The physicians should be aware of the possibility of BS or something other than bullous pemphigoid in patients who have bullous pemphigoid-like eruptions associated with pruritic papules, which show a poor response to ste- roids and even immunosuppressants. Acknowledgments We thank Dr. Rashmi Sarkar, Department of Dermatol- ogy, Maulana Azad Medical College and LNJP Hospital, New Delhi, India, for her assistance in revising English grammatical errors in this manuscript. Ming-Chun Chen, MMS Department of Dermatology Sun Yat-sen Memorial Hospital Sun Yat-sen University Guangzhou China Di-Qing Luo, MMS Department of Dermatology Huangpu Hospital of The First Affiliated Hospital Sun Yat-sen University Guangzhou China E-mail:
[email protected];
[email protected] Funding sources: None. Conflicts of interest: None. References 1 Konishi N, Suzuki K, Tokura Y, et al. Bullous eruption associated with scabies: evidence for scabetic induction of true bullous pemphigoid. Acta Derm Venereol 2000; 80: 281–283. 2 Wu H-H, Luo D-Q. Bullous scabies. Chin J Dermatol 2012; 45: 527–528 (In Chinese). 3 Shahab RK, Loo DS. Bullous scabies. J Am Acad Dermatol 2003; 49: 346–350. 4 Rossell LG, Redonnet MS, Millet PU. Bullous scabies responding to ivermectin therapy. Actas Dermosifiliogr 2010; 101: 81–84. 5 Wozniacka A, Hawro T, Schwartz RA. Bullous scabies: a diagnostic challenge. Cutis 2008; 82: 350–352. 6 Nakamura E, Taniguchi H, Ohtaki N. A case of crusted scabies with a bullous pemphigoid-like eruption and nail involvement. J Dermatol 2006; 33: 196–201. Psychocutaneous disease: knowledge and clinical attitudes of Chilean dermatologists Editor, Many dermatological diseases have a significant psycho- somatic component. The skin and brain interact through mechanisms that strongly affect the development of skin disorders. It has been shown that dermatology patients have a higher prevalence of psychiatric symptoms than the general population.1,2 Despite increasing evidence and awareness of the psychosomatic component involved in skin diseases, recent studies have shown dermatologists lack knowledge in psychodermatology.3 In addition, the need for the best collaboration of dermatology and psy- chiatry specialists in handling psychodermatology patients is often analyzed and discussed.4 The purpose of this investigation was to assess the level of training in, and knowledge and awareness of, psychocutaneous diseases in Chile. A semi-quantitative transversal study was con- ducted based on a questionnaire that was sent out and returned by e-mail. It was sent to 232 dermatologist mem- bers of the Chilean Society of Dermatology. A total of 102 (44%) dermatologists responded. Of these dermatolo- gists, 76% considered psychocutaneous presentations to occur frequently in their patients (Table 1). The diseases most likely to have an emotional component were psoria- sis (24%), alopecia areata (11%), vitiligo (10%), and ato- pic dermatitis (8%). With the exception of hyperhidrosis, these diseases reflect those indicated by Jafferany et al.3 who conducted similar research in the USA. This differ- ence may be explained by a lower rate of consultation for hyperhidrosis in Chile than in the USA. According to our findings, 77% of respondents frequently discuss emotional issues with their patients, but only 41% feel confident in dealing with them; these results are in full agreement with those of the earlier investigation.3 Of our respondents, only 12% prescribed drugs for psychological or psychia- tric issues. A total of 81% of the Chilean dermatologists in our study reported that they had only limited training in dealing with these types of disease, a higher percentage than the 49% reported by Jafferany et al.3 This may be explained by differences between the USA and Chile in the training of dermatologists. By contrast, 50% of the Chilean dermatologists in our study said they would be interested in continuing medical education in psychoder- matology, which is higher than the 39% reported by Jaf- ferany et al.3 Our results are in general agreement with those of the authors of the earlier investigation, who reported that ‘‘the majority of dermatologists have lim- ited knowledge about cutaneous disorders with psycho- logic components, but most want to learn more.’’3 Furthermore, another investigation on the same subject, performed in Wisconsin, USA, found that training during International Journal of Dermatology 2014, 53, e240–e316 ª 2013 The International Society of Dermatology Correspondencee266 medical school and dermatology residency was insuffi- cient for professionals to feel confident in prescribing psy- chotropic medications.5 In this study, 88% of respondents reported that they did not feel comfortable in prescribing antidepressants, and 88% did not feel com- fortable in prescribing antipsychotics.5 The present report marks the first study of its kind in Chile. It is limited by the low response rate to the survey and by the fact that Chilean dermatologists who have a special interest in psy- chodermatology would have been more likely to respond. Subsequent to appropriate educational changes, it will be interesting to measure these data in future generations of dermatologists. Leoncio U. Mu~noz, MD Perla H. Calder�on, MD Ariel L. Castro Viviana D. Zemelman, MSc Department of Dermatology Clinical Hospital of the University of Chile Santiago Chile E-mail:
[email protected] References 1 Woodruff PWR, Higgins EM, Du Vivier AWP, et al. Psychiatric illness in patients referred to a dermatology– psychiatric clinic. Gen Hosp Psychiatry 1997; 19: 29–35. 2 Wessely SC, Lewis GH. The classification of psychiatric morbidity in attenders at a dermatology clinic. Br J Psychiatry 1989; 155: 686–691. 3 Jafferany M, van der Stoep A, Dumitrescu A, et al. The knowledge, awareness, and practice patterns of dermatologists toward psychocutaneous disorders: results of a survey study. Int J Dermatol 2010; 49: 784–789. 4 Mercan S, Altunay IK. Psychodermatology: a collaboration between psychiatry and dermatology. Turk J Psychiatry 2006; 17: 305–313. 5 Kawahara T, Henry L, Mostaghimi L. Needs assessment survey of psychocutaneous medicine. Int J Dermatol 2009; 48: 1066–1070. Ziprasidone-induced hypersensitivity syndrome confirmed by reintroduction Editor, Drug hypersensitivity syndrome (HS) is a potentially fatal adverse event and is most commonly associated with the administration of anticonvulsants, allopurinol, long- acting sulfonamides, dapsone, and minocycline.1 Charac- teristic clinical and biological manifestations include fever, facial edema, erythroderma followed by an exfolia- tive dermatitis, lymphadenopathy, eosinophilia, atypical circulating lymphocytes, and abnormal results of liver function tests. Numerous systemic manifestations may also occur, including pneumonitis, pancreatitis, renal fail- ure, neurologic symptoms, and many others.1 Ziprasidone has been approved and prescribed for the treatment of schizophrenia, for acute manic and mixed episodes, and as maintenance therapy for people affected by bipolar disorder.2 Only one case of ziprasidone-induced HS has been reported.3 To our knowledge, this is the first report of a case of ziprasidone-induced HS confirmed by reintroduction. A 33-year-old, well-nourished, married woman with no significant medical history was admitted to a psychiatric ward with a history suggestive of bipolar II disorder. The patient was initially treated with lithium carbonate (600 mg/d) and ziprasidone (80 mg/d). The results of lab- oratory examinations were within normal limits at the beginning of the treatment. After three weeks, the patient developed a temperature of 39.7 °C and a pruritic skin rash. Physical examination demonstrated generalized mor- billiform exanthem, pronounced facial edema, and cervi- cal lymphadenopathy. The hematological report showed a Table 1 Summary of data derived from responses to a survey of dermatologists in Chile (response rate 44%, n = 102/232) Frequency of psychodermatology in clinical practice % Frequent 75 Rare 24 Don’t know/no answer 1 Level of comfort in managing psychocutaneous disease Very comfortable 10 Comfortable 31 Uncomfortable 14 Very uncomfortable 2 Neutral 43 Prescription of psychotropic drugs Frequent 12 Rarely 56 Never 30 Don’t know/no answer 2 Adequacy of practices learned during residency for managing patients with psychocutaneous disease Adequate 19 Poor 80 Too much 1 Interested in continuing medical education on psychodermatology Yes 50 May be 40 No 10 ª 2013 The International Society of Dermatology International Journal of Dermatology 2014, 53, e240–e316 Correspondence e267