Depression Screening in Dermatology—Think Isotretinoin

Abstract

In Reply We appreciate the interest of Drs Rustagi and Weiss in our proposed screening guidelines for thyroid function in children with alopecia. 1 We have noted that many blood tests are performed in children with alopecia areata who have no symptoms outside of their hair loss, and so the goal of our article was to suggest a reduction in the number of patients who are being screened for thyroid disease when they present with alopecia areata. We stand by our conclusions that the specific subpopulation of patients who have both alopecia areata and trisomy 21 should undergo thyroid screening at the occurrence of new-onset alopecia areata if they have not had recent screening. The association between Down syndrome and thyroid disorders is well recognized, and patients with Down syndrome have an increased prevalence of both congenital hypothyroidism and acquired thyroid dysfunction, with hypothyroidism being most common. 2 The American Academy of Pediatrics recommends screening at age 6 months, age 12 months, and annually thereafter or at the development of new symptoms. 3 We found a statistically significant association between Down syndrome in patients with alopecia areata who also had thyroid abnormalities.The second concern raised by Rustagi and Weiss was that the patients in our study were undergoing more testing because of symptoms. Our retrospective review looked at 751 patients of whom 298 had thyroid testing. Patients who underwent thyroid testing did not differ in the severity of their disease or increased symptoms from those who did not have testing. The 298 included were as likely to undergo thyroid testing without clinical signs or symptoms of thyroid dysfunction as those who did not have testing.The third concern was about the subcategory "subclinical thyroid dysfunction." This is an entity defined broadly as patients with no symptoms, normal T4, and mild elevation in thyrotropin levels (between 4.5 and 10.0 μU/mL). In our review, these were patients without outward signs or symptoms but who were found to have small changes in thyrotropin levels when laboratory analyses were performed (7 of 59).Our screening guideline should hopefully significantly decrease the number of children (without symptoms and with a negative review of systems) who are currently undergoing thyroid testing at the occurrence of new-onset alopecia areata.

Psychiatric Adverse Events in Patients Taking Isotretinoin as Reported in a Food and Drug Administration Database From 1997 to 2017

“…Our study builds on prior papers that have called for use of Patient Health Questionnaire-2 or Patient Health Questionnaire-9 to screen for depression in patients taking isotretinoin, and we also advocate for the integration of these screening tools into the existing iPLEDGE infrastructure. These changes to the iPLEDGE system should be evaluated prospectively and in a randomized fashion to determine the benefits vs burdens of an expanded intervention.…”

Psychodermatology of acne: Dermatologist's guide to inner side of acne and management approach

“…Extra caution is required in diseases such as AV, psoriasis, atopic dermatitis, malignant melanoma, which can progress with high anxiety and depression. 36 When depression or suicidal tendency is suspected in the routine examinations of the patients, an opinion can be formed about whether a person has suicidal ideation by applying Patient Health Questionnaire-2 37 (Table 1). Table 1: Patient Health Questionnaire-2 questions and scoring conducted to reveal the tendency to depression and suicide in individuals.…”