellaneous eczema (41.4%) in
patients with mental disorders showed elevated tendency compared with those in
general clinic patients (18.7%). The distribution of contact dermatitis and
seborrheic dermatitis in patients with mental disorders showed no difference
with those in general clinic patients, respectively. Of cutaneous infectious
diseases, the distribution of tinea pedis/ unguim, acne, cellulitis, skin
candidiasis, herpes zoster and scabies in patients with mental disorders showed
no differences compared with those in with general clinic patients,
respectively. Of cutaneous tumors, the distribution of tyrosis, epidermal cyst,
seborrheic dermatitis, pigmented nevus and lipoma in patients with mental
disorders showed no difference compared with those in general clinic patients,
respectively. Of cutaneous inflammatory diseases, the distribution of psoriasis
(0.6%) in patients with mental disorders showed decreased tendency compared
with those in general clinic patients (4.4%). The distribution of erythema
nodosum, idiopathic pigmentary purpura and drug eruption in patients with
mental disorders showed no difference with those in general clinic patients,
respectively. Of exogenous dermatological diseases, the distribution of
pressure ulcer (16.0%) and miscellaneous nail disorder (4.1%) in patients with
mental disorders showed increased tendency compared with those in general clinic
patients (0.9%; 0.59%), respectively. The distribution of burn, ingrown nail
and trauma in patients with mental disorders showed no difference compared with
those in general clinic patients, respectively.
The distribution of dermatological diseases
in each mental disorder
The
distributions of dermatological diseases in each mental disorder were studied(Table 3). Of dermatitis, the distributions
of miscellaneous eczema in patients with schizophrenia (41.0%) and geriatric
psychiatric disease (53.8%) showed elevated tendency compared with those in
general clinic patients (18.7%). Other distributions in other patients showed
no differences compared with those in general clinic patients. Of cutaneous
infectious diseases, the distributions of tinea pedis/unguim, acne, cellulitis,
skin candidiasis, herpes zoster and scabies in each mental disorder showed no
differences compared with those in with general clinic patients, respectively.
Of cutaneous tumors, the distribution of tyrosis, epidermal cyst, seborrheic
dermatitis, pigmented nevus and lipoma in each mental disorder showed no
difference compared with those in general clinic patients, respectively. Of
cutaneous inflammatory diseases, the distributions of psoriasis, erythema
nodosum, idiopathic pigmentary purpura and drug eruption in each mental
disorder showed no differences compared with those in general clinic patients,
respectively. Of exogenous dermatological diseases, the distributions of
pressure ulcer in patients with schizophrenia (12.8%), dementia (33.3%) and
geriatric psychiatric disease (38.5%) showed elevated tendency compared with
those in general clinic patients (0.90%), respectively. The distribution of
miscellaneous nail disorder in patients with schizophrenia (3.4%) and geriatric
psychiatric disease (7.7%) showed increased tendency compared with those in
general dermatological clinic patients (0.56%). Other distributions in other
patients showed no differences compared with those in general clinic patients.
The
distributions of dermatological diseases comparing with no dermatological
disease patients in each mental disorder were studied. The distributions of
miscellaneous eczema in patients with schizophrenia (41.0%), dementia (27.8%),
geriatric psychiatric disease (53.8%) and organic mental disorder (83.3%) were
significantly elevated compared with those without dermatological disease
patients (4.3%, 0%, 0%, 0%) (P<0.01, P<0.05, P<0.05, P<0.05),
respectively. The distributions of pressure ulcer in patients with
schizophrenia (12.8%), dementia (33.3%) and geriatric psychiatric disease
(38.5%) were significantly elevated compared with those without dermatological
disease patients (4.3%, 0%, 0%, 0%) (P<0.05, P<0.05, P<0.05), respectively.
In addition, the distributions of pressure ulcer in patients with dementia
(33.3%) and geriatric psychiatric disease (38.5%) were significantly elevated
compared with those with schizophrenia (12.8%) (P<0.05, P<0.05),
respectively.
Two
patients with psychogenic reaction presented with tinea pedis and pressure
ulcer. A patient with psychosomatic disease presented with trauma. These 3
patients in 2 kinds of mental disorders were not statistically analyzed,
because of small numbers of patients.
DISCUSSION
The present study showed elevated distribution of miscellaneous eczema, pressure ulcer and miscellaneous nail disorders in patients with schizophrenia and other mental disorders. Increased distribution of dermatitis indicated that dermatological most common disease may be overlooked in general practice of mental disorders. A study showed that exanthematous eruptions, urticaria, photosensitivity, pigmentary problems, acne, alopecia, fixed drug eruptions, and lichenoid reactions are the most common dermatologic side effects associated with the administration of psychopharmacologic agents [4]. The study may represented elevated prevalence of dermatitis with pruritic symptoms. A study showed that emollient improved the course of dermatitis including atopic dermatitis and can improved the Quality of Life (QoL) of patients and their families [5]. A trial revealed the efficacy of the product in improving parent QoL, with 80% favorable opinions in parents' declarative judgments and dermatologists' assessments. Disease activity correlated better with QoL when disease activity was less severe and disease extent correlated better with QoL than disease severity [6].
A study
indicated high comorbidity, with 20.2% of schizophrenia patients experiencing
concurrent atopic disorders (AD) [7]. Another study indicated the existence of
an association between atopic disorders in general and asthma in particular and
the risk of developing schizophrenia [8]. The study added to a growing body of
literature suggesting the possible involvement of immune processes in the
pathophysiology of schizophrenia. A population-based study of atopic disorders
showed that childhood atopic disorders increase the risk of psychotic
experiences in adolescence [9]. It is known that itch is associated with
psychological variables. In patients with AD, depression was a significant
predictor of self-rated induced itch; while agreeableness and public
self-consciousness were significant predictors of induced scratching [10].
These results implied that a special group of patients with AD might benefit
from certain psychological interventions. A study sought to determine the role
of atopic disorders in depression using data from a randomly-selected,
population-based study of men and women [11]. A study performed a
cross-sectional, questionnaire-based study to explore the relationship of
suicidal ideation, mental health problems, and social functioning with eczema
[12]. Among those with current eczema, 15.5% reported suicidal ideation compared
with 9.1% among those without eczema, significantly associated in a
multivariate model. A study determined the prevalence of injuries requiring
medical treatment in US children with allergic disease [13]. The results
suggested that the association between allergic disease and injury is
multifactorial, including being secondary to psychiatric and behavioral
disorder. Accordingly, mental disorders and dermatitis may have close
relationship, and intervention by dermatologist is mandatory.
Pressure
ulcer showed elevated distribution in patients with schizophrenia, dementia and
geriatric psychiatric disease. Pressure ulcers are the result of unrelieved
pressure, usually over a bony prominence [14]. A comprehensive team approach
can address both prevention and treatment of these recalcitrant wounds. The
presence of increasing pain may make infection of a chronic wound more likely
[15]. The increased distribution of pressure ulcer in dementia patients in the
present study showed that they have lower ability to complain symptoms
including pain. Geriatric dermatoses including pressure ulcer are a challenging
job for the physician in terms of diagnosis, management, and follow up [16]. A
retrospective medical records review of all long-term care (LTC) residents
referred to a wound consultative service was conducted to assess predictors of
6-month healing outcome [17]. A higher number of chronic ulcers and lower
hemoglobin counts increased the risk of no healing after 6 months of care. The
presence of a pressure ulcer constitutes a geriatric syndrome consisting of
multifactorial pathological conditions [18]. The accumulated effects of
impairment due to immobility, nutritional deficiency and chronic diseases
involving multiple systems predispose the aging skin of the elderly person to
increasing vulnerability. Compared with less severely demented residents,
residents with severe dementia showed more decline on measures where they still
had room for change in 2 prospective cohort studies [19]. A study showed that
persons with schizophrenia were more likely to experience the most common types
of medical injuries [20]. Improved understanding of factors related to hospital
quality of care and outcomes in this group will be important to plan
interventions to enhance patient safety for persons with schizophrenia other
patients with mental disorders.
A
meta-review was conducted to explore the risks of all-cause and suicide
mortality in major mental disorders [21]. All mental disorders had an increased
risk of all-cause mortality compared with the general population. These higher
mortality risks translate into substantial (10-20 years) reductions in life
expectancy. The excess risks of mortality and suicide in all mental disorders
justify a higher priority for the research, prevention, and treatment of the
determinants of premature death in psychiatric patients. Intervention for
dermatological diseases may prevent substantial reductions in life expectancy
and improve QoL.
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