Excoriated acne

Excoriated acne also called acne excorie, acné excoriée or picker’s acne, is a term used to describe scratched or picked pimples because it occurs when the affected individual picks at the acne lesions. Acne excoriee is most often seen in teen girls. The picking exacerbates the acne and causes scars; the scarring leads to more acne and, ultimately, more picking. Anxiety, depression, and other emotional problems may accompany acne excoriee.

The acne itself, known as common acne or acne vulgaris, is a very common skin condition caused by many factors. Treatments are aimed at these various factors and include antibiotics, medications to increase skin turnover, and medications to decrease inflammation. In the case of excoriated acne, the treatment should also address possible emotional problems.

Figure 1. Acne excoriee

Footnote: This patient had small amounts of acne, but her picking resulted in scars.

Who’s at risk of acne excoriee?

Anyone who gets acne can suffer from acne excoriee. Acne excoriee is usually seen in teen girls and may persist into adulthood, particularly women with late-onset acne. Common acne (acne vulgaris) is quite common and affects almost everyone at some point in their lives.

Spending hours in front of the mirror can also be a sign of stress or depression. Psychiatrists may classify acne excorie with body dysmorphic disorder (bodily focused anxiety).

Sometimes it is just a bad habit that’s hard to break; the acne may not actually be all that severe. In fact there seems to be two subgroups of acne excoriee patients – one where patients have primary acne lesions and those who have none or hardly any acne lesions.

There are two reasons for acne excoriee presentation:

1. Very occasionally patients with very mild acne just pick acne spots in the belief that simply by so doing that will help the acne. A simple explanation from the doctor of the harm that they are doing can help considerably
2. In the other subgroup, the majority, there may be underlying psychological problems, which are often difficult to unravel. There may even be no pathological acne lesions, the patient just scratches the skin – such patients may be considered to have dermatitis artifacta and / or dysmorphophobia

Excoriated acne can be very upsetting and embarrassing.

Excoriated acne causes

Acne is a common chronic inflammatory disorder affecting the hair follicle and sebaceous gland (skin oil glands), in which there is expansion and blockage of the follicle and inflammation. You may hear people call acne as “pimples”, “spots” or “zits”. The most common type of acne is “acne vulgaris”, which is the medical term for “common acne”. Acne is given this name to distinguish it from less common variants of acne.

The precise reasons that acne is most severe during the teenage years are being studied. There are several theories. There are higher levels of sex hormones after puberty than in younger children.

• Sex hormones are converted in the skin to dihydrotestosterone (DHT), which stimulates sebaceous (oil) glands at the base of hair follicles to enlarge.
• The sebaceous glands produce sebum. Changes in sebum composition may lead to acne lesions.
• The activated sebaceous gland cells (sebocytes) also produce pro-inflammatory factors, including lipid peroxides, cytokines, peptidases and neuropeptides.
• Hair follicles are tiny canals that open into skin pores (tiny holes) on the skin surface. The follicles normally carry sebum and keratin (scale) from dead skin cells to the surface. Inflammation and debris leads to blockage of the skin pores — forming comedones.
• The wall of the follicle may then rupture, increasing an inflammatory response.
• Bacteria within the hair follicle may enhance inflammatory lesions.

While acne is most common in adolescents, acne can affect people of all ages and all races. It usually becomes less of a problem after the age of 25 years, although about 15% of women and 5% of men continue to have acne as adults. It may also start in adult life.

With acne there is a variety of spots that appear on your face, neck, shoulders, chest and back.

• Inflamed papules and pustules are commonly called spots, pimples and zits.
• Dark- or skin-colored papules are comedones. These are better known as blackheads and whiteheads.
• Acne can lead to secondary skin color changes (red, white and brown patches) and scarring.

Acne most often affects the face, but it may spread to involve the neck, chest and back, and sometimes even more extensively over the body.

Individual lesions are centered on the pilosebaceous unit, ie the hair follicle and its associated oil gland. Several types of acne spots occur, often at the same time. They may be inflamed papules, pustules and nodules; or non-inflamed comedones and pseudocysts.

Most people squeeze or pick some of their acne in an attempt to be rid of them. This can makes the acne look worse. The acne may become secondarily infected and picking it may also cause scarring.

Some individuals excessively pick their spots. When their skin is examined, they have no active acne spots, only scratch marks, sores, pigmentation and scars. All the inflammatory lesions and comedones have been removed by picking or squeezing. This appearance is called acne excoriee or excoriated acne.

Most people are aware that their facial sores are due to skin picking, but they do not always admit to it openly.

Excoriated acne signs and symptoms

Acne results in a variety of lesions. The most common acne locations include the face, neck, chest, and back, where the most sebaceous glands are located. “Blackheads” (open comedones) and “whiteheads” (closed comedones) are follicular plugs that are either oxidized from being exposed to the air (blackhead) or sitting below the skin surface (whitehead). Papules are small pink to reddish-brown bumps, pustules are superficial pus-filled lesions, and nodules or cysts are deeper pus-filled lesions.

Mild acne consists of a few papules/pustules and/or comedones. Moderate acne has an increased number of lesions. Severe acne has numerous comedones, papules, and pustules and may have painful nodules.

Picking can result in scabs, shallow sores, and permanent scars, which can appear as either depressions in the skin or hyperpigmentation, which is dark red or brown flat marks where the acne lesions were. The habit of picking at the skin may persist long after the acne has improved.

Excoriated acne treatment

Treatment of excoriated acne depends on whether or not the patient has primary acne lesions. Active acne spots can be managed using acne treatment depending on their clinical severity.

Some patients with acne excoriee may just need to break the habit of picking, whilst other patients may have a compulsive skin picking disorder. This may require psychological therapy and psychotropic drug treatments.

Self-care guidelines

Traditional acne treatments often do not stop the habit of picking at the skin. These traditional treatments are:

• Gentle cleansing with mild soap or cleansers. (But don’t scrub!)
• Resist picking at lesions.
• Avoid irritants (rubbing and other alcohols, abrasive scrubs) and oily creams, cosmetics, hair products, and sunscreens.
• Use products labeled “water-based” or “noncomedogenic.”
• Keep hair, hands, and devices such as cell phones off the face.
• Avoid greasy products on the skin and scalp.

Over-the-counter medications:

• All over-the-counter therapies listed below should be used as a preventive therapy, applied in a thin to moderate quantity to entire regions. Acne treatment is not intended for existing individual lesions but is applied consistently over months to prevent new lesions. Expect slow improvement. Develop a skin care regimen that is modified slowly over time, not week to week.
• Benzoyl peroxide (most effective), available in a variety of forms and strengths. Benzoyl peroxides tend to dry the skin. If you have dry skin, use a weaker concentration product; for oily skin, consider higher strengths.
• A combination of a vitamin B3 (nicotinamide) and zinc is available in cream and gel form.
• Exfoliants (or peeling agents) such as salicylic acid, sulfur, resorcinol, alpha-hydroxy acids (glycolic, lactic, pyruvic, and citric acid).
• Aluminum chloride hexahydrate (an antiperspirant available as Xerac-AC™) may be useful, but can also be irritating.
• Clinac OC is a copolymer that absorbs oil, helping reduce the look of “greasy skin.” It also is produced combined with benzoyl peroxide.

Note:

• Acne can have significant psychological effects. Talk to your doctor about any feelings of depression. Counseling may be a key factor for improvement for acne excoriée.
• Some people with acne have reported improvement in their skin when they follow a low-glycemic index (low GI) diet and increase their consumption of whole grains, fresh fruits and vegetables, fish, olive oil, garlic, while keeping their wine consumption moderate. It’s a good idea to drink less milk and eat less of high glycemic index (high GI) foods such as sugar, biscuits, cakes, ice creams and bottled drinks. Reducing your intake of meat and amino acid supplements may also help. Seek medical help if you are concerned about your skin, as changing diet does not always help.

Treatments your physician may prescribe

Topical (or external) treatments include one or more creams, washes, or gels that include:

• Antibiotics such as benzoyl peroxide, clindamycin, erythromycin, sulfur, sodium sulfacetamide, and azelaic acid.
• Retinoids – vitamin A-derived products such as tretinoin, tazarotene, and adapalene.

Oral treatments may include:

• Antibiotics such as tetracycline, minocycline, doxycycline, erythromycin, ampicillin, clindamycin, trimethoprim-sulfamethoxazole, azithromycin, or cephalosporins.
• Oral contraceptives and spironolactone have been found to help regulate hormones.
• Isotretinoin, a strong drug with many side effects, for severe acne unresponsive to the above treatments.

Procedures:

• Special “blue light” treatments are a new way being investigated to treat acne but are usually not covered by insurance.
• Several types of laser treatments also help acne and are often used with other treatment methods; however, treatments are expensive, must be repeated for several months, and have variable efficacy. Insurance may not cover laser therapy.
• Laser resurfacing, plastic surgery, and/or dermabrasion may help reduce the prominence of old acne scars.

If there is evidence of excessive anxiety or depression, counseling may be suggested. Sometimes, anti-anxiety or anti-depressant medication may be prescribed.