Patient-Centered Management Strategies

During the final session on day one of the APP Institute Dermatology 2024, meeting co-chairs Lakshi Aldredge MSN, ANP-BC, DCNP, FAANP, and Cynthia Trickett, MPAS, PA-C, led a panel that reviewed appropriate patient management and the critical point of when to refer patients with complex dermatologic conditions. The session featured, John Koo, MD; Joseph Merola, MD, MMSc, FAAD, FACR; and Melissa Costner, MD, who provided valuable insights into the challenges of treating patients with chronic dermatologic issues, particularly when they intersect with psychiatric concerns.

Dr John Koo, a professor of dermatology and psychiatry at the University of California, San Francisco, brought a unique perspective to the discussion, given his dual board certifications. Dr Joseph Merola, the chair of dermatology at UT Southwestern Medical Center, added depth to the conversation with his expertise in dermatology, internal medicine, and rheumatology.

The session began by outlining the learning objectives, emphasizing the importance of a systematic approach to evaluating patients with complex dermatologic conditions, particularly those with overlapping immune-mediated issues. The panel aimed to develop comprehensive assessment plans and individualized treatment strategies based on patient-specific factors.

A challenging case was presented involving a 62-year-old woman who had been suffering from intractable itching for 3 years after a trip to Mexico. Her primary care physician had already treated her with various medications, including permethrin, lindane shampoo, and ivermectin, all of which failed to provide lasting relief. The patient believed she had contracted a parasitic infection while swimming in a river, and her condition had severely impacted her quality of life, leading to job loss and significant distress.

Dr Koo approached this case by first acknowledging the complexities of managing patients who might be experiencing delusional parasitosis, a psychiatric condition where individuals falsely believe they are infested with parasites. Instead of immediately resorting to antipsychotic medications, Dr Koo emphasized the importance of building a connection with the patient. He noted that without establishing trust, even the most appropriate treatment might be ineffective if the patient is unwilling to adhere to it.

One critical aspect Dr Koo highlighted was the distinction between fully delusional and almost delusional patients. Fully delusional patients often resist any suggestion that their condition might not be parasitic, making it crucial to tread carefully in conversations. In contrast, those who are almost delusional might be open to discussing alternative diagnoses, allowing for a more collaborative approach to treatment.

Dr Koo also stressed the importance of determining whether the delusional state is primary (spontaneous) or secondary to other factors such as drug use or underlying medical conditions. For secondary cases, referral to appropriate specialists is essential, even if the patient is resistant to it.

To effectively manage these patients, Dr Koo recommended a compassionate approach, acknowledging their suffering and expressing a genuine interest in their case. He suggested scheduling follow-up appointments at the end of the day when more time can be devoted to these complex cases. This strategy not only helps in managing time effectively but also reassures the patient that their concerns are being taken seriously.

Regarding treatment, Dr Koo discussed the use of low-dose antipsychotic medications like pimozide or risperidone. He emphasized that these medications are not prescribed as, "psych meds," but rather as effective treatments for the distressing symptoms the patient is experiencing. He also pointed out the importance of a slow and cautious tapering of these medications over several months, as patients often become very reliant on them once they start experiencing relief.

Cases like these underscore the importance of a patient-centered approach in dermatology, particularly when dealing with complex cases involving psychiatric elements. The key takeaways of the panel included the necessity of building trust, carefully assessing the patient's mental state, and managing treatment over the long term with patience and compassion. This thoughtful approach not only improves patient outcomes but also enhances the therapeutic relationship, making it easier to navigate the challenges of treating chronic dermatologic conditions.

For more meeting coverage, visit the APP Institute Dermatology 2024 newsroom.

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Reference

Trickett C, Aldredge L, Koo J, Merola J, Costner M. Next steps: appropriate patient management and when to refer. Presented at: APP Institute Dermatology; Aug 16–17, 2024; Virtual.