Neurotic excoriation

Neurotic excoriation is a condition in which there is excessive scratching or picking of normal skin or of skin with minor surface irregularities. This often results in scarring and inflammation.

Epidemiology^[1]

• It is seen in about 2% of dermatology clinic patients.^[1]
• One study using a community-based questionnaire found that 62.7% of 354 respondents confirmed some form of skin picking and 5.4% reported clinical levels of skin picking and associated distress/impact.^[2]
• It is more commonly seen in women.
• The mean age of onset is in middle-age (30-45 years).
• It is the most common factitial skin disease of childhood.^[3]

Presentation^[1]

• There is a history of picking, digging or scraping of the skin. There may or may not be an obvious inciting incident. The patient may be unaware of the self-inflicted trauma at the time and may only notice the resulting lesions.
• Picking continues until material can be pulled from the skin.
• Nasal ulceration can occur; trigeminal neuralgia can be a predisposing condition.
• Psychological comorbidities are common (for example: depression, anxiety, obsessive-compulsive disorder, body dysmorphic syndrome, eating disorders, kleptomania or borderline personality disorders).
• Right-handed patients generally tend to produce lesions on the left side and vice versa. The lesions tend to have angulated borders and consist of erosions and older scars. The number can vary from a few to several hundred.
• Consider the diagnosis when lesions do not conform to any known other dermatological condition and are confined to areas which can be reached by the patient.

Differential diagnosis^[1]

• Scabies
• Dermatitis herpetiformis
• Renal disease and uraemia
• Cocaine/opiate/amfetamine use
• Lymphoma
• Diabetes mellitus
• Thyroid disease
• Iron deficiency
• Delusions of parasitosis
• Dermatitis artefacta.

Investigations^[1]

These are primarily to exclude other diagnoses and may include:

• FBC.
• Chemistry profile including fasting glucose.
• TFTs.
• Tests for cancer if indicated by presentation (eg CXR for lymphoma).
• Tests for food allergy and contact dermatitis.
• Skin biopsy.

Management^[1]

• Underlying psychopathology should be addressed. Habit reversal therapy and hypnosis have been used to good effect.^[4]
• Topical corticosteroids may help to reduce inflammation.
• Medications found useful include SSRIs, doxepin, clomipramine, naltrexone, pimozide. Reports suggest that olanzapine (2.5-5 mg daily for 2-4 weeks) may also be helpful.
• Pulsed dye laser therapy may be helpful in the management of scarring.^[5]

Complications^[1]

• Scarring
• Worsening anxiety

Prognosis^[1]

This depends on the underlying psychological condition and how responsive it is to treatment. Natural resolution without therapy is unusual.

Acne excoriée

Acne excoriée is a type of neurotic or psychogenic excoriation. It can be classified as a factitial skin disease in that it is consciously or subconsciously fabricated by the patient. It is a condition in which patients pick at their acne lesions. Because the condition was first detected in young girls, it was called 'acné excoriée des jeunes filles'.^[6] The picked lesions become scarred and infected, causing itching which leads to further picking. Sometimes the picking continues long after the original acne has healed. There appear to be two subgroups - patients in whom there are primary acne lesions and those who have virtually no lesions at all.

Epidemiology^[7]

• There is no epidemiological information concerning the prevalence of acne excoriée per se but it is thought to be relatively rare, particularly with the advent of more effective forms of acne treatment.
• It is more commonly seen in women with late-onset acne.

Presentation^[6]

• Always consider diagnosis in acne not responding to treatment, atypical presentations and where scarring is predominant.
• Most of the lesions are excoriated papules with few obvious comedones. Erosions can become frank ulcers.
• Lesions occur where the patient can scratch: face, trunk, extensor extremities and upper back.
• Scars tends to be:
  • Round, oval or stellate in shape.
  • Hypopigmented or hyperpigmented.
  • With angulated borders.
  • Approximately the same size and shape.

Differential diagnosis^[1][6]

• Scabies
• Dermatitis herpetiformis
• Sterile eosinophilic pustulosis
• Gram-negative folliculitis
• Acneiform eruptions
• Delusions of parasitosis
• Dermatitis artefacta

Management

• Trial of systemic antibiotics for six months, as for acne vulgaris, but frequently response is poor.^[1]
• Medication options are as for neurotic excoriation. .
• Therapies other than the treatment of the underlying acne may best be instituted in conjunction with a specialist.^[7]

Complications

As for neurotic excoriation.

Prognosis^[1]

The prognosis is similar to other forms of neurotic excoriation - ie it has a tendency to become chronic, although improvement can occur with treatment of underlying psychological illness.