More Lessons From Dermatology......

 

I have several dermatological ailments and fortunately a very good clinic of dermatologists.  The main problems have been atopic dermatitis (eczema) that did not start until I was 65 and rosacea starting slightly later.  I have posts on the pathophysiology of these conditions at the links.  I have the predisposing factors including genetics, ethnicity (fair-skinned individuals of Celtic and northern European heritage (Fitzpatrick skin types I–II), and associated conditions (childhood and adult allergic asthma) but did not get the associated atopic dermatitis at the time.  One of my siblings had both in childhood.  My father probably had rosacea but he lived during a time when dermatology treatment was generally not done by dermatologists and quite primitive. By primitive I mean, physicians tried to excise inflammatory areas from his face instead of treating them medically like they do now.

The global prevalence of rosacea is estimated at 5.46% (4).  Women are affected more than men and peak prevalence occurs in middle age (45-60 years old).  In a study that looked at how many people were untreated – the prevalence was 12.3% in Germany and 5% in Russia.  Nearly half of those affected had not received any care in the previous year despite 1/3 endorsing a significant effect on quality of life (5).  In addition to cosmetic effects rosacea is a cause of dry eyes and other significant ocular complications and sensitive skin lowering the threshold for pain and irritation.

I was doing quite well until I needed a change in sleep apnea treatment.  Three months ago I changed from APAP to BiPAP because of an increasing AHI.  Because it was running at much higher pressure, they suggested using a mask rather than nasal CPAP.  That mask led to a flareup of rosacea that required a month of treatment with doxycycline.  But even after that treatment I was left with a 4-5 mm inflammatory nodule beneath my right eye that did not resolve. 

I saw a new dermatologist today and the conversation went something like this:

Me:  “This started about 3 months ago when I tried a CPAP mask and it caused a flare-up of rosacea.  This nodular area did not clear with doxycycline.  At about 2 weeks the area of inflammation extended up into the orbital area but stopped there ever since.

Derm:  “Are you still using the triple cream?”

Me:  “Yes twice a day.  It generally works great.”

Derm:  Inspects the area with a dermatoscope in detail and then: ’Yes, it looks like inflammation.  There may be some microabscesses in the area.  It does not look like cancer or infection.  What we need to do is try a different antibiotic for a month and then if it doesn’t clear up – do a biopsy.  I am going to prescribe cefuroxime after we make sure there are no drug interactions.  I notice you are on flecainide.  We were told never to prescribe it so I want to make sure it does not interact.”

His scribe ran a drug interaction check. I set up an appointment to see him in a month and picked up the prescription for cefuroxime.  On the way to the pharmacy, I recalled enrolling patients in a cefuroxime trial for urinary tract infections.  And then I tried to recall all of the serious side effects of cephalosporins – the class of antibiotics the cefuroxime is in.  That is just the way my mind works. 

What are the lessons about psychiatry here?  I don’t think the lessons are for psychiatrists because we know better.  The lessons are basically to counter all of the misinformation about psychiatric treatment and medications from antipsychiatrists, health and wellness influencers, and other critics who don’t seem to know very much about the field.  Here goes:

1:  Diagnoses are not easy – and experts are more likely to make them and even then most are provisional.  In all my teaching about diagnostic thinking in medicine pattern matching is a significant component.  Dermatologists and ophthalmologists are the examples I typically used comparing their diagnoses to other physicians. In this case, the question is what any other physician would have diagnosed the mark on my face as and how it would have been treated.  I have actually been there and done that and it would vary from no diagnosis or treatment to acne and metronidazole. 

2:  Transdiagnostic – yes probably – you would think the term had been invented for psychiatry in the last 10 years.  It is typically used as a criticism of categorical diagnosis as in “there are just so many transdiagnostic symptoms nothing is specific?”  The reality is there are many so-called transdiagnostic symptoms across all of medicine and many of them are more robust than psychiatric symptoms.  Rash is one of the more robust.  Rashes are transdiagnostic across the 2,000 to 3,000 conditions that produce rashes as well as within the same category.  There are many different rashes (intermediate phenotypes) presenting as rosacea for example, in this case a solitary inflammatory papule.

3:  No labs?  There is no lab test for rosacea or most dermatology conditions. They are clinical diagnoses made on that basis considering all of the findings at the time of the exam.

4:  Is there a biopsy result specific for rosacea?  This is a familiar criticism of psychiatric diagnoses – there is no specific test that rules in the diagnosis. From reference 1 below: “A skin-biopsy specimen is obtained only to rule out other diagnoses, since the histopathological features of rosacea are typically not specific to rosacea.”  Rosacea is a clinical diagnosis based on history and phenotypic criteria and no specific diagnostic test is needed to confirm it (3).

4:  Prevalence and Quality of Life Considerations – prevalence and quality of life considerations for rosacea and common psychiatric disorders is similar. 

 

Rosacea studies looked at pooled prevalence (5.46%) and geographic prevalence (Germany 2.1–12.3%, Russia 5.0%, U.K. incidence rate 1.65 per 1,000 person-years (the only study to quantify incidence) rather than interval prevalence (4-6).  Rosacea is not reported in the same intervals as psychiatric disorders because it is considered a chronic relapsing condition even though a segment of these specific psychiatric disorders has that same property.    

Although dermatology and psychiatry use different quality of life (QoL) impairment scales, in the respective disorders about 11% of rosacea patients report severe impairment and anxiety and depressive disorders report ranges of 26-85% using a cut-off of 2 standard deviations over average community ratings (7).  There are also comorbidity considerations with high percentages of rosacea patients reporting significant levels of depression and anxiety. 

5:  Under and missed diagnoses – deference to expert diagnosis is a time-honored tradition in medicine with a more recently established empirical basis. Overall diagnostic accuracy for dermatology conditions is 37-57%.  Roughly ½ of these conditions are incorrectly diagnosed in primary care compared with dermatologists (8). That rate of misdiagnoses is similar to the rate for anxiety and depressive disorders in primary care of 40-50% (9-11).

6:  Under treatment – undertreatment follows underdiagnosis in most cases, but undertreatment can also occur when the diagnosis has been established.  In the case of rosacea delayed diagnosis can lead to progressive (granulomatous) disease and ocular complications. Seborrheic dermatitis is also a frequently co-occurring condition and patients are often unaware that they have this condition as well.

Not treating depression and anxiety on a timely basis leads to similar chronicity and conditions more resistant to treatment.  It increases both the risk of suicide and self harm with chronicity. Untreated depression and anxiety are risk factors for cardiovascular disease and substance use. Chronic pain can be increased.  Both conditions are well documented causes of significant disability.

7:  Uncertain pathophysiology – The pathophysiology of most psychiatric disorders where the possible cause has been ruled out is not known.  The same is true for rosacea.  In any similar group of medical disorders there are commonly suggested hypotheses that can be grouped by general mechanism as indicated in the table below:

8:  Uncertain medication mechanism of action/placebo response -  Since the underlying pathophysiological is unknown the mechanisms of action of the recommended treatments is unknown for rosacea and psychiatric disorders.   This means that clinical trials are needed to test the efficacy and safety of treatments and clinical care follows.

Comparisons of response rates in a selection of antidepressant and rosacea medication trials show significant placebo response in both with a slightly higher response rate in the rosacea trials (66% v. 50%).  At the same time the metrics used for effect size in both tables are not comparable.  If we change to a comparable metric like Number Needed to Treat (NNT) we see ranges of 3-8 for rosacea and 4-6 for antidepressants.  On that basis it is fair to say that response rates to rosacea medication and antidepressants are generally comparable.

The strict comparison is limited by the fact that studies have different outcome measures.  Rosacea studies use a clinician rated global improvement score.  Antidepressant trials may also have a global improvement score but more likely use clinical scales like the HAM-D or MADRS.  Both types of ratings have a consensus marker for improvement but they are not calibrated against one another.    The placebo response rates may have different mechanisms.  Both may have a regression to the mean and clinical care/therapeutic alliance component but the rosacea trials can also be affected by atmospheric conditions and additional topicals that can affect skin moisture.  Rosacea trials tend to be longer than antidepressant trials (12-16 weeks versus 8-12 weeks).

There is a question of real-world effectiveness with both conditions.  It has been studied in depression (12). It was found that for MDD, there is a 90% gap between those with the diagnosis and this receiving effective treatment (41.8% receive treatment and of those only 23.2% of those diagnosed received effective treatment.)  The RISE study (5) suggests that in a screened population 80% were never previously diagnosed.  Of the 20% who were 47.5% had received no rosacea care whatsoever, and only 23.7% had received topical and/or systemic drugs suggesting similar underdiagnosis and treatment as depression.   

Whenever clinical trials of antidepressant are discussed, some critics say that the lack of hard outcomes (all-cause mortality, cause-specific mortality (MI, stroke, suicide), hospitalization) as opposed to symptom-based outcomes is a major problem.  In the comparison with rosacea – all of the outcome measures are symptom-based and no evidence that treatment prevents associated or long-term complications like rhinophyma, telangiectasia, or ocular complications.  There are register based/naturalistic studies (outside of clinical trial design) that show long term use of antidepressants reduces all cause mortality, suicidal ideation, and cardiovascular mortality (13-17).  Not all analyses degree and in some cases the argument was made that it was an antidepressant class effect (18,19).  Rosacea on the other hand has not been studied against an all cause mortality endpoint because it is not associated with increased mortality       

9: Politicalization – the only real criticism I have seen of dermatologists was comedic. In an episode of Seinfeld, Jerry was trivializing what dermatologists do until he was reminded that they diagnose and treat skin cancer.  Despite the parallels to psychiatry, they have no anti-factions or health and wellness influencers suggesting they are creating more problems than they solve or negative media coverage or high visibility criticism by experts in their own field.  The head of HHS is not suggesting their treatments are overprescribed.

There is no great agitation over dermatology – their methods or treatments despite similar levels of uncertainty and clinical methods with psychiatry.  I am not suggesting there should be.  I am suggesting that psychiatry should be approached by outsiders with the same levels of acceptance that they have for dermatology.  I am also suggesting that if you have a skin condition and nobody seems to be able to diagnose or treat it – see a dermatologist. The advice applies to a mental disorder.  See an expert in that field. 

I know this does happen but there is always a delay.  And there are always plenty of misinformation about the field.  As I have posted here before – practically all of the people I saw over my 40-year career had seen somebody else first – often many different people over a number of years before they decided to see a psychiatrist. In many cases it was a referral decision.  But most importantly – don’t believe what you read in the papers whether it is health and wellness advice or recommendations by the current Secretary of HHS. If it is a serious problem with your mental state – see the right person.

 

George Dawson, MD, DFAPA

 

1:  van Zuuren EJ. Rosacea. N Engl J Med. 2017 Nov 2;377(18):1754-1764. doi: 10.1056/NEJMcp1506630. PMID: 29091565.

2:  Frazier W, Zemtsov RK, Ge Y. Rosacea: Common Questions and Answers. Am Fam Physician. 2024 Jun;109(6):533-542. PMID: 38905551.

3:  Dirr MA, Ahmed A, Schlessinger DI, et al. Rosacea Core Domain Set for Clinical Trials and Practice: A Consensus Statement. JAMA Dermatol. 2024 Jun 1;160(6):658-666. doi: 10.1001/jamadermatol.2024.0636. PMID: 38656294.

4:  van Zuuren EJ, Arents BWM, van der Linden MMD, Vermeulen S, Fedorowicz Z, Tan J. Rosacea: New Concepts in Classification and Treatment. Am J Clin Dermatol. 2021 Jul;22(4):457-465. doi: 10.1007/s40257-021-00595-7. Epub 2021 Mar 23. PMID: 33759078; PMCID: PMC8200341.

4:  Gether L, Overgaard LK, Egeberg A, Thyssen JP. Incidence and prevalence of rosacea: a systematic review and meta-analysis. Br J Dermatol. 2018 Aug;179(2):282-289. doi: 10.1111/bjd.16481. Epub 2018 May 31. PMID: 29478264.

5:  Tan J, Schöfer H, Araviiskaia E, Audibert F, Kerrouche N, Berg M; RISE study group. Prevalence of rosacea in the general population of Germany and Russia - The RISE study. J Eur Acad Dermatol Venereol. 2016 Mar;30(3):428-34. doi: 10.1111/jdv.13556. PMID: 26915718; PMCID: PMC5067643.

6:  Hilbring C, Augustin M, Kirsten N, Mohr N. Epidemiology of rosacea in a population-based study of 161,269 German employees. Int J Dermatol. 2022 May;61(5):570-576. doi: 10.1111/ijd.15989. Epub 2021 Dec 12. PMID: 34897653.

7:  Rapaport MH, Clary C, Fayyad R, Endicott J. Quality-of-life impairment in depressive and anxiety disorders. Am J Psychiatry. 2005 Jun;162(6):1171-8. doi: 10.1176/appi.ajp.162.6.1171. PMID: 15930066.

8:  Bridges C, Morris C, McElroy JA, Quinn K, Dyer J, Becevic M. Utility of Dermatology Extension for Community Healthcare Outcomes (ECHO) sessions in the adult and paediatric population. J Telemed Telecare. 2021 Jul;27(6):376-381. doi: 10.1177/1357633X19874200. Epub 2019 Sep 16. PMID: 31526083.

9:  US Preventive Services Task Force. Screening for Depression and Suicide Risk in Adults: US Preventive Services Task Force Recommendation Statement. JAMA. 2023;329(23):2057–2067. doi:10.1001/jama.2023.9297

10:  Jackson-Triche  ME, Unützer  J, Wells  KB.  Achieving mental health equity: collaborative care.   Psychiatr Clin North Am. 2020;43(3):501-510. doi:10.1016/j.psc.2020.05.008

11:  Wang  PS, Angermeyer  M, Borges  G,  et al.  Delay and failure in treatment seeking after first onset of mental disorders in the World Health Organization’s World Mental Health Survey Initiative.   World Psychiatry. 2007;6(3):177-185.

12:  Vigo D, Haro JM, Hwang I, et al. Toward measuring effective treatment coverage: critical bottlenecks in quality- and user-adjusted coverage for major depressive disorder. Psychol Med. 2022 Jul;52(10):1948-1958. doi: 10.1017/S0033291720003797. Epub 2020 Oct 20. PMID: 33077023; PMCID: PMC9341444.

13:  Chan JKN, Solmi M, Lo HKY, Chan MWY, Choo LLT, Lai ETH, Wong CSM, Correll CU, Chang WC. All-cause and cause-specific mortality in people with depression: a large-scale systematic review and meta-analysis of relative risk and aggravating or attenuating factors, including antidepressant treatment. World Psychiatry. 2025 Oct;24(3):404-421. doi: 10.1002/wps.21354. PMID: 40948054; PMCID: PMC12434377.

14:  Lagerberg T, Fazel S, Sjölander A, Hellner C, Lichtenstein P, Chang Z. Selective serotonin reuptake inhibitors and suicidal behaviour: a population-based cohort study. Neuropsychopharmacology. 2022 Mar;47(4):817-823. doi: 10.1038/s41386-021-01179-z. Epub 2021 Sep 24. PMID: 34561608; PMCID: PMC8882171.

15:  Gusmão R, Quintão S, McDaid D, Arensman E, Van Audenhove C, Coffey C, Värnik A, Värnik P, Coyne J, Hegerl U. Antidepressant Utilization and Suicide in Europe: An Ecological Multi-National Study. PLoS One. 2013 Jun 19;8(6):e66455. doi: 10.1371/journal.pone.0066455. PMID: 23840475; PMCID: PMC3686718.

16:  Korkeila J, Salminen JK, Hiekkanen H, Salokangas RK. Use of antidepressants and suicide rate in Finland: an ecological study. J Clin Psychiatry. 2007 Apr;68(4):505-11. doi: 10.4088/jcp.v68n0403. PMID: 17474804.

17:  Pan YJ, Yeh LL. Associations between mortality and exposure to psychotropic medication: A population-based cohort study for depressive disorders. Aust N Z J Psychiatry. 2023 Sep;57(9):1253-1262. doi: 10.1177/00048674221145337. Epub 2023 Jan 11. PMID: 36629047.

18:  Zhou S, Wang C, Zhang Y. Antidepressant use and all-cause mortality in depressed individuals: A real-world cohort study. PLoS One. 2025 Jul 11;20(7):e0327844. doi: 10.1371/journal.pone.0327844. PMID: 40644427; PMCID: PMC12250549.

19:  Zhuang X, Chen W, Zhan Y, Feng X, Liu C. Antidepressant selection modifies survival in depression: A National Cohort Study Using NHANES 2005 - 2018 data. Gen Hosp Psychiatry. 2026 Jan-Feb;98:33-40. doi: 10.1016/j.genhosppsych.2025.12.001. Epub 2025 Dec 3. PMID: 41351935.

20:  Andrade C. A Primer on How to Critically Read an Observational Study on Adverse Medical Outcomes Associated With Long-Term Antidepressant Drug Use. J Clin Psychiatry. 2022 Dec 7;83(6):22f14733. doi: 10.4088/JCP.22f14733. PMID: 36479952.

21:  Egeberg A, Fowler JF Jr, Gislason GH, Thyssen JP. Nationwide Assessment of Cause-Specific Mortality in Patients with Rosacea: A Cohort Study in Denmark. Am J Clin Dermatol. 2016 Dec;17(6):673-679. doi: 10.1007/s40257-016-0217-1. PMID: 27480418.

22:  Egeberg A, Hansen PR, Gislason GH, Thyssen JP. Assessment of the risk of cardiovascular disease in patients with rosacea. J Am Acad Dermatol. 2016 Aug;75(2):336-9. doi: 10.1016/j.jaad.2016.02.1158. PMID: 27444070.