Figure 1. Clinical Global Impression (CGI) scores at baseline and at the end of the study. The graph shows the evolution of the CGI score during treatment from a median score of 5 (P25-75) at baseline to a median score of 1 at the end of treatment (P = .01).
Figure 2. Global Barrat Impulsiveness Scale (BIS) scores at baseline and at the end of the study. The graph shows the evolution of the BIS score during treatment from a median score of 57 (P25-75) at baseline to a median score of 23 at the end of treatment (P = .01).
Tribó MJ, Rozas-Muñoz EA, Gallardo F, Casanova N, Ros-Montalban S, Bulbena A, Pujol R. Zonisamide for the Treatment of Self-inflicted Dermatoses Related to Impulse Control Disorders. Arch Dermatol. 2012;148(6):762–764. doi:10.1001/archdermatol.2011.3620
Author Affiliations: Departments of Dermatology (Drs Tribó, Rozas-Muñoz, Gallardo, and Pujol), Psychiatry (Dr Casanova, Ros-Montalban, and Bulbena), and Psychology (Dr Casanova), Hospital del Mar, Parc de Salut Mar, Barcelona, Spain.
Self-inflicted dermatoses (SIDs) related to impulse-control disorders (ICDs), which are rather common in dermatologic practice, are caused by a patient's failure to control impulses and self-inflicting lesions on the skin without rational motivation and despite negative consequences. Patients are partly conscious of the disorder and often admit to manipulation if queried.1 They may have an emotionally unstable personality or an obsessive-compulsive disorder, especially those with borderline, histrionic, and/or dependent personality subtypes. Anxiety and low stress tolerance are also common features.
Zonisamide is an anticonvulsant drug that has some structural similarities to topiramate, which has been shown to improve ICDs,2 particularly in patients with Parkinson disease.3 However, the possible therapeutic role of zonisamide in the management of SIDs-ICDs has not been evaluated.
Nine patients with SIDs-ICDs were studied. The diagnosis was established after a complete dermatologic and psychiatric evaluation by 2 of us (M.J.T. and N.C.). Failure of common treatments (ie, occlusive bandages, topical corticosteroids, antihistaminics, and antidepressants) was the rule. Four patients were treated with other concomitant treatments, and none of these was modified after starting zonisamide therapy (Table).
Psychopathologic examination revealed that all patients had active ICDs. Psychopathologic evaluation of subjects was performed at baseline and after treatment with the Spanish versions of the Clinical Global Impression (CGI) and the Barrat Impulsiveness Scale (BIS).
The CGI consists of 2 subscales, one to assess severity, the other to assess improvement. The severity evaluation was performed at the beginning and the end of the study, and the improvement scale was used to measure the improvement experienced by the patient from the start of the treatment. The BIS has a total of 30 items grouped into 3 subscales: cognitive, motor, and nonplanned impulsivity. The final score is the sum of the 3 subscales.
Treatment with zonisamide was started at a dose of 25 mg/d, and the dose was gradually increased by 25 mg every 3 days until it reached 100 or 150 mg/d. All patients completed a minimum of 3 months of treatment. The final dose was established according to tolerance.
The study was approved by the Municipal Institute of Medical Research, Parc de Salut Mar, Barcelona, Spain.
Two patients with excoriated acne responded dramatically to zonisamide after 3 and 8 months of treatment, respectively, and 4 patients with nodular prurigo and/or neurotic excoriations also showed a marked improvement after 5 to 12 months of treatment. Two of the 3 patients with trichotillomania, 1 of them with associated neurotic excoriations, showed a dramatic clinical improvement after 9 and 12 months of treatment, respectively.
We found a significant reduction in BIS severity (from a baseline median score of 5 to a median score of 1 at the end of study) (P = .01) and CGI score (from a baseline median score of 57 to a median score of 23) (P = .01) in all patients at the end of the study (Figure 1 and Figure 2).
Zonisamide was a well-tolerated treatment. One patient presented somnolence and fatigue, and the treatment was discontinued. Tingling sensation in the fingers of both hands was observed in 1 patient, and another patient presented weight loss.
Specific evaluation and classification of SIDs has improved our understanding and aided in the development of successful therapeutic strategies. Treatment of SIDs-ICDs consists mainly of behavioral measures for learning impulse control. However, inpatient psychotherapy and psychotropic drugs may also be indicated in selected patients. Low-potency antipsychotic agents and antidepressants may be helpful to improve accompanying psychopathologic symptoms.
Zonisamide, a sulfonamide analogue, has been recently approved in Europe and the United States as an adjunctive therapy for patients with partial-onset epilepsy. Several studies have supported its potential role in managing compulsive behaviors such as binge-eating disorders, obesity, and ICDs associated with Parkinson disease.3- 5 The recommended initial daily dose in patients with epilepsy is 100 to 200 mg, with a progressive increase until a maintenance dose of 400 to 600 mg/d is reached. There is no consensus about the recommended dose to treat ICDs, and both high and low doses have been used with good results.3- 5 In our study, doses of zonisamide ranging from 100 to 150 mg/d achieved a good clinical response with minimal adverse effects.
Although our results were obtained in an open treatment protocol and included a small number of subjects, the significant reduction in psychologic and skin symptoms suggests that zonisamide should be subjected to investigation in controlled trials for treatment of ICDs in skin diseases.
Correspondence: Dr Tribó, Department of Dermatology, Hospital del Mar, Parc de Salut Mar, Barcelona, Spain, Passeig Marítim 25-29, 08003 Barcelona, Spain (firstname.lastname@example.org).
Accepted for Publication: December 20, 2012.
Author Contributions: All authors had full access to all the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis. Study concept and design: Tribó. Acquisition of data: Tribó, Rozas-Muñoz, Gallardo, Casanova, and Pujol. Analysis and interpretation of data: Tribó, Casanova, Ros-Montalban, and Bulbena. Drafting of the manuscript: Tribó and Rozas-Muñoz. Critical revision of the manuscript for important intellectual content: Tribó, Gallardo, Casanova, Ros-Montalban, Bulbena, and Pujol. Statistical analysis: Tribó and Rozas-Muñoz. Administrative, technical, and material support: Casanova. Study supervision: Tribó, Gallardo, Ros-Montalban, Bulbena, and Pujol.
Financial Disclosure: None reported.