Journal Article Annotations
2025, 2nd Quarter

Psychodermatology

Annotations by J. Jewel Shim, MD, FACLP, FAPA
July, 2025

Increased Risk of Suicide Attempt in Patients With Atopic Dermatitis: A Nationwide Population-Based Cohort Study.
MRI-based neuroimaging alterations in immune-related skin diseases: a comprehensive review.
A Retrospective Review of Oral N-Acetylcysteine for Habit-Driven Cutaneous Disorders.

Of interest:

Ethical and Communicative Challenges in Informing Patients with Delusional Infestation: Insights from Moral Case Deliberation.

PUBLICATION #1 — Psychodermatology

Increased Risk of Suicide Attempt in Patients With Atopic Dermatitis: A Nationwide Population-Based Cohort Study.

Mu-Chun Lin, Sheng-Hsiang Ma, Ying-Hsuan Tai, Ying-Xiu Dai, Mu-Hong Chen, Chih-Chiang Chen

Abstract: J Clin Psychiatry. 2025 May 5;86(2):24m15590. doi: 10.4088/JCP.24m15590.

Introduction:
Atopic dermatitis (AD) is associated with an increased risk of mental illness. However, few studies have explored the association between AD and suicidal risk. This study aimed to investigate the risk of suicide attempts in patients with AD.

Methods:
Between 1997-2013, 5,169 patients with AD and 20,676 controls (1:4) matched according to age, sex, socioeconomic status, and selected comorbidities were enrolled from the Taiwan’s National Health Insurance Research Database to analyze the risk of suicide attempt.

Results:
Individuals with AD were found to have an elevated risk of suicide attempts, with an adjusted hazard ratio of 3.44 (95% CI, 1.83-6.46), compared to the control group. In the stratification analysis, the risk of suicide remained significantly higher in patients with AD of younger age, female sex, and those with cumulative systemic corticosteroid use for <30 days.

Conclusions:
Dermatologists must recognize the potential increased suicidal risk in patients with AD, especially in vulnerable groups and those with certain comorbidities. Furthermore, patients with mild AD did not have a reduced suicidal risk.

Annotation

The finding:
Atopic dermatitis (AD) has been associated with mental health disorders, particularly depression and anxiety. Previous studies have identified a possible increased prevalence of suicide in patients with AD, particularly in females, adolescents and young adults. The study aimed to explore the risk of suicide in a cohort of patients with AD. This was a nation-wide cohort study using data from the National Health Insurance (NHI) Research Database in Taiwan. The study period spanned 1997-2013, following about 5000 patients with AD and approximately 20,000 control subjects. The study investigators found an elevated risk for suicide in patients with AD as compared to the control group. Cox proportional hazards regression was used to evaluate the association between study variables and suicide attempts. This analysis revealed subjects with major depression and asthma had higher risk for suicide attempts. Younger age, female sex, and corticosteroid use less than 30 days were identified as significant risk factors for suicide attempt in the stratification analysis.

Strength and weaknesses:
The study was conducted in a homogenous population (Taiwan) limiting the generalizability of the results. The study authors also pointed out that the study excluded subjects younger than 10 years of age which is a population that generally has a higher prevalence of AD and may have other risk factors. The authors also stated that the NHI database may have coding errors.

Relevance:
The study highlights a significantly increased risk for suicide in AD patients, identifying further risk factors of younger age, female sex, comorbid asthma, and short-term corticosteroid use. These factors can be helpful in identifying higher risk populations, leading to increased screening and more opportunity for early intervention.

PUBLICATION #2 — Psychodermatology

MRI-based neuroimaging alterations in immune-related skin diseases: a comprehensive review.

Siqi Tan, Ziyan Chen, Liu Yunyao, Yang Hedan, Tong Lin

Abstract: Arch Dermatol Res. 2025 Mar 8;317(1):529. doi: 10.1007/s00403-025-04023-2.

The skin, as the largest organ in the human body, serves as the primary physical barrier and plays a crucial role in the immune defense process. Immune-related skin diseases encompass a spectrum of complex dermatological conditions characterized by aberrant immune responses, including the production of autoantibodies and dysregulation of inflammatory mediators. Growing evidence suggest a heightened prevalence of comorbid neuropsychiatric disorders among patients with immune-related skin diseases, indicative of potential shared pathogenesis. In recent years, the brain connectome, delineating the intricate network of neural connections, has gained prominence in elucidating various neurological and psychiatric conditions. Researchers have begun to investigate whether alterations in brain connectivity occur in patients with immune-related skin diseases, thereby exploring the connectome perspective in understanding the pathogenesis of these diseases. This review aims to synthesize and analyze recent neuroimaging studies about immune-related skin diseases, including systemic lupus erythematosus, psoriasis, chronic spontaneous urticaria, and atopic dermatitis. We mainly discussed the connectome studies related to these diseases and summarized the underlying mechanisms associated with their clinical manifestations, progression, and treatment. Then from our perspectives, we believe that interdisciplinary collaborations encompassing fields such as neurology, psychiatry, dermatology, and neuroimaging will be instrumental in advancing our understanding of immune-related skin diseases. Furthermore, multi-omics approaches will enable a comprehensive exploration of the molecular mechanisms underlying these neural changes, facilitating the identification of novel diagnostic biomarkers and therapeutic targets.

Annotation

The finding:
There is a body of work demonstrating the correlation between immune-mediated skin diseases and neuropsychiatric disorders, such as psoriasis and atopic dermatitis (AD). Research in the brain connectome, the network of structural and functional neural connections in the brain, has helped understand the development of various neuropsychiatric conditions. The study authors summarize and analyze the recent neuroimaging studies regarding immune-related skin diseases which describe possible alterations in brain connectivity and underlying mechanisms in these disorders. These studies include investigations in structural neuroimaging changes, resting-state fMRI findings, and task functional fMRI changes in various immune-mediated skin diseases, including systemic lupus erythematosus, psoriasis, AD, and chronic spontaneous urticaria.

Strength and weaknesses:
The study is a qualitative review of the recent literature rather than a meta-analysis or systematic review. The research in the brain connectome is relatively new and the current focus has been on identifying simple structural and functional connections, as of yet falling short of elucidating any cause and effect relationships.

Relevance:
This is an interesting study that provides more depth into understanding the etiology of immune-mediated skin disease that have a high association with mental health disorders. This is a growing area of new research that has great potential to advance the understanding of the pathogenesis of mental health disorders and offer possible novel treatment alternatives.

PUBLICATION #3 — Psychodermatology

A Retrospective Review of Oral N-Acetylcysteine for Habit-Driven Cutaneous Disorders.

Diana H Zarowin, Amy Buros Stein, Sarah E Sheppard, James R Treat.

Abstract: Pediatr Dermatol. 2025 May-Jun;42(3):560-563. doi: 10.1111/pde.15852. Epub 2025 Jan 16.

Oral N-acetylcysteine (NAC) has shown efficacy for debilitating habit-driven and neuropsychiatric disorders in small, mostly adult studies. We retrospectively evaluated the therapeutic use and safety of oral NAC in 93 children from the Children’s Hospital of Philadelphia. This study supports the use of oral NAC for habit-driven skin, hair, and nail abnormalities in pediatric patients.

xiety (e.g., through a Delphi study) and psychometrically comparing the different questionnaires.

Annotation

The finding:
This is a retrospective review of hospitalized children who were treated with N-acetylcysteine (NAC), excluding cases where NAC was used for metabolic disorders, acetaminophen toxicity, or administered for an unclear indication. Sixteen habit-driven behavioral disorders were included, though there was no significant difference in response to NAC based on diagnosis. Seventy-three percent of subjects either had complete remission of their behaviors, were significantly better, or at least somewhat better. Twenty-seven percent of patients experienced no effect. There were no subjects who had worse outcomes with NAC treatment. Patients who either remitted or were significantly better had a significantly longer period of treatment. No adverse effects were observed in the subjects.

Strength and weaknesses:
The study was conducted at a single site – tertiary care center – which may limit the generalizability of the results. The authors also pointed out that outcomes data was missing from a number of subjects. A clear conclusion of cause and effect is limited due to the retrospective nature of the study and the lack of a control group. In addition, the study investigators did not discuss the potential impact on results from confounding variables such as comorbid medical and psychiatric diagnoses as well concurrently prescribed medications.

Relevance:
This is the largest study evaluating the use of NAC in the pediatric population and further adds to the literature that NAC is a safe and potentially effective treatment for body focused repetitive behaviors in children.

PUBLICATION #4 — Psychodermatology

Ethical and Communicative Challenges in Informing Patients with Delusional Infestation: Insights from Moral Case Deliberation.

Patrick M J H Kemperman, Vanessa Saradjzada, Nienke C C VulinkMenno A De Rie, Yolande Voskes.

Abstract: Acta Derm Venereol. 2025 May 27:105:adv43511. doi: 10.2340/actadv.v105.43511.

Delusional infestation is a rare psychiatric condition where patients falsely believe they are infested by organisms, often accompanied by physical symptoms such as pruritus. Communicating the diagnosis and initiating treatment present significant challenges, as healthcare providers must balance honesty, sensitivity, and trust to avoid damaging the therapeutic relationship. This qualitative study explored ethical and communicative dilemmas through interviews and moral case deliberations with 11 multidisciplinary experts. Three themes emerged: the importance of building trust in the doctor-patient relationship, employing sensitive communication strategies, and enhancing multidisciplinary collaboration. Effective approaches include avoiding stigmatizing terminology, focusing on symptom management, and centralizing care in psychodermatology clinics. These findings provide recommendations to improve care outcomes and highlight the need for guidelines on communication strategies in the management of patients with delusional infestation.

Annotation (unstructured)

This is an interesting study addressing the ethical and communication challenges in informing patients with delusional infestation (DI) of their diagnosis, using a moral case deliberation model (MCD). MCD is a structured approach in clinical ethics that promotes systematic consideration of moral questions. Using structured interviews with a group of experts and focus groups applying the MCD model, three core tenets or values were identified in optimally working with patients with DI: building trust in the physician-patient relationship, using effective communication strategies, and the importance of multidisciplinary collaboration among various providers involved in the care of the patient. The authors summarized helpful language to engage patients in the treatment relationship and subsequent treatment planning, shifting the focus away from conflicts over specific diagnoses to an emphasis on minimizing the burdens of their symptoms.