Acne Excoriee

Synonyms: Neurotic or psychogenic excoriation, pathological or compulsive skin picking, dermatotillomania.

Excessive scratching or picking of normal skin or skin with minor surface irregularities can result in severe and prolonged acne, with an exacerbation of underlying inflammatory processes and scarring.

• Seen in about 2% dermatology clinic patients²
• More commonly seen in women
• Mean age of onset in middle-age (30-45 years)
• Although rare, it is the most common factitial skin disease of childhood³
• Common psychological co-morbidities (for example: depression, anxiety, obsessive-compulsive disorder, body dysmorphic syndrome, eating disorders, kleptomania, obsessive-compulsive or borderline personality disorders).²

• Most of the lesions are excoriated papules with few obvious comedones and papules. Erosions can become frank ulcers.
• Lesions occur where the patient can scratch: face, trunk, extensor extremities and upper back.
• There is usually a bilateral distribution, with a tendency for more lesions on the left in right-handed individuals and the right in left-handers.
• Scars tends to be:
  • Round, oval or stellate in shape
  • Hypo or hyper-pigmented
  • Have angulated borders
  • Approximately the same size and shape.

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

• Trial of systemic antibiotics for 6 months as for acne vulgaris but frequently response is poor.
• Always consider diagnosis in acne not responding to treatment, atypical presentations and where scarring is predominant.

• Refer to dermatologist where treatment with retinoids is required. Note that relapse following roaccutane therapy is common.
• Refer to psychiatry for consideration of medication (including SSRIs and neuroleptics such as olanzapine), psychological therapies (cognitive behavioural therapy, habit reversal) and hypnosis.^2,5

• Scarring
• Worsening anxiety.

The condition has a tendency to become chronic although improvement can occur with treatment of underlying psychological illness.