To the Editor: We report a case of a patient treated with lamotrigine for bipolar disorder. The patient had a long history of eczema with regular flare-ups. During lamotrigine treatment, his eczema resolved and he had no flare-ups. Case report. Mr A, a married, 53-year-old white man, had a past medical history remarkable for tobacco use, which he stopped in 1997; low serum testosterone, for which he has been treated since 2003 with topical testosterone and, since 2006, with injectable testosterone cypionate; alcoholism, for which he has been abstinent and in recovery for the past 15 years and attends Alcoholics Anonymous meetings regularly; allergies, for which he takes daily loratadine; and severe eczema. He works as a technical instructor for a medical device manufacturer. He has 2 children from a prior marriage and 2 stepchildren from his present marriage. His family history is remarkable for alcoholism and depression; his father, paternal uncle, and sister all struggle with alcohol dependence, and his mother and sister suffer from depression. At the age of 14 years, Mr A was diagnosed with eczema, also known as atopic dermatitis. At the time of this diagnosis, the patient reported having eczema “from head to toe.” Since then, his eczema would usually affect only the extensor surfaces of his elbows, knees, shoulders, and neck, for which he was treated with daily, topical steroids. He reported that stress exacerbated his eczema. During these exacerbations, the eczema involved his entire body, including his face, his entire torso, and all of his extremities. His treatment for eczema during a flare-up consisted of topical steroid creams, pimecrolimus cream, and, occasionally, oral steroids. Mr A presented in 2006 for evaluation and treatment of “depression.” Elucidation of his mental health history revealed periods of sadness, “melancholy,” lack of enthusiasm for life, insomnia, and excessive worrying. In addition, he also endorsed episodes of mood swings; periods of hypomania characterized by excessive energy and creativity; poor concentration and distractibility; and intrusive, inappropriate behavior at work. He was diagnosed with bipolar II disorder (DSM-IV criteria) and was started on 100 mg/d of lamotrigine after a 5-week titration. Since receiving lamotrigine, he had stabilization of his moods with no breakthroughs of hypomania or depressive episodes until 2007, when the dose of lamotrigine was increased to 150 mg/d to address minor breakthrough of depression and anxiety. Prior to starting lamotrigine, he was using daily topical steroids and would occasionally have flare-ups requiring pimecrolimus and oral steroids. However, for at least the past 3 years he has had complete remission/resolution of his atopic eczema. He has not needed or used daily steroid creams, and has not had an exacerbation of eczema requiring pimecrolimus or oral steroids. The patient’s current dose of lamotrigine is 150 mg/d. Mr A’s bipolar disorder has been controlled for the past 4 years, at which time he has been undergoing a regimen of lamotrigine, regular exercise, and psychotherapy. According to the DSM-IV, bipolar II disorder is characterized by …the occurrence of one or more Major Depressive Episodes accompanied by at least one Hypomanic Episode. Hypomanic Episodes should not be confused with the several days of euthymia that may follow remission of a Major Depressive Episode…. Episodes of Substance-Induced Mood Disorder (due to the direct physiological effects of a medication, other somatic treatments for depression, drugs of abuse, or toxin exposure) or of Mood Disorder Due to a General Medical Condition do not count toward a diagnosis of Bipolar II Disorder. 1(p359) Eczema is a chronic skin disorder due to a hypersensitivity reaction in the skin leading to inflammation. Eczema typically involves scaly and itchy rashes and is primarily diagnosed based on its appearance on the skin. The most common form of eczema is atopic eczema. Patients with atopic eczema have hyperirritable skin and can be sensitive to humidity. Their symptoms often tend to become worse during the winter and under periods of stress. Interestingly, Mr A reports that his eczema has been in remission without any exacerbation during the past 4 years. This outcome suggests possible stabilization/remission from atopic eczema in a recovering alcoholic who has bipolar II disorder treated with lamotrigine 150 mg/d.
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May 9, 2014
Seung-Hyun Shon + 3
Open Access