Journal Article Annotations
2026, 1st Quarter
Psychodermatology
Annotations by J. Jewel Shim, MD, FAPA, FACLP
March, 2026
- Prevalence of dermatologic side effects of mood stabilizers in bipolar disorder: A systematic review and meta-analysis
- Treatment Strategies for Pediatric Trichotillomania: State-of-the-Art Review on Progress and Persistent Challenges
- The brain-gut-skin axis in inflammatory and disfiguring skin diseases: mechanistic insights, clinical correlations, and therapeutic strategies
PUBLICATION #1
Prevalence of dermatologic side effects of mood stabilizers in bipolar disorder: A systematic review and meta-analysis
Francesca Pampaloni, Mete Ercis, Dawn Marie R Davis, Michela Starace, Bianca Maria Piraccini, Aysegul Ozerdem, Balwinder Singh, Mark A Frye, Jacquetta Blacker, Marin Veldic
Abstract:
Background: Mood stabilizers are commonly used in bipolar disorder (BD) but are often associated with dermatologic adverse events (AEs). This systematic review and meta-analysis investigated the prevalence and types of dermatologic AEs associated with mood stabilizers in patients with BD.
Methods: We searched Ovid MEDLINE®, Embase, Cochrane Library, Web of Science, Scopus, and PsycINFO from 1970 for studies on dermatologic AEs in BD patients treated with lithium, valproate, carbamazepine, or lamotrigine (CRD42022357268). Two reviewers handled study selection, data extraction, and bias risk assessment. Meta-analyses estimated prevalence rates for dermatologic AEs.
Results: Out of 6980 studies identified, 50 met the inclusion criteria. Lithium was associated with acneiform eruptions in 4.2 % (95 % CI: 1.0-16.2 %), rash in 1.3 % (95 % CI: 0.4-4.3 %), and hair loss in 1.9 % (95 % CI: 0.5 %-6.3 %) of patients. For valproate, hair loss was observed in 4.6 % of patients (95 % CI: 3.0-6.7 %) and rash in 2.9 % (95 % CI: 1.6-5.3 %). Carbamazepine was associated with rash in 6.0 % of patients (95 % CI: 4.4-7.6 %), but severe reactions such as Stevens-Johnson syndrome and toxic epidermal necrosis were not reported. Lamotrigine had the highest rash prevalence with 9.2 % (95 % CI: 7.2-11.8 %), while severe reactions were rare (0.04 %, 95 % CI: 0.00-0.62 %).
Limitations: Heterogeneity in study designs and outcome definitions, reliance on self-reporting or assessments by non-dermatologists, frequent use of concomitant medications.
Conclusions: Mood stabilizers showed varying levels of dermatologic AEs, but severe reactions were rare. Future studies should explore factors influencing these outcomes, their impact on quality of life and treatment participation, and potential management strategies.
Annotation
The finding: This is a systematic review of the existing literature on the dermatological side effects of various mood stabilizers in the treatment of bipolar disorder. Depending on the mood stabilizer, certain skin conditions were found to be more prevalent . For example. Lamotrigine had the highest incidence of rash. Dermatological side effects tended to occur within the first 2 months of medication administration. However, serious cutaneous reactions such as Stevens Johnson Syndrome were uncommon.
Strength and weaknesses: This is the first comprehensive review of this kind. Included studies did not account for concurrently administered psychotropic medications and thus could not quantify the contribution of these other agents to the development of the observed skin conditions. However, by the same token, the results of these studies reflect real-world practice and thus increases the generalizability of the results. The authors acknowledged significant heterogeneity in study designs, patient populations, and how outcomes were defined. Many studies relied on self-reporting or the diagnosis of the skin condition was made by a non-dermatologist physician and thus there may have been underreporting or misdiagnosis/misclassification of the cutaneous reaction. The analysis was restricted to investigations published in English, and thus may not have captured data from other geographic regions and ethnic populations, limiting the generalizability of the results.
Relevance: This study highlights the most common dermatological side effects of 4 commonly prescribed mood stabilizers for the treatment of bipolar disorder which is helpful for clinical practice.
PUBLICATION #2
Treatment Strategies for Pediatric Trichotillomania: State-of-the-Art Review on Progress and Persistent Challenges
Sheila Sharifi, Mariah Estill, Lea Tordjman, Sarah H Millan, Jessica X Ouyang
Abstract:
Trichotillomania (TTM) is a condition characterized by recurrent hair pulling, often resulting in hair loss and functional impairment. The disorder remains underreported in the pediatric population, despite high rates of psychiatric comorbidities. Moreover, diagnosing and treating TTM among children remains challenging due to a lack of standardized guidelines. Hence, this systematic review aims to evaluate the current treatment approaches for pediatric TTM. A comprehensive search was conducted of five databases, using the search concepts of trichotillomania, pediatric populations, and treatments/interventions. Studies were included if they (1) directly addressed the topic, (2) were of an appropriate study type (e.g., clinical trials, case-control studies, cohort studies, cross-sectional studies, or interview studies), (3) were published within the past 10 years, and (4) appeared in peer-reviewed journals published in English. Ultimately, 10 studies met our inclusion criteria, from which data were extracted and synthesized following formal quality assessment. Our results indicate that behavioral interventions, particularly habit reversal training, consistently demonstrated the greatest therapeutic benefit. Pharmacological treatments, including selective serotonin reuptake inhibitors, have been explored in various case series. Although some individuals have shown improvement, overall evidence remains insufficient to support pharmacotherapy as first-line. Alternative therapies, such as N-acetylcysteine, have also been studied, though findings are variable and require further investigation in pediatric cohorts. Our review underscores the importance of early behavioral intervention and the need for larger, controlled studies to inform standardized treatment protocols. Given the functional and psychosocial burden of TTM in youth, comprehensive management strategies are essential.
Keywords: pediatrics; psychodermatology; treatment; trichotillomaniacognitive behavioral therapy.
Annotation
The finding: This systematic review summarizes and evaluates the current treatment approaches for pediatric trichotillomania (TTM). Behavior interventions, specifically habit reversal training, are found to be the most effective treatment strategy and are considered the standard treatment. Dialectical behavioral therapy (DBT) and Acceptance and commitment therapy (ACT) and response inhibition training have also been found to have therapeutic benefit for pediatric TTM. Pharmacological interventions, including SSRIs and anxiolytics have thus far not shown robust benefit and the current evidence base is limited. Other therapies such as N-acetyl cysteine and milk thistle have been studied in clinical trials but have not demonstrated significant benefit in children.
Strength and weaknesses: This review summarizes the current evidence on the treatment of TTM and is a step toward conceptualizing standardized treatment guidelines. The existing literature is quite limited, however, to small trials at single sites, often unblinded and at risk for reporting bias.
Relevance: Increased knowledge of the current evidence for treatment strategies in pediatric TTM will potentially support earlier intervention and better long-term outcomes.
PUBLICATION #3
The brain-gut-skin axis in inflammatory and disfiguring skin diseases: mechanistic insights, clinical correlations, and therapeutic strategies
Zijian Guo, Jiao Yang, Rui Zang, Yixuan Yang, Qingnan Wang, Chenchen Xu
Abstract:
Emerging evidence suggests that the brain-gut-skin axis (BGSA) plays a critical role in the pathogenesis of inflammatory and disfiguring skin diseases. Conditions such as acne, atopic dermatitis, psoriasis, rosacea, vitiligo, and alopecia areata, once regarded as localized disorders driven mainly by cutaneous immune dysfunction, are now recognized as systemic conditions associated with neuroendocrine stress responses, gut microbial dysbiosis, and chronic low-grade inflammation. Mechanistic studies elucidate the intricate interorgan communication mediated by microbial metabolites (e.g., short-chain fatty acids and tryptophan derivatives), cytokine networks, neuropeptides, and hypothalamic-pituitary-adrenal (HPA) axis signaling. Building on these insights, therapeutic strategies are evolving rapidly. Microbiome-directed interventions (probiotics, postbiotics, dietary modification, and fecal microbiota transplantation), together with psychoneuroimmunological approaches, have shown potential to alleviate disease severity. Integrative therapies, including traditional herbal medicine, offer promising effects; however, we emphasize that mechanistic depth and robust clinical validation for these modalities are currently limited. This review integrates mechanistic findings, clinical correlations, and emerging therapeutic approaches, while critically distinguishing between correlation and causation. Future studies should emphasize longitudinal multi-omics analyses and standardized clinical trials to clarify causal pathways and guide precision, patient-centered management for systemic and cutaneous health.
Keywords: brain–gut–skin axis; gut microbiota; inflammatory skin diseases; integrative medicine; neuroimmunology; psychodermatology.
Annotation
The finding: This paper discusses the brain-gut-skin axis as a critical part of the development of inflammatory skin diseases. It details the mechanisms of this triangular, bidirectional network as interconnected through neuroendocrine, immune, and microbial pathways. As such, this interconnection offers potential therapeutic targets. For example, dietary interventions such as probiotics may restore microbial balance and thus mitigate skin inflammation via these pathways. Cognitive approaches such as mindfulness and CBT may moderate stress induced neuroendocrine activity and in so doing reduce systemic inflammation. Traditional herbal medicines may modulate multiple targets in this network, affecting microbial, immune and neuroendocrine pathways.
Strength and weaknesses: This review highlights the emerging thinking of inflammatory skin diseases as systemic disorders involving multiple organ systems and the central role of the gut-brain-skin axis. Current evidence is restricted to small studies with brief follow up periods, heterogeneous study populations, or cross-sectional data. There is a lack of standard measurement of psychosocial and neuroendocrine variables. Traditional herbal medicine approaches have yet to be rigorously clinically validated.
Relevance: This study extends our understanding of the development and exacerbation of inflammatory skin diseases and offers novel, integrative approaches to treating these disorders.