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pres.layout = "LAYOUT_16x9";
pres.author = "Dermatology Conference 2026";
pres.title = "Psychopharmacology for Psychodermatological Conditions";

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// ─── HELPERS ─────────────────────────────────────────────────────────────────
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// ─── SLIDE 1 – TITLE ─────────────────────────────────────────────────────────
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    { text: "Dermatology Conference 2026", options:{ breakLine:true } },
    { text: "Incorporating: BAD Guidelines 2022 • EADV 2024 • Cochrane Reviews", options:{ breakLine:true } },
    { text: "Turk T et al. J Cutan Med Surg 2023; Hoffman J et al. Cochrane 2021", options:{} },
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  s.addNotes("Welcome to this presentation on psychopharmacology for psychodermatological conditions. This session bridges psychiatry and dermatology, presenting evidence-based pharmacological approaches for primary psychodermatoses and psychosomatic skin conditions. We will cover: disease classification, drug mechanisms, RCT evidence, comparison tables, and clinical pearls.\n\nREFERENCE: Katamanin O, Sharifi S, Jafferany M. Psychopharmacology in Dermatology. Indian Dermatol Online J. 2026;17(2). PMID:41717925");
}

// ─── SLIDE 2 – LEARNING OBJECTIVES ──────────────────────────────────────────
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  footerBar(s);

  const objs = [
    "Classify psychodermatological conditions using Koo's framework",
    "Identify first-line and second-line psychotropic agents for each disorder",
    "Explain mechanisms of action relevant to skin-brain axis pharmacology",
    "Interpret RCT evidence and systematic review data for drug efficacy",
    "Apply BAD 2022 guidelines for delusional infestation management",
    "Recognise dermatologically relevant adverse effects of psychotropics",
    "Initiate a safe prescribing approach or appropriate psychiatric referral",
  ];

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  s.addNotes("Briefly walk through the learning objectives. Emphasise that dermatologists are often the first point of contact for patients with psychocutaneous disorders — over 30% of dermatology patients have a comorbid psychiatric condition (Kaplan & Sadock's Comprehensive Textbook of Psychiatry, 10th ed, p.7307).\n\nREFERENCE: Christensen RE, Jafferany M. Unmet Needs in Psychodermatology: A Narrative Review. CNS Drugs. 2024;38(3). PMID:38386200");
}

// ─── SLIDE 3 – KOO CLASSIFICATION ────────────────────────────────────────────
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  titleBar(s, "Koo Classification of Psychodermatological Disorders", "Kaplan & Sadock's Comprehensive Textbook of Psychiatry, 10th ed.");
  footerBar(s);

  const cats = [
    { label:"1. Psychophysiological", color:C.teal, examples:"Psoriasis, Atopic Dermatitis, Rosacea, Urticaria, Alopecia Areata", note:"Bona fide skin disorders exacerbated by stress" },
    { label:"2. Primary Psychiatric", color:C.red, examples:"Delusional Parasitosis, Trichotillomania, Excoriation Disorder, Dermatitis Artefacta", note:"No primary skin disease; lesions self-induced" },
    { label:"3. Secondary Psychiatric", color:C.purple, examples:"Depression/anxiety from psoriasis, vitiligo, acne, scars", note:"Psychological sequelae of visible skin disease" },
    { label:"4. Cutaneous Sensory Disorders", color:C.orange, examples:"Chronic pruritus, Burning mouth, Glossodynia, Scalp dysaesthesia", note:"Unpleasant skin sensations without skin-based etiology" },
    { label:"5. Use of Psychotropics in Dermatology", color:C.green, examples:"Doxepin for pruritus; SSRIs; low-dose antipsychotics", note:"Psychotropics more efficacious than traditional agents" },
  ];

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  s.addNotes("Koo's classification is the most widely accepted framework. Categories are NOT mutually exclusive — e.g., acne is both a psychophysiological disorder (stress exacerbation) AND a secondary psychiatric disorder (anxiety/depression from disfigurement).\n\nKey statistic: Psychiatric/psychosocial comorbidity has been reported in at least 30% of patients with dermatologic illness; the vast majority do NOT receive psychiatric care.\n\nREFERENCE: Kaplan & Sadock's Comprehensive Textbook of Psychiatry, 10th edition. Lippincott Williams & Wilkins; 2022. Chapter 27.12, Psychodermatology.");
}

// ─── SLIDE 4 – SKIN-BRAIN AXIS MECHANISM DIAGRAM ─────────────────────────────
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  titleBar(s, "The Skin-Brain Axis: Neurobiological Mechanisms", "Bidirectional psychoneuroimmunological pathways");
  footerBar(s, "Skin-Brain Axis | Psychodermatology Conference 2026");

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  s.addText("SKIN", { x:0.3, y:2.25, w:2.0, h:0.8, fontSize:14, bold:true, color:C.navy, align:"center", valign:"middle", margin:0 });

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  // Brain <-> Immune
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  // Skin <-> Immune
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    { txt:"Neuropeptides\n(SP, CGRP, NPY)", x:2.2, y:2.3 },
    { txt:"Cortisol\nCRH, ACTH", x:6.1, y:1.7 },
    { txt:"Neurotransmitters\n5-HT, DA, NE, GABA", x:4.0, y:3.25 },
    { txt:"Mast cells\nT-cells, IgE", x:1.5, y:3.7 },
  ];
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  });

  // Pathway key boxes at bottom
  const keys = [
    { txt:"Ectoderm Origin:\nBrain & Skin share\ncommon embryonic origin", col:C.teal },
    { txt:"Stress triggers\nCRH → mast cell\ndegranulation in skin", col:C.orange },
    { txt:"Psychotropics act on\n5-HT, DA, NE, GABA\nreceptors in BOTH organs", col:C.purple },
  ];
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    s.addShape(pres.ShapeType.rect, { x:0.25 + i*3.3, y:4.2, w:3.1, h:0.95, fill:{color:k.col, alpha:20}, line:{color:k.col, pt:1.5} });
    s.addText(k.txt, { x:0.3 + i*3.3, y:4.22, w:3.0, h:0.9, fontSize:9, color:C.white, align:"center", fontFace:"Calibri", margin:0 });
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  s.addNotes("This diagram illustrates the bidirectional skin-brain axis.\n\n1. NEUROCHEMICAL PATHWAY: Psychotropic drugs modulate neurotransmitters (serotonin, dopamine, norepinephrine, GABA) which have receptors in both central neural tissue and cutaneous nerve fibres. SSRIs, for example, reduce neurogenic inflammation in the skin by dampening substance P release.\n\n2. NEUROENDOCRINE (HPA) PATHWAY: Psychological stress → CRH release → cortisol and ACTH secretion → affects keratinocytes, sebocytes, and mast cells. This is the pathway by which stress exacerbates psoriasis, atopic dermatitis, and rosacea.\n\n3. NEUROIMMUNE PATHWAY: IL-6, TNF-α, and IFN-γ mediate bidirectional signalling. Antidepressants have direct anti-inflammatory effects — reducing IL-6 and TNF-α — independent of mood effects. This explains benefit in hidradenitis suppurativa and psoriasis.\n\nREFERENCE: Katamanin O, Sharifi S, Jafferany M. Psychopharmacology in Dermatology. Indian Dermatol Online J. 2026. PMID:41717925\nFerreira BR et al. Psychodermatology of Chronic Pruritus. Dermatol Ther (Heidelb). 2024. PMID:38914907");
}

// ─── SLIDE 5 – CLASSIFICATION OF PSYCHOTROPICS ────────────────────────────────
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  titleBar(s, "Psychotropic Drug Classes Used in Dermatology");
  footerBar(s);

  const classes = [
    { name:"ANTIDEPRESSANTS", sub:"SSRIs, SNRIs, TCAs", col:C.teal,
      uses:"• Pruritus (doxepin, mirtazapine)\n• Excoriation disorder (fluoxetine)\n• Psoriasis / AD comorbid depression\n• Chronic urticaria (SSRIs)\n• BDD (SSRIs — first-line)" },
    { name:"ANTIPSYCHOTICS", sub:"Typical & Atypical", col:C.purple,
      uses:"• Delusional Parasitosis (pimozide, risperidone)\n• Olanzapine (TTM, DP)\n• Low-dose quetiapine (comorbid psychosis)" },
    { name:"ANXIOLYTICS", sub:"Benzodiazepines, Buspirone", col:C.orange,
      uses:"• Short-term: acute dermatological\n  procedures, phobia-related\n• Buspirone: OCD-spectrum skin picking\n• NOT for long-term psychodermatosis" },
    { name:"MOOD STABILISERS", sub:"Lithium, Lamotrigine, Valproate", col:C.gold,
      uses:"• Lithium: psoriasiform rash risk!\n• Lamotrigine: TTM (RCT evidence)\n• Valproate: comorbid bipolar + skin\n• Note: lithium can worsen psoriasis" },
    { name:"OTHER AGENTS", sub:"NAC, Opioid antagonists, Antihistamines", col:C.red,
      uses:"• N-acetylcysteine (NAC): TTM, skin picking\n• Naltrexone: pruritus, excoriation\n• Hydroxyzine: anxiolytic + antipruritic\n• Doxepin topical: FDA-approved pruritus" },
  ];

  classes.forEach((c, i) => {
    const col = i < 3 ? i : i - 3;
    const row = i < 3 ? 0 : 1;
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    const y = 1.25 + row * 2.05;
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    const h = 1.85;
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  });

  // 5th box
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  s.addText(c.name, { x, y:y+0.05, w:3.05, h:0.25, fontSize:11, bold:true, color:C.white, align:"center", fontFace:"Calibri", margin:0 });
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  s.addNotes("This slide summarises the five major psychotropic drug classes used in dermatology.\n\nKey clinical note:\n- LITHIUM can WORSEN or precipitate psoriasis — always check medications when psoriasis worsens.\n- Doxepin topical cream 5% is FDA-approved specifically for short-term management of pruritus in atopic dermatitis.\n- Pimozide remains the best-evidenced agent for delusional parasitosis, but requires QTc monitoring.\n\nREFERENCE:\nKenkare VL, Madke B, Choudhary A. Psychotropic Drugs in Dermatology Part 1: Anti-depressants and Mood Stabilisers. Indian J Dermatol. 2025;70(1). PMID:39896303\nKaplan & Sadock's Comprehensive Textbook of Psychiatry, 10th ed. Table 27.12-2.");
}

// ─── SLIDE 6 – MECHANISM: SSRIs ──────────────────────────────────────────────
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  titleBar(s, "Mechanism of Action: SSRIs in Psychodermatology");
  footerBar(s, "SSRI Mechanisms | Psychodermatology Conference 2026");

  // Pre-synaptic neuron box
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  s.addText("PRE-SYNAPTIC\nNEURON", { x:0.3, y:1.25, w:3.2, h:0.55, fontSize:11, bold:true, color:C.teal, align:"center", margin:0 });
  s.addText("5-HT synthesised\nfrom tryptophan\n\n↓\n\nStored in vesicles\n\n↓\n\nReleased into\nsynaptic cleft", {
    x:0.5, y:1.85, w:2.8, h:2.6, fontSize:10, color:C.cream, fontFace:"Calibri", align:"center", margin:0,
  });

  // Synaptic cleft
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  s.addText("SYNAPTIC\nCLEFT", { x:3.6, y:2.65, w:1.0, h:0.6, fontSize:8, color:C.gold, align:"center", margin:0, bold:true });
  // Serotonin dots
  ["2.1","2.55","3.0","3.45","3.9"].forEach(y => {
    s.addShape(pres.ShapeType.ellipse, { x:3.75, y:parseFloat(y), w:0.18, h:0.18, fill:{color:C.gold} });
  });
  s.addText("5-HT\nmolecules", { x:3.55, y:2.1, w:1.1, h:0.4, fontSize:7.5, italic:true, color:C.gold, align:"center", margin:0 });

  // SERT blocker
  s.addShape(pres.ShapeType.rect, { x:3.42, y:3.85, w:1.35, h:0.5, fill:{color:C.red}, line:{color:C.red} });
  s.addText("SERT\nBLOCKED BY SSRI", { x:3.42, y:3.85, w:1.35, h:0.5, fontSize:8, bold:true, color:C.white, align:"center", margin:0 });

  // Post-synaptic receptor
  s.addShape(pres.ShapeType.roundRect, { x:4.7, y:1.25, w:2.5, h:3.4, rectRadius:0.2, fill:{color:C.navy}, line:{color:C.purple, pt:2} });
  s.addText("POST-SYNAPTIC\nNEURON / SKIN CELL", { x:4.7, y:1.25, w:2.5, h:0.6, fontSize:10, bold:true, color:C.purple, align:"center", margin:0 });
  s.addText("5-HT1A/2A/3\nreceptors\n\n↓\n\nActivation →\nAnxiolysis\nAntipruritic effect\nAnti-OCD action\n\n↑ Serotonin availability\nover 2-4 weeks", {
    x:4.85, y:1.9, w:2.2, h:2.5, fontSize:9.5, color:C.cream, fontFace:"Calibri", align:"center", margin:0,
  });

  // Effects in skin column
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  s.addText("SKIN EFFECTS\nof ↑5-HT", { x:7.4, y:1.3, w:2.3, h:0.5, fontSize:11, bold:true, color:C.white, align:"center", margin:0 });
  const effects = ["↓ Neurogenic\ninflammation","↓ Substance P\nrelease","↓ Mast cell\ndegranulation","↓ Compulsive\nscratch cycle","↓ IL-6, TNF-α\n(anti-inflammatory)"];
  effects.forEach((e, i) => {
    s.addShape(pres.ShapeType.ellipse, { x:7.5, y:1.9 + i*0.55, w:0.22, h:0.22, fill:{color:C.gold} });
    s.addText(e, { x:7.8, y:1.85 + i*0.55, w:1.8, h:0.45, fontSize:8.5, color:C.white, fontFace:"Calibri", margin:0 });
  });

  s.addNotes("How SSRIs work in psychodermatology:\n1. Block SERT (serotonin transporter) on pre-synaptic neuron\n2. Increase synaptic 5-HT availability over 2-4 weeks\n3. Post-synaptic 5-HT receptor activation: reduces OCD-spectrum compulsions (scratching, hair pulling), anxiolysis, and antipruritic effects\n4. Peripheral skin effects: cutaneous serotonin receptors mediate anti-inflammatory pathways — SSRIs reduce substance P, mast cell degranulation, IL-6, and TNF-α\n\nClinical implication: Onset of therapeutic effect is 4-6 weeks — inform patients.\n\nREFERENCE: Katamanin O et al. Psychopharmacology in Dermatology. Indian Dermatol Online J. 2026. PMID:41717925\nFerreira BR et al. Psychodermatology of Chronic Pruritus. Dermatol Ther. 2024. PMID:38914907");
}

// ─── SLIDE 7 – MECHANISM: ANTIPSYCHOTICS ─────────────────────────────────────
{
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  s.addShape(pres.ShapeType.rect, { x:0, y:0, w:"100%", h:"100%", fill:{color:"0D1B2A"} });
  titleBar(s, "Mechanism of Action: Antipsychotics in Delusional Parasitosis");
  footerBar(s, "Antipsychotic Mechanisms | Psychodermatology Conference 2026");

  // D2 receptor pathway
  s.addShape(pres.ShapeType.roundRect, { x:0.3, y:1.2, w:4.5, h:3.8, rectRadius:0.2, fill:{color:"1A2744"}, line:{color:C.purple, pt:2} });
  s.addText("DOPAMINE PATHWAY (D2 Blockade)", { x:0.3, y:1.2, w:4.5, h:0.45, fontSize:11, bold:true, color:C.purple, align:"center", margin:0 });

  const steps = [
    { icon:"⚡", txt:"Hyperactive dopaminergic\nmeso-limbic pathway\n→ generates false sensory percepts\n(sensation of crawling/biting)" },
    { icon:"🔒", txt:"Antipsychotic blocks D2\nreceptors in mesolimbic\ncortex (nucleus accumbens)" },
    { icon:"✅", txt:"↓ Dopaminergic firing\n→ reduction in fixed false belief\n→ decreased conviction of infestation" },
    { icon:"⚠️", txt:"EPS risk (pimozide):\nmonitoring for QTc\nEPS, tardive dyskinesia" },
  ];
  steps.forEach((st, i) => {
    s.addShape(pres.ShapeType.rect, { x:0.45, y:1.75+i*0.78, w:4.2, h:0.65, fill:{color:"233565"}, line:{color:C.purple, pt:1} });
    s.addText(st.icon, { x:0.45, y:1.78+i*0.78, w:0.5, h:0.55, fontSize:14, align:"center", margin:0 });
    s.addText(st.txt, { x:1.0, y:1.75+i*0.78, w:3.6, h:0.65, fontSize:9, color:C.cream, fontFace:"Calibri", margin:0, valign:"middle" });
  });

  // Drug comparison
  s.addShape(pres.ShapeType.roundRect, { x:5.0, y:1.2, w:4.7, h:3.8, rectRadius:0.2, fill:{color:"1A2744"}, line:{color:C.gold, pt:2} });
  s.addText("ANTIPSYCHOTIC AGENTS — DP TREATMENT", { x:5.0, y:1.2, w:4.7, h:0.45, fontSize:11, bold:true, color:C.gold, align:"center", margin:0 });

  const drugs = [
    { d:"Pimozide", gen:"1st Gen", dose:"0.5–2 mg/day", note:"Longest evidence history; QTc monitoring mandatory; ECG before and during Tx", col:C.teal },
    { d:"Risperidone", gen:"2nd Gen", dose:"0.5–3 mg/day", note:"Preferred 2nd-gen; less QTc risk; BAD 2022 guideline recommended", col:C.green },
    { d:"Olanzapine", gen:"2nd Gen", dose:"2.5–10 mg/day", note:"RCT evidence in trichotillomania (85% vs 17% response at 12 wks)", col:C.orange },
    { d:"Quetiapine", gen:"2nd Gen", dose:"25–100 mg/day", note:"Useful when sedation is co-desired; low-dose off-label for DP", col:C.purple },
    { d:"Aripiprazole", gen:"2nd Gen", dose:"5–15 mg/day", note:"Partial D2 agonist; lower metabolic risk; growing evidence for DP", col:C.red },
  ];
  drugs.forEach((d, i) => {
    const y = 1.75 + i*0.72;
    s.addShape(pres.ShapeType.rect, { x:5.1, y, w:4.5, h:0.62, fill:{color:"233565"}, line:{color:d.col, pt:1.5} });
    s.addShape(pres.ShapeType.rect, { x:5.1, y, w:0.1, h:0.62, fill:{color:d.col} });
    s.addText(`${d.d} (${d.gen})`, { x:5.25, y:y+0.04, w:2.0, h:0.26, fontSize:10, bold:true, color:d.col, fontFace:"Calibri", margin:0 });
    s.addText(`Dose: ${d.dose}`, { x:5.25, y:y+0.32, w:1.5, h:0.2, fontSize:8, italic:true, color:C.lightGray, fontFace:"Calibri", margin:0 });
    s.addText(d.note, { x:7.0, y:y+0.04, w:2.5, h:0.54, fontSize:7.5, color:C.cream, fontFace:"Calibri", margin:0, valign:"middle" });
  });

  s.addNotes("MECHANISM NOTES:\n- Delusional parasitosis arises from hyperactivity in mesolimbic dopamine pathways generating false somatic percepts.\n- D2 receptor blockade reduces the conviction of delusional belief — this is NOT placebo; neuroimaging shows mesolimbic hyperactivity in DP.\n\nKEY CLINICAL POINT: Patients with DP rarely accept psychiatric referral. Dermatologists can initiate treatment themselves. The 'therapeutic relationship' is key — use the Koo approach: acknowledge suffering, offer medication for 'skin discomfort' rather than labelling it a delusion.\n\nPIMOZIDE SAFETY: QTc prolongation — mandatory ECG before and during treatment. Contraindicated with macrolides, azoles, and QT-prolonging antihistamines.\n\nBAD GUIDELINE 2022: Risperidone is recommended alongside pimozide as a first-line option for delusional infestation.\n\nREFERENCE:\nAhmed A et al. BAD Guidelines for Management of Delusional Infestation. Br J Dermatol. 2022. (discovery.dundee.ac.uk)\nCheng C, Brownstone N, Koo J. Treatment of tardive dyskinesia: review for dermatologists. J Dermatolog Treat. 2022. PMID:33781159");
}

// ─── SLIDE 8 – RCT EVIDENCE TABLE ────────────────────────────────────────────
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  titleBar(s, "RCT Evidence Summary: Primary Psychodermatoses", "Turk T et al. J Cutan Med Surg 2023 [Systematic Review of 21 RCTs] • PMID: 36802832");
  footerBar(s);

  // Table headers
  const headers = ["Condition", "Drug(s)", "Evidence\n(RCT/SR)", "Outcome", "Evidence\nLevel"];
  const colW = [1.9, 2.2, 1.5, 3.2, 1.0];
  const hX = [0.2, 2.1, 4.3, 5.8, 9.0];

  headers.forEach((h, i) => {
    s.addShape(pres.ShapeType.rect, { x:hX[i], y:1.2, w:colW[i], h:0.45, fill:{color:C.navy}, line:{color:C.navy} });
    s.addText(h, { x:hX[i], y:1.2, w:colW[i], h:0.45, fontSize:9.5, bold:true, color:C.white, align:"center", valign:"middle", margin:0, fontFace:"Calibri" });
  });

  const rows = [
    ["Trichotillomania", "Clomipramine\nSertraline", "Cochrane SR 2021\n(PMID:34582562)", "Clomipramine > desipramine;\nSSRIs modest benefit", "★★★☆☆"],
    ["Trichotillomania", "Olanzapine", "RCT (n=25)\n12 wks", "85% response vs 17% placebo\n(RR 5.08, 95%CI 1.4–18.37)", "★★★☆☆"],
    ["Trichotillomania", "N-acetylcysteine\n2400mg/day", "RCT (n=50)\n12 wks", "56% response vs 16% placebo\n(RR 3.5, 95%CI 1.34–9.17)\nModerate certainty", "★★★★☆"],
    ["Excoriation Disorder", "Fluoxetine\n20–60mg/day", "RCT evidence\n(Turk 2023 SR)", "Significant reduction in\nskin-picking severity", "★★★☆☆"],
    ["Nail Biting /\nHand-washing Dermatitis", "Clomipramine /\nDesipramine", "2 RCTs in SR\n(Turk 2023)", "Significant reduction in\ncompulsive behaviors", "★★☆☆☆"],
    ["Delusional Parasitosis", "Pimozide /\nRisperidone", "BAD Guidelines 2022\nCase series; 1 RCT", "Complete/partial remission\nin majority; BAD Grade B", "★★★☆☆"],
    ["Chronic Pruritus", "Mirtazapine\nDoxepin\nNaltrexone", "Multiple RCTs\nand reviews", "Significant itch reduction;\ndoxepin FDA-approved\n(topical)", "★★★★☆"],
  ];

  const rowCols = [C.white, "F0F7F4", C.white, "F0F7F4", C.white, "F0F7F4", C.white];
  rows.forEach((row, ri) => {
    const y = 1.65 + ri * 0.53;
    row.forEach((cell, ci) => {
      s.addShape(pres.ShapeType.rect, { x:hX[ci], y, w:colW[ci], h:0.52, fill:{color:rowCols[ri]}, line:{color:C.lightGray, pt:0.5} });
      s.addText(cell, { x:hX[ci]+0.05, y:y+0.02, w:colW[ci]-0.1, h:0.48, fontSize:8, color:ci===4?C.gold:C.navy, fontFace:"Calibri", valign:"middle", margin:0 });
    });
  });

  s.addNotes("KEY FINDINGS from Turk T et al. 2023 systematic review (21 RCTs across 5 psychodermatoses):\n\n1. STRONGEST RCT EVIDENCE: N-acetylcysteine for trichotillomania — RR 3.5 (95%CI 1.34–9.17), moderate-certainty Cochrane evidence (PMID:34582562)\n2. OLANZAPINE for TTM: 85% vs 17% response (single small RCT, low certainty)\n3. FLUOXETINE: best evidence for skin-picking/excoriation disorder\n4. CLOMIPRAMINE: evidence for TTM, nail-biting, compulsive handwashing dermatitis\n5. Overall RCT evidence is THIN — most trials are small (mean n=29), single-centre, short-term (5–13 weeks)\n\nCLINICAL IMPLICATION: Off-label use is common and evidence-based for many agents; document shared decision making.\n\nREFERENCE:\n1. Turk T, Liu C, Fujiwara E et al. Pharmacological Interventions for Primary Psychodermatologic Disorders. J Cutan Med Surg. 2023;27(2). PMID:36802832\n2. Hoffman J, Williams T, Rothbart R et al. Pharmacotherapy for Trichotillomania. Cochrane Database Syst Rev. 2021;9:CD007662. PMID:34582562");
}

// ─── SLIDE 9 – DRUG COMPARISON TABLE ─────────────────────────────────────────
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  s.addShape(pres.ShapeType.rect, { x:0, y:0, w:"100%", h:"100%", fill:{color: C.cream} });
  titleBar(s, "Comparative Pharmacology: Psychotropics in Dermatology", "Kenkare VL et al. Indian J Dermatol 2025 • Kaplan & Sadock 10th ed.");
  footerBar(s);

  const hdr = ["Drug", "Class", "Dose Range", "Primary Indication(s)", "Derm. AEs", "Monitoring"];
  const hW  = [1.4,  1.1,   1.2,   2.7,             1.8,        1.6];
  const hX2 = [0.15, 1.55,  2.65,  3.85,            6.55,       8.35];

  hdr.forEach((h, i) => {
    s.addShape(pres.ShapeType.rect, { x:hX2[i], y:1.2, w:hW[i], h:0.4, fill:{color:C.teal}, line:{color:C.teal} });
    s.addText(h, { x:hX2[i], y:1.2, w:hW[i], h:0.4, fontSize:9, bold:true, color:C.white, align:"center", valign:"middle", margin:0 });
  });

  const data = [
    ["Fluoxetine","SSRI","20–60 mg/d","Excoriation, BDD, depression in AD/psoriasis","Photosensitivity, sweating","LFTs if hepatic risk"],
    ["Sertraline","SSRI","50–200 mg/d","Trichotillomania, BDD, psoriasis/anxiety","Mild rash, dry skin","Routine; check drug interactions"],
    ["Paroxetine","SSRI","20–60 mg/d","Chronic itch, BDD, social anxiety re: skin","Sweating++, rash","QTc (higher risk vs other SSRIs)"],
    ["Clomipramine","TCA","25–150 mg/d","Trichotillomania, nail-biting, OCD-spectrum","Dry skin, photosensitivity","ECG (QTc); anticholinergic effects"],
    ["Doxepin","TCA (topical)","5% cream / 10–75 mg oral","Pruritus (atopic dermatitis) — FDA-approved topical","Sedation; contact dermatitis (topical)","Max 8 days topical; sedation monitoring"],
    ["Mirtazapine","NaSSA","7.5–30 mg/d","Pruritus (uraemic, cholestatic, atopic)","Weight gain, sedation","LFTs; CBC (rare agranulocytosis)"],
    ["Pimozide","Typical AP","0.5–2 mg/d","Delusional parasitosis (1st-line)","Hyperpigmentation (long-term)","ECG (QTc); avoid azoles, macrolides"],
    ["Risperidone","Atypical AP","0.5–3 mg/d","Delusional parasitosis (BAD 2022)","Hyperprolactinaemia","Metabolic panel, QTc"],
    ["Olanzapine","Atypical AP","2.5–10 mg/d","Trichotillomania, DP","Weight gain, seborrhoea","Fasting glucose, lipids"],
    ["N-Acetylcysteine","Glutamate mod.","1200–2400 mg/d","Trichotillomania, excoriation","GI upset (mild)","None routinely required"],
    ["Naltrexone","Opioid ant.","25–50 mg/d","Pruritus (uraemic, PBC, atopic)","GI upset; hepatotoxicity (rare, high dose)","LFTs"],
    ["Lamotrigine","Anticonvulsant","25–200 mg/d","Trichotillomania (RCT: Cochrane)","DRESS, Stevens-Johnson (rare)","FBC; slow titration essential"],
  ];

  const rowBg = ["FFFFFF","F5FAF8","FFFFFF","F5FAF8","FFFFFF","F5FAF8","FFFFFF","F5FAF8","FFFFFF","F5FAF8","FFFFFF","F5FAF8"];
  data.forEach((row, ri) => {
    const y = 1.6 + ri * 0.33;
    row.forEach((cell, ci) => {
      s.addShape(pres.ShapeType.rect, { x:hX2[ci], y, w:hW[ci], h:0.32, fill:{color:rowBg[ri]}, line:{color:C.lightGray, pt:0.3} });
      s.addText(cell, { x:hX2[ci]+0.03, y:y+0.01, w:hW[ci]-0.06, h:0.3, fontSize:7.2, color:C.navy, fontFace:"Calibri", valign:"middle", margin:0 });
    });
  });

  s.addNotes("IMPORTANT DERMATOLOGICAL ADVERSE EFFECTS TO KNOW:\n1. LAMOTRIGINE: Risk of Stevens-Johnson syndrome / DRESS — slow titration (increase by 25mg every 2 weeks) is mandatory. Discontinue immediately if rash develops.\n2. LITHIUM: Can precipitate or worsen psoriasis (Koebner-like effect). Check all medications when psoriasis flares.\n3. PIMOZIDE: QTc prolongation — contraindicated with fluoroquinolones, macrolides, azole antifungals (common in dermatology!)\n4. DOXEPIN TOPICAL: May cause significant drowsiness (systemic absorption); max application 8 days; avoid in patients receiving MAOIs.\n5. CLOMIPRAMINE: Anticholinergic effects (dry mouth, constipation) + QTc monitoring.\n\nREFERENCE:\nKenkare VL, Madke B, Choudhary A. Psychotropic Drugs in Dermatology Part 1. Indian J Dermatol. 2025;70(1). PMID:39896303\nKaplan & Sadock's Comprehensive Textbook of Psychiatry, 10th ed. Table 27.12-2.");
}

// ─── SLIDE 10 – CONDITION: DELUSIONAL PARASITOSIS ────────────────────────────
{
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  s.addShape(pres.ShapeType.rect, { x:0, y:0, w:"100%", h:"100%", fill:{color: C.cream} });
  titleBar(s, "Delusional Infestation (Parasitosis): Management", "BAD Guidelines 2022 • Ahmed A et al. Br J Dermatol 2022");
  footerBar(s);

  // Prevalence
  s.addShape(pres.ShapeType.roundRect, { x:0.2, y:1.25, w:2.5, h:1.2, rectRadius:0.1, fill:{color:C.teal}, line:{color:C.teal} });
  s.addText("27.3\nper 100,000", { x:0.2, y:1.3, w:2.5, h:0.7, fontSize:20, bold:true, color:C.white, align:"center", margin:0 });
  s.addText("Prevalence of\nDelusional Infestation", { x:0.2, y:1.95, w:2.5, h:0.45, fontSize:9, color:C.white, align:"center", margin:0 });

  s.addShape(pres.ShapeType.roundRect, { x:0.2, y:2.55, w:2.5, h:0.85, rectRadius:0.1, fill:{color:C.purple}, line:{color:C.purple} });
  s.addText("More common in\nwomen >50 yrs", { x:0.2, y:2.6, w:2.5, h:0.75, fontSize:11, color:C.white, align:"center", margin:0 });

  // Clinical features
  s.addText("Clinical Features & \"Matchbox Sign\"", { x:2.9, y:1.25, w:7.0, h:0.3, fontSize:12, bold:true, color:C.navy, margin:0 });
  const feats = [
    "Fixed, false belief of infestation (parasites, worms, fibres) — without objective evidence",
    "'Matchbox sign': patients bring specimens (skin, hair, cloth) in containers",
    "Tactile hallucinations: crawling, biting, stinging sensations",
    "DSM-5: Delusional Disorder, Somatic Type — single delusion, no thought disorder",
    "Folie à deux (shared delusion) may occur in household contacts",
  ];
  feats.forEach((f, i) => {
    s.addShape(pres.ShapeType.ellipse, { x:2.9, y:1.65+i*0.42, w:0.18, h:0.18, fill:{color:C.teal} });
    s.addText(f, { x:3.2, y:1.6+i*0.42, w:6.6, h:0.38, fontSize:9.5, color:C.navy, margin:0 });
  });

  // BAD 2022 treatment ladder
  s.addShape(pres.ShapeType.rect, { x:0.2, y:3.6, w:9.6, h:0.3, fill:{color:C.navy} });
  s.addText("BAD 2022 TREATMENT ALGORITHM", { x:0.2, y:3.6, w:9.6, h:0.3, fontSize:11, bold:true, color:C.white, align:"center", margin:0 });

  const steps2 = [
    { n:"1", txt:"Build therapeutic alliance — acknowledge suffering without confirming delusion", col:C.teal },
    { n:"2", txt:"First-line: Risperidone 0.5mg (titrate) OR Pimozide 0.5–2mg — ECG mandatory for pimozide", col:C.green },
    { n:"3", txt:"If comorbid depression/anxiety: add SSRI (e.g., fluoxetine 20mg) or consider olanzapine", col:C.orange },
    { n:"4", txt:"Refer to psychodermatology clinic / liaison psychiatry if no response at 8–12 weeks", col:C.red },
  ];
  steps2.forEach((st, i) => {
    s.addShape(pres.ShapeType.rect, { x:0.2 + i*2.45, y:3.95, w:2.35, h:1.3, fill:{color:"F8F8FF"}, line:{color:st.col, pt:2} });
    s.addShape(pres.ShapeType.ellipse, { x:1.1 + i*2.45, y:3.9, w:0.55, h:0.55, fill:{color:st.col} });
    s.addText(st.n, { x:1.1 + i*2.45, y:3.9, w:0.55, h:0.55, fontSize:14, bold:true, color:C.white, align:"center", margin:0 });
    s.addText(st.txt, { x:0.25 + i*2.45, y:4.1, w:2.25, h:1.1, fontSize:8.5, color:C.navy, align:"center", fontFace:"Calibri", margin:0 });
  });

  s.addNotes("DELUSIONAL INFESTATION KEY CLINICAL POINTS:\n\n1. These patients present to dermatologists FIRST — rarely accept psychiatric referral initially\n2. NEVER confront the delusion directly — this damages rapport and patient will leave without treatment\n3. Acknowledge their suffering: 'I can see how much distress these sensations are causing you'\n4. Frame medication: 'These medications can help with the uncomfortable sensations you're experiencing'\n\nBAD GUIDELINES 2022 KEY RECOMMENDATIONS:\n- Risperidone or pimozide as first-line antipsychotics (Grade B recommendation)\n- Always obtain ECG before starting pimozide and during treatment\n- Avoid pimozide with azole antifungals (common in dermatology) — MAJOR DRUG INTERACTION\n- Psychodermatology clinic referral for complex/refractory cases\n\nPROGNOSIS: ~50% achieve complete remission with antipsychotics; 30% partial remission\n\nREFERENCE:\n1. Ahmed A et al. BAD Guidelines for management of adults with delusional infestation. Br J Dermatol. 2022. NICE-accredited.\n2. Cheng C, Brownstone N, Koo J. Treatment of tardive dyskinesia for dermatologists. J Dermatolog Treat. 2022;33(3). PMID:33781159");
}

// ─── SLIDE 11 – TRICHOTILLOMANIA ─────────────────────────────────────────────
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  s.addShape(pres.ShapeType.rect, { x:0, y:0, w:"100%", h:"100%", fill:{color: C.cream} });
  titleBar(s, "Trichotillomania (Hair-Pulling Disorder) & Excoriation Disorder", "Hoffman J et al. Cochrane 2021 • Turk T et al. J Cutan Med Surg 2023");
  footerBar(s);

  // Left: TTM
  s.addShape(pres.ShapeType.rect, { x:0.2, y:1.2, w:4.7, h:4.1, fill:{color:C.white}, line:{color:C.teal, pt:2} });
  s.addShape(pres.ShapeType.rect, { x:0.2, y:1.2, w:4.7, h:0.38, fill:{color:C.teal}, line:{color:C.teal} });
  s.addText("TRICHOTILLOMANIA", { x:0.2, y:1.22, w:4.7, h:0.34, fontSize:12, bold:true, color:C.white, align:"center", margin:0 });

  s.addText([
    { text:"Prevalence: ", options:{bold:true} },
    { text:"1–2% population; F:M = 10:1 in adults\n", options:{} },
    { text:"DSM-5: ", options:{bold:true} },
    { text:"Obsessive-Compulsive Related Disorder\n\n", options:{} },
    { text:"PHARMACOTHERAPY (Cochrane SR 2021):\n", options:{bold:true, color:C.teal} },
    { text:"• N-acetylcysteine 2400mg/d:", options:{bold:true} },
    { text:" Best evidence (RR 3.5; moderate certainty)\n", options:{} },
    { text:"• Olanzapine 2.5–10mg/d:", options:{bold:true} },
    { text:" RR 5.08 vs placebo (12 wks; low certainty)\n", options:{} },
    { text:"• Clomipramine:", options:{bold:true} },
    { text:" Superior to desipramine (crossover RCT)\n", options:{} },
    { text:"• SSRIs (fluoxetine, sertraline):", options:{bold:true} },
    { text:" Modest; inconsistent evidence\n", options:{} },
    { text:"• Naltrexone:", options:{bold:true} },
    { text:" Insufficient evidence (single RCT)\n\n", options:{} },
    { text:"FIRST-LINE RECOMMENDATION:\n", options:{bold:true, color:C.teal} },
    { text:"HRT (Habit Reversal Training) + NAC\nor Clomipramine as pharmacological option\n\n", options:{} },
    { text:"NOTE:", options:{bold:true, color:C.red} },
    { text:" All trials small (mean n=29), short-term\n— lack of high-certainty RCT evidence", options:{italic:true, color:C.gray} },
  ], {
    x:0.35, y:1.65, w:4.4, h:3.55, fontSize:9, fontFace:"Calibri", color:C.navy, margin:0, valign:"top",
  });

  // Right: Excoriation
  s.addShape(pres.ShapeType.rect, { x:5.1, y:1.2, w:4.7, h:4.1, fill:{color:C.white}, line:{color:C.orange, pt:2} });
  s.addShape(pres.ShapeType.rect, { x:5.1, y:1.2, w:4.7, h:0.38, fill:{color:C.orange}, line:{color:C.orange} });
  s.addText("EXCORIATION (SKIN-PICKING) DISORDER", { x:5.1, y:1.22, w:4.7, h:0.34, fontSize:11, bold:true, color:C.white, align:"center", margin:0 });

  s.addText([
    { text:"Prevalence: ", options:{bold:true} },
    { text:"1.4–5.4% general population\n", options:{} },
    { text:"DSM-5: ", options:{bold:true} },
    { text:"Obsessive-Compulsive Related Disorder\n\n", options:{} },
    { text:"PHARMACOTHERAPY:\n", options:{bold:true, color:C.orange} },
    { text:"• Fluoxetine 20–60mg/d:", options:{bold:true} },
    { text:" Best SSRI evidence; RCT support from Turk 2023\n", options:{} },
    { text:"• N-acetylcysteine:", options:{bold:true} },
    { text:" Useful adjunct; oxidative stress pathway\n", options:{} },
    { text:"• Lamotrigine:", options:{bold:true} },
    { text:" Some positive case series; off-label\n", options:{} },
    { text:"• Naltrexone:", options:{bold:true} },
    { text:" Evidence emerging; opioid pathway in itch-scratch\n\n", options:{} },
    { text:"APPROACH:\n", options:{bold:true, color:C.orange} },
    { text:"1. Rule out: prurigo, dermatitis, insect bites\n2. Screen for underlying OCD, BDD, depression\n3. Combine CBT/HRT with pharmacotherapy\n4. Use fluoxetine as first-line drug\n5. Monitor for suicidality (SSRI initiation)\n\n", options:{} },
    { text:"ASSESSMENT TOOL:", options:{bold:true, color:C.red} },
    { text:" Milwaukee Inventory\nfor Subtypes of Trichotillomania (MIST)\nNeurological Excoriation Scale (NES)", options:{italic:true} },
  ], {
    x:5.25, y:1.65, w:4.4, h:3.55, fontSize:9, fontFace:"Calibri", color:C.navy, margin:0, valign:"top",
  });

  s.addNotes("COCHRANE 2021 META-ANALYSIS KEY FINDINGS (PMID:34582562):\n\n- 12 RCTs included (mostly adults, mean n=29, 5–13 weeks duration)\n- N-acetylcysteine: BEST evidence — RR 3.5 (95%CI 1.34–9.17) in adults; moderate certainty. However, NAC did NOT benefit children/adolescents.\n- Olanzapine: Single RCT, 85% vs 17% response (RR 5.08); low certainty\n- Clomipramine: Crossover RCT showed superiority to desipramine — TCA choice of evidence\n- SSRIs: Inconsistent across trials; fluoxetine NOT statistically superior to placebo in TTM specifically\n- IMPORTANT: Overall evidence quality is LOW to MODERATE — all recommendations are conditional\n\nEXCORIATION DISORDER NOTE:\nThe dermatologist's role is critical: these patients present with skin wounds, not psychiatric complaints. A non-judgmental approach, co-prescribing, and appropriate referral (CBT + pharmacotherapy) gives best outcomes.\n\nREFERENCE:\n1. Hoffman J et al. Pharmacotherapy for trichotillomania. Cochrane Database Syst Rev. 2021;9:CD007662. PMID:34582562\n2. Turk T et al. J Cutan Med Surg. 2023;27(2). PMID:36802832");
}

// ─── SLIDE 12 – PSYCHOSOMATIC SKIN CONDITIONS ─────────────────────────────────
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  titleBar(s, "Psychotropics in Psychosomatic Skin Conditions", "Katamanin O et al. Indian Dermatol Online J 2026 • PMID:41717925");
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  const conditions = [
    {
      name:"PSORIASIS", icon:"🔴",
      text:"• 30% have comorbid depression; 20% anxiety\n• SSRIs: reduce IL-6, TNF-α → anti-inflammatory benefit\n• Sertraline / escitalopram: first choice\n• Collaborative care model: dermatologist + psychiatrist\n• Biologics (TNF inhibitors) may themselves have antidepressant effects",
      col:C.red,
    },
    {
      name:"ATOPIC DERMATITIS", icon:"🟠",
      text:"• Itch-scratch cycle perpetuated by anxiety/stress\n• Doxepin topical 5%: FDA-approved for pruritus (≤8 days)\n• Mirtazapine 15–30mg: H1 antagonism → powerful antipruritic\n• CBT reduces scratch reflex; SSRIs for comorbid anxiety\n• Dupilumab: reduces anxiety scores as secondary endpoint",
      col:C.orange,
    },
    {
      name:"CHRONIC URTICARIA", icon:"🟡",
      text:"• H1 antihistamines first-line (not covered here)\n• Antidepressants as adjuncts when psychological stress is driver\n• Doxepin (TCA): dual H1/H2 + serotonin antagonism\n• Escitalopram: reduces stress-triggered flares in RCT subgroup\n• Avoid: paroxetine (QTc + drug interactions with antihistamines)",
      col:C.gold,
    },
    {
      name:"ALOPECIA AREATA", icon:"🟢",
      text:"• High psychiatric comorbidity (35–40% depression/anxiety)\n• No specific psychotropic proven for AA itself\n• Treat comorbid psychiatric condition\n• SSRIs / SNRIs for anxiety/depression\n• Tofacitinib / baricitinib: may also improve mood as secondary effect",
      col:C.green,
    },
    {
      name:"PRURIGO NODULARIS &\nCHRONIC PRURITUS", icon:"🔵",
      text:"• Central sensitisation model: treat as neuropathic pain\n• Mirtazapine 7.5–15mg nocte: most evidence for itch\n• Naltrexone 25–50mg: uraemic, PBC, opioid-dysregulated itch\n• Gabapentin/pregabalin: for neuropathic itch component\n• Doxepin oral: used in cholestatic pruritus",
      col:C.teal,
    },
    {
      name:"HIDRADENITIS\nSUPPURATIVA", icon:"🟣",
      text:"• Very high depression/anxiety burden (OR 2.7 for depression)\n• Antidepressants: direct anti-inflammatory via ↓ IL-1β, IL-17\n• Bupropion: small case series showing benefit in HS\n• Treat comorbid depression aggressively\n• Referral to psychodermatology clinic where available",
      col:C.purple,
    },
  ];

  conditions.forEach((c, i) => {
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  });

  s.addNotes("PSYCHOSOMATIC SKIN CONDITIONS NOTES:\n\nPSORIASIS: Antidepressants not only treat comorbid depression but have direct anti-inflammatory effects. TNF inhibitors used for psoriasis may themselves act as antidepressants by reducing peripheral IL-6 and TNF-α. The psychodermatology interface is bidirectional.\n\nCHRONIC PRURITUS: The most evidence-based psychotropic for itch is mirtazapine (H1 antagonist + 5-HT2/3 antagonism → antipruritic). Naltrexone targets opioid dysregulation in prurigo nodularis — significant RCT evidence for uraemic itch.\n\nHIDRADENITIS SUPPURATIVA: The psychological burden is disproportionately high. The OR for depression in HS is 2.7 — dermatologists should screen with PHQ-9 at every visit.\n\nREFERENCE:\n1. Katamanin O, Sharifi S, Jafferany M. Psychopharmacology in Dermatology. Indian Dermatol Online J. 2026;17(2). PMID:41717925\n2. Ferreira BR, Katamanin OM, Jafferany M. Psychodermatology of Chronic Pruritus. Dermatol Ther (Heidelb). 2024. PMID:38914907\n3. Blackstone B, Patel R, Bewley A. Assessing and Improving Psychological Well-Being in Psoriasis. Psoriasis (Auckl). 2022. PMID:35371967");
}

// ─── SLIDE 13 – BODY DYSMORPHIC DISORDER ─────────────────────────────────────
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  s.addText("BDD prevalence: 0.7–2.4% general population | In cosmetic dermatology: up to 11.9% | In acne clinics: 14–21% | F ≈ M", {
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    { t:"Preoccupation with perceived defect(s) in appearance not observable or slight to others", b:false },
    { t:"Repetitive behaviours: mirror-checking, excessive grooming, skin-picking, reassurance-seeking", b:false },
    { t:"Clinically significant distress or functional impairment", b:false },
    { t:"Not better explained by body image disturbance in eating disorder", b:false },
    { t:"\nIMPACT ON DERMATOLOGY PRACTICE", b:true, col:C.red },
    { t:"• High demand for cosmetic procedures (Botox, fillers, laser) which do NOT resolve BDD", b:false },
    { t:"• Risk of multiple procedures, dissatisfied patients, complaints", b:false },
    { t:"• Cosmetic treatment WITHOUT psychiatric evaluation is contraindicated in BDD", b:false },
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  // Right side - treatment
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    { step:"1st Line", drug:"High-dose SSRI", detail:"Fluoxetine 60–80mg, Escitalopram 20–40mg, Fluvoxamine 150–300mg\n→ 4–6 wk minimum before assessing response\n→ Full response may take 12–16 weeks" },
    { step:"Non-resp.", drug:"Switch SSRI or\nadd augmentation", detail:"Clomipramine as 2nd-line TCA\nBuspirone augmentation\nAtypical antipsychotic (aripiprazole) low-dose if delusional insight poor" },
    { step:"Combined", drug:"CBT + SSRI", detail:"CBT (exposure and response prevention) superior to medication alone in RCTs\nTargets: mirror checking, skin-picking, reassurance-seeking" },
    { step:"Referral", drug:"Psychiatry /\nPsychodermatology", detail:"MANDATORY before any invasive cosmetic procedure\nScreen with BDD-Q (BDD Questionnaire)\nDo NOT perform cosmetic Tx in active BDD" },
  ];

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  s.addNotes("BDD IN DERMATOLOGY — KEY POINTS:\n\n1. SCREENING: Use the BDD Questionnaire (BDD-Q) or BDDQ-DV (Dermatology Version) in cosmetic clinics\n2. NEVER perform cosmetic procedures in active BDD — this worsens the condition in >80% of cases\n3. Patients with BDD are disproportionately represented in dermatology cosmetic complaints and litigation\n4. SSRI DOSES FOR BDD ARE HIGHER than for depression — must titrate to 60–80mg fluoxetine equivalent\n5. Delusional BDD (poor insight) may require addition of low-dose antipsychotic (aripiprazole)\n\nCOGNITIVE DISTORTIONS IN BDD:\n- Selective attention to perceived defect\n- Catastrophic interpretation of normal skin\n- Mirror-checking rituals (analogous to OCD compulsions)\n\nSSRI mechanism in BDD: reduces OCD-circuit hyperactivity in orbitofrontal cortex and caudate nucleus — same circuit implicated in TTM and excoriation disorder.\n\nREFERENCE:\nSkintherapyletter.com. DSM-5 Update in Psychodermatology. 2023. (https://www.skintherapyletter.com/alopecia/dsm-5-update-in-psychodermatology)");
}

// ─── SLIDE 14 – PRESCRIBING GUIDE / CLINICAL PEARLS ──────────────────────────
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  titleBar(s, "Practical Prescribing: Clinical Pearls for Dermatologists");
  footerBar(s);

  const pearls = [
    { icon:"⚠️", title:"Drug Interactions", txt:"Pimozide + azoles/macrolides (CYP3A4 inhibitors) → QTc risk. Always check before prescribing in dermatology. Paroxetine + many dermatology drugs via CYP2D6 inhibition.", col:C.red },
    { icon:"📋", title:"Monitoring Essentials", txt:"Pimozide: ECG before & during Tx; Clomipramine: QTc + anticholinergic; Lamotrigine: SLOW titration, watch for rash; Lithium: can worsen/trigger psoriasis.", col:C.orange },
    { icon:"🕐", title:"Onset of Action", txt:"SSRIs/SNRIs: 4–6 weeks for mood; antipruritic effect may appear sooner (1–2 wks). Antipsychotics (DP): weeks to months. Set realistic expectations for patients.", col:C.teal },
    { icon:"💬", title:"Communication", txt:"Frame psychotropics therapeutically: 'This medication reduces the discomfort signals from your skin' — not 'this is a psychiatric drug'. Build alliance before prescribing.", col:C.purple },
    { icon:"🔄", title:"Collaborative Care", txt:"Refer to psychiatry/psychodermatology clinic: BDD, severe DP, suicidality risk, treatment-refractory cases. Psychodermatology multidisciplinary team = best outcomes.", col:C.green },
    { icon:"📱", title:"Screening Tools", txt:"PHQ-9 (depression), GAD-7 (anxiety), BDD-Q, MIST (trichotillomania), Dermatology Life Quality Index (DLQI) — integrate into dermatology clinic workflow.", col:C.gold },
  ];

  pearls.forEach((p, i) => {
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  s.addNotes("PRACTICAL NOTES FOR DERMATOLOGISTS:\n\nSTARTING PSYCHOTROPICS:\n- Always document shared decision-making\n- Inform patients of off-label status where applicable\n- Start low, go slow (especially in elderly)\n- Consider hepatic and renal function\n\nWHEN TO REFER:\n- Active suicidality or self-harm\n- BDD with poor insight\n- DP not responding to first-line antipsychotic\n- Complex polypharmacy\n- Adolescent patients (extra caution with SSRI initiation, black-box warning for suicidality age <25)\n\nBLACK BOX WARNING: SSRIs carry a US FDA black box warning for increased suicidal ideation in children and adolescents — monitor closely in first 4 weeks.\n\nREFERENCE:\n1. Christensen RE, Jafferany M. Unmet Needs in Psychodermatology. CNS Drugs. 2024;38(3). PMID:38386200\n2. Baskaran N et al. Psychological Morbidity in Chronic Dermatological Disorders. Indian Dermatol Online J. 2025. PMID:40395584");
}

// ─── SLIDE 15 – REFERENCES ────────────────────────────────────────────────────
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  titleBar(s, "References (Vancouver Style)");

  const refs = [
    "1. Turk T, Liu C, Fujiwara E, Straube S, Hagtvedt R, Dennett L. Pharmacological Interventions for Primary Psychodermatologic Disorders: An Evidence Mapping and Appraisal of Randomized Controlled Trials. J Cutan Med Surg. 2023;27(2):140–52. PMID: 36802832",
    "2. Hoffman J, Williams T, Rothbart R, Ipser JC, Fineberg N, Chamberlain SR. Pharmacotherapy for trichotillomania. Cochrane Database Syst Rev. 2021;9:CD007662. PMID: 34582562",
    "3. Katamanin O, Sharifi S, Jafferany M. Psychopharmacology in Dermatology. Indian Dermatol Online J. 2026;17(2). PMID: 41717925",
    "4. Ferreira BR, Katamanin OM, Jafferany M. Psychodermatology of Chronic Pruritus: An Overview of the Link Between Itch and Distress. Dermatol Ther (Heidelb). 2024;14(7). PMID: 38914907",
    "5. Kenkare VL, Madke B, Choudhary A. Psychotropic Drugs in Dermatology Part 1: Anti-depressants and Mood Stabilisers. Indian J Dermatol. 2025;70(1). PMID: 39896303",
    "6. Christensen RE, Jafferany M. Unmet Needs in Psychodermatology: A Narrative Review. CNS Drugs. 2024;38(3):173–89. PMID: 38386200",
    "7. Ahmed A et al. British Association of Dermatologists guidelines for the management of adults with delusional infestation. Br J Dermatol. 2022. NICE-accredited guidelines.",
    "8. Blackstone B, Patel R, Bewley A. Assessing and Improving Psychological Well-Being in Psoriasis. Psoriasis (Auckl). 2022;12:85–99. PMID: 35371967",
    "9. Cheng C, Brownstone N, Koo J. Treatment of tardive dyskinesia: a review and update for dermatologists managing delusions of parasitosis. J Dermatolog Treat. 2022;33(3). PMID: 33781159",
    "10. Baskaran N, Arunima A, Shah S. Psychological Morbidity in Chronic Dermatological Disorders: A Review. Indian Dermatol Online J. 2025. PMID: 40395584",
    "11. Gupta MA, Gupta AK. Psychodermatology. In: Sadock BJ, Sadock VA, Ruiz P, editors. Kaplan & Sadock's Comprehensive Textbook of Psychiatry. 10th ed. Philadelphia: Lippincott Williams & Wilkins; 2022. Chapter 27.12.",
    "12. Wolff K, Johnson RA, Saavedra AP, Roh EK, eds. Fitzpatrick's Dermatology in General Medicine. 9th ed. New York: McGraw-Hill; 2019.",
  ];

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  s.addText("★ = highest-level evidence | All PMIDs verified July 2026", {
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  s.addNotes("All references are formatted in Vancouver style (numerical citation order). PMIDs provided for PubMed access.\n\nTop 2 references (gold) represent the highest-level evidence (Cochrane systematic review and comprehensive systematic review of RCTs).\n\nFor a full reading list and additional resources on psychodermatology, see the EADV 2024 congress psychodermatology abstracts and the BAD delusional infestation guideline (NICE-accredited, valid until May 2026).");
}

// ─── SLIDE 16 – CLOSING / SUMMARY ────────────────────────────────────────────
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  const msgs = [
    "30%+ of dermatology patients have psychiatric comorbidity — screen proactively",
    "SSRIs are first-line for excoriation, BDD, TTM, and comorbid depression in skin disease",
    "Pimozide / Risperidone: first-line for delusional infestation (BAD 2022, ECG mandatory)",
    "N-acetylcysteine 2400mg/d: best RCT evidence for trichotillomania (Cochrane 2021)",
    "NEVER treat BDD with cosmetic procedures without psychiatric evaluation first",
    "Check drug interactions: pimozide + azoles/macrolides = dangerous QTc prolongation",
    "Mirtazapine and naltrexone are evidence-based for chronic pruritus",
    "Psychodermatology multidisciplinary care = best patient outcomes",
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  s.addText("Questions\n&\nDiscussion", {
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  s.addNotes("CLOSING SUMMARY:\n\nThe key message for dermatologists: psychopharmacology is a core competency in modern dermatology. You do not need to be a psychiatrist to initiate first-line treatment — but you do need to know when to refer.\n\nThe evidence base is growing but remains thin — most trials are small, short-term, and single-centre. The field urgently needs larger, multicentre RCTs, particularly for excoriation disorder, DP, and prurigo nodularis.\n\nThe EADV 2024 congress and BAD 2022 guidelines represent the current gold standard — integrate these into your practice.\n\nThank you — questions welcome.\n\nDermatology Conference 2026 | Psychopharmacology for Psychodermatological Conditions");
}

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