Neurotic excoriations

Neurotic excoriations also known as compulsive skin picking, dermatillomania or pathological skin picking, is a disorder characterized by the repetitive picking of one’s own skin to the point of causing open sores that may bleed and leave scarring. Neurotic excoriations are skin lesions produced by the patient through repetitive scratching, without an underlying physical pathology. Because there is no known physical problem of the skin, neurotic excoriation is a physical manifestation of an emotional or psychological problem with the patient often having a comorbid mental illness usually anxiety or a mood disorder ¹. People suffering from neurotic excoriation may pick at normal skin variations such as freckles and moles, at pre-existing skin defects such as scabs, sores or acne blemishes, or in some cases imagined skin defects that are not actually visible by others. Individuals with neurotic excoriation not only use their fingernails to pick and scratch but may also use their teeth and/or other instruments such as tweezers, blades and pins. The compulsion to scratch, pick or peel pimples is called acne excorié and could be considered a subtype of neurotic excoriation. The quantity of lesions varies, ranging from a few to several hundred, and the lesions are located in easily accessible places on the body ². Although any part of the body may be attacked, often the face is the targeted area. The classic lesions are characterized by clean, linear erosions, scabs and scars that can be hypopigmented or hyperpigmented. The lesions are usually similar in size and shape, and are grouped on easily accessible and exposed body sites, such as extensor surfaces of the extremities, face and upper back ³.

Skin damage caused from neurotic excoriation can range from mild to extreme. Bleeding, bruising and secondary infections are not uncommon. In severe cases, patients may create wounds so large that they require hospitalized care. Compulsive skin picking often leads to permanent disfigurement, shame and social impairment. Sufferers will often try to hide the damaged caused to their skin by wearing make-up and/or clothes to cover the marks and scars. In extreme cases, they will avoid social situations to hide their condition from those around them.

Unlike other self-inflicted dermatoses (e.g., dermatitis artefacta and malingering), the patient with neurotic excoriations acknowledges the self-inflicted nature of the lesions.

Although it has not been reported in the primary care literature, the incidence and prevalence of neurotic excoriations is thought to be common and underreported. There is a 2 percent incidence of neurotic excoriations among dermatology clinic patients ⁴ and a 9 percent prevalence of neurotic excoriations in patients with itch (pruritus) ⁵. Neurotic excoriations or compulsive skin picking primarily affects female patients (52 to 92 percent in various studies) ¹. Most studies report a mean onset between ages 30 and 45 years ¹.

Psychotropic medications and appropriate psychotherapy can be effective treatments.

The patient’s denial of psychic distress and the possible negative feelings aroused in health care personnel make management of excoriation (skin-picking) disorder difficult. It is has been estimated that about 20% of patients with excoriation (skin-picking) disorder look for treatment. This is thought to be due to the belief that the condition is untreatable or considering it a “bad habit” or due to fear of social embarrassment. A dermatologist rather than a psychiatrist or psychologist often first sees those that do seek treatment ⁶.

There is currently no medication approved by the US Food and Drug Administration approved for the treatment of excoriation (skin picking) disorder ⁷. Attempts to treat it with a variety of psychotropic medication classes include antipsychotic agents, antianxiety agents, antidepressant agents, topical cortisone agents, and antiepileptic agents.

If the patient refuses referral to a psychiatrist, psychotropic drug therapy prescribed by dermatologists is helpful and appropriate. The upper dose range of selective serotonin reuptake inhibitors (SSRIs) or low-dose atypical antipsychotic agents may be effective.

Studies have shown that the serotonergic effect of SSRIs produces an antipruritic effect ⁸. The relief of pruritus is unrelated to changes in the patient’s mood and happens faster than would be expected for antidepressant effects.

Olanzapine may be an effective adjunctive therapy in the management of acne excoriée ⁹. Paroxetine was reportedly effective in a case of psychogenic pruritus and neurotic excoriations ¹⁰. Lithium has been used to treat neurotic excoriations, but further study is needed ¹¹. Dereli et al ¹² found that gabapentin is a useful treatment for recalcitrant chronic prurigo nodularis.

Using hypnosis to facilitate resolution of psychogenic excoriations in acne excoriée has been reported ¹³.

Neurotic excoriation causes

Individuals with neurotic excoriation often have a co-existing psychiatric disorder. The most common co-existing psychiatric conditions are major depression and anxiety disorders, especially obsessive-compulsive disorder (OCD). In one study, 52% of patients with neurotic excoriation were also diagnosed with OCD. An organic disease such as anemia, uremia or liver disease may also cause neurotic excoriation. It is essential for the doctor to consider all possible causes.

In many sufferers of neurotic excoriation, skin picking is preceded or accompanied by a high level of tension, anxiety or stress and a strong urge to itch or scratch. Often certain events or situations trigger skin-picking episodes. For some, the act of skin picking provides a feeling of relief or pleasure. Skin-picking episodes can be a conscious response to anxiety or may be done as an unconscious habit.

Neurotic excoriations may also be associated with methamphetamine or cocaine abuse.

An French survey of neurotic excoriations in 10 patients found that most patients linked their initial excoriations with personal problems; 4 of the patients noted abuse in childhood or in adolescence ¹⁴. This study appeared to suggest that skin picking was an impulsive reaction rather than an obsessive-compulsive disorder; however, the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5), currently classifies excoriation disorder among the obsessive-compulsive and related disorders ¹⁵.

Patients can have a psychiatric history that includes a comorbid mental disorder. Most patients with excoriation disorder do not have any particular psychopathology; however, psychiatric diagnoses to be considered include the following:

• Depression
• Trichotillomania
• Anxiety
• Tic disorder
• Obsessive-compulsive disorder (OCD)
• Body dysmorphic disorder
• Somatoform disorders (eg, facial dermatitis, somatization, or hypochondriasis)
• Borderline personality disorder (self-mutilation)
• Delusions of parasitosis (may be part of a larger diagnostic group, such as schizophrenia)

Patients pick at areas until they can pull material from the skin. This may be referred to as “pulling a thread from the skin.”

Setyadi et al ¹⁶ noted that trigeminal trophic syndrome can result in ulcerations on the nose (in the nasal ala and paranasal locations), most commonly manifesting in older women after therapy for trigeminal neuralgia.

Young women who pick at their faces may have a history of mild acne. Such cases are referred to as acne excoriée. The erosions can heal slowly because of recurrent picking.

It is helpful to ask patients which came first, the lesion or the urge to itch. When closely questioned, most patients say that they first scratched their skin and then saw a lesion. The lesions of neurotic excoriations have a component of an itch-scratch cycle, whereby the urge to scratch generates an even greater urge to scratch.

Because a variety of physical conditions can cause itching and skin lesions, these must be excluded or, at least, established as being relatively unlikely before a firm diagnosis of excoriation disorder can be made. Such conditions include the following:

• Scabies
• Dermatitis herpetiformis
• Dermatitis artefacta
• Prurigo nodularis
• Renal disease
• Cocaine use
• Opiate use
• Medication reactions
• Multiple sclerosis
• Hepatic disease
• Lymphoma
• Pregnancy
• Internal cancers
• Uremia
• Carcinoid
• Delirium
• Polycythemia vera
• Diabetes mellitus
• Hypothyroidism
• Iron deficiency anemia
• Hyperthyroidism
• Xerosis. Xerosis, or generalized dry, flaky skin, is the most common cause of pruritus in the elderly population ¹⁷. The elderly lack fatty acids in the skin that augment hydration and barrier function, leading to the development of xerosis. The generalized itching that results can lead to anxiety or depression, and, subsequently, progression to neurotic excoriations.
• Urticaria
• Intestinal parasitosis
• Myeloma may be noted
• Patients may report headache or menstrual disorders.

Neurotic excoriation differential diagnosis

The differential diagnosis of self-inflicted skin lesions can be separated between purely medical causes (Table 1), purely psychiatric etiologies (Table 2) and a combination of both ¹⁸. Depression, anxiety and obsessive-compulsive disorder (OCD) are the psychiatric diagnoses most commonly associated with patients who have neurotic excoriations. Another frequent association in these patients is many social stressors, particularly those related to family and work ¹⁹. Some of the psychiatric disorders and social stressors may be well hidden because of shame or a delusional belief system. Psychodynamic issues may center on suppression or repression of aggression relating to unmet emotional needs. These may arise from past or current situations and be difficult to resolve directly. Some associated traits include: low self confidence, generalized apprehension, meticulousness, depressive mood and hypersensitivity to perceived negativism toward themselves ²⁰. Some physicians propose that certain cases of neurotic excoriations are actually a subtype of OCD.

Usually the history, presentation and physical examination will quickly narrow the diagnostic choices.

Table 1. Medical causes of self-inflicted skin lesions

Hepatic disease

Pregnancy

Uremia

Delirium

Polycythemia vera

Hypothyroidism

Hyperthyroidism

Urticaria

Malignant lymphoma

Other malignancies

Carcinoid

Myeloma

Diabetes mellitus

Iron deficiency anemia

Xerosis

Intestinal parasitosis

Table 2. Psychiatric causes of self-inflicted skin lesions

Depression

Anxiety

Obsessive-compulsive disorder

Somatoform disorders (facial dermatitis, somatization, hypochondriasis)

Delusions of parasitosis (may be part of a larger diagnostic group, such as schizophrenia)

Trichotillomania

Tic disorder

Body dysmorphic disorder

Borderline personality (self-mutilation)

Neurotic excoriation signs and symptoms

Neurotic excoriations are self-inflicted skin lesions produced by repetitive scratching ³. Patients with neurotic excoriation disorder often give a history of picking, digging, or scraping their skin. Sometimes an inciting incident is the cause, and sometimes no inciting incident is present. Patients might note that they do not scratch themselves consciously; rather, they pick and then notice that they are picking. The classic lesions are characterized by clean, linear erosions, scabs and scars that can be hypopigmented or hyperpigmented. The lesions are usually similar in size and shape, and are grouped on easily accessible and exposed body sites, such as extensor surfaces of the extremities, face and upper back. Concurrent symptoms of headache or menstrual disorders are common in these patients.

Skin features

Neurotic excoriations are characterized as clean, linear erosions, scabs and scars that are frequently hypopigmented or hyperpigmented. All lesions are usually of similar size and shape. Patients “dig”at their skin to relieve itching or to extract imaginary objects that they believe are imbedded or extruding from their skin. The lesions are grouped at sites of the body that are easily accessible and usually exposed, such as the extensor surfaces of the extremities, face and upper back. The excoriations present in various stages: dug-out ulcers, ulcers covered with crusts and surrounded by erythema, and areas receding into depressed scars ²¹. The number of excoriations can vary from a few to several hundred, and they often exhibit delayed healing because of recurrent picking.

The self-excoriation is often initiated by a disturbing sensation in the skin (i.e., pruritic),1 or because of an urge to excoriate a benign irregularity of the skin ²². This generates the “itch-scratch” cycle which, in some patients, develops into chronic dermatitis ²³.

Neurotic excoriation diagnosis

Neurotic excoriations are a diagnosis of exclusion ²⁴. A patient’s history may suggest some obvious reasons for itching, such as atopic dermatitis, contact dermatitis or food allergies. The following tests should be performed to eliminate any medical causes of generalized itching: complete blood count with differential chemistry profile, determination of thyroid-stimulating hormone levels and fasting plasma glucose level. The appropriate work-up for malignancy should be performed if indicated by the patient’s history.

Findings from the history may include the following:

• History of picking, digging, or scraping the skin
• Presence or absence of an inciting incident
• Personal problems (eg, history of abuse)
• Psychiatric history that includes a comorbid mental disorder
• Nasal ulcerations
• Facial acne

Psychiatric and medical diagnoses that should be considered include the following:

• Depression
• Trichotillomania
• Anxiety
• Tic disorder
• Obsessive-compulsive disorder (OCD)
• Body dysmorphic disorder
• Somatoform disorders
• Borderline personality disorder
• Delusions of parasitosis
• Scabies

Physical findings may include the following:

• Crusted or noncrusted lesions
• Erosions and scars with angulated borders
• Variable quantity of erosions and scars (from several to hundreds)
• Occasional evolution into frank ulcers

To rule out systemic disease, the following tests are indicated:

• Complete blood count (CBC) with differential
• Chemistry profile
• Determination of thyrotropin levels
• Fasting plasma glucose level

The appropriate workup for cancer can be performed if indicated by the patient’s history. A chest radiograph can help to rule out suspected lymphoma. Patients can be assessed for contact dermatitis or food allergies. A skin biopsy can be helpful to rule out other pathologic conditions.

Histologic findings

Biopsy samples of neurotic excoriations generally reveal epidermal ulceration with a mild superficial mixed infiltrate and crusts formed from fluid and red blood cells (RBCs). In older lesions, superficial dermal scar tissue and changes of lichen simplex chronicus (eg, irregular epidermal hyperplasia with hyperkeratosis, hypergranulosis, and vertical streaking of papillary dermal collagen) may be observed.

DSM-5 diagnostic criteria

The American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) ¹⁵, places excoriation (skin-picking) disorder in the category of obsessive-compulsive and related disorders and notes that it is characterized by recurrent body-focused repetitive behavior (skin picking) and repeated attempts to decrease or stop the behavior.

The specific DSM-5 criteria for excoriation (skin-picking) disorder are as follows ¹⁵:

• Recurrent skin-picking, resulting in skin lesions
• Repeated attempts to decrease or stop skin picking
• The skin picking causes clinically significant distress or impairment in social, occupational, or other important areas of functioning
• The skin picking cannot be attributed to the physiologic effects of a substance (eg, cocaine) or another medical condition (eg, scabies)
• The skin picking cannot be better explained by the symptoms of another mental disorder (eg, delusions or tactile hallucinations [psychotic disorder], attempts to improve a perceived defect or flaw in one’s appearance [body dysmorphic disorder], stereotypies [stereotypic movement disorder], or intention to harm oneself [nonsuicidal self-injury])

Associated features supporting the diagnosis include a range of behaviors or rituals involving the skin that has been picked. Examples include examining, playing with or even swallowing the skin after it has been pulled off. Picking can be accompanied by different emotional states. The act of picking can be triggered by anxiety or boredom and be preceded by a sense of tension. Afterwards individuals might feel a sense of pleasure, relief or gratification. Pain is not routinely reported ¹⁵.

Neurotic excoriation treatment

Treatment for neurotic excoriation depends on the cause and the level of awareness the patient has regarding the problem. Compulsive skin picking stemming from a psychological disorder is best treated with psychotherapy. Collaborative care is an important consideration, because many patients need active psychotherapy in addition to medication. When neurotic excoriation is generally an unconscious habit the treatment of choice is a form of cognitive behavior therapy (CBT) called Habit Reversal Training.

Psychotherapy

• Habit Reversal Training – this is a form of psychotherapy that helps patients to become more consciously aware of situations and events that trigger skin-picking episodes. Patients are then taught alternative behaviors in response to these situations and events.
• Exposure and Response Prevention – this is commonly used in the treatment of obsessive-compulsive disorders and is useful in cases of neurotic excoriation where the patient is already aware of the situations and events that cause skin-picking episodes. Most patients using this technique have already made significant recovery using Habit Reversal Training.

Initially, psychotherapy should be supportive and empathic but open to other approaches as issues emerge. Cognitive-behavioral approaches may focus on helping the patient understand the illness through education and finding alternative responses to the pruritic sensations (i.e., changes in assumptions and automatic thoughts about the symptoms themselves, the substitution of a healthy ritual such as an oatmeal soak or distraction with other activities). The most difficult time for many patients is at night, when itching occurs while the patient is in the near-sleep state.

A close working relationship with a therapist will alert the physician to increasing stress in the patient’s life that may present as new somatic concerns. The possibility of other psychiatric diagnoses emerging with therapy may also necessitate alterations in the treatment approach, including medications. Treatment aimed at a primary psychiatric diagnosis is usually fundamental for effective treatment of these patients ²⁵.

Drug treatments

Medications used for the treatment of OCDs are also frequently used in neurotic excoriation. They are often used in conjunction with cognitive behavior therapy. The drugs of choice are the selective serotonin reuptake inhibitors (SSRIs) such as fluoxetine, paroxetine, sertraline and fluvoxamine. Acetylcysteine has also been reported to be effective.

Several studies ²⁶, ²⁷ have shown that the serotonergic effect of selective serotonin reuptake inhibitors (SSRIs) consistently produces the strongest antipruritic response in patients with neurotic excoriations. These studies also found that the relief of pruritus was unrelated to changes in the patient’s mood and occurred sooner than would be expected for antidepressant effects. This finding, combined with reports ²⁸ of a similar effect using the serotonin type 3 receptor antagonist ondansetron (Zofran), suggests that serotonin sites other than the 5-HT1a receptor may be key in the treatment of pruritus. There may also be an association with the reportedly effective treatment of neuropathic pain by SSRIs, implying a possible central, as well as peripheral, action on the pain/itch fibers.

OCD may be an underlying component in some cases, but the patient may deny or minimize it ²². Often, a lower dosage of an SSRI is required to lift symptoms of depression compared with improving symptoms of OCD. It is important to increase the dosages whenever lower dosages produce a partial response, initial response or nonresponse. If the patient is unresponsive to a specific SSRI, another SSRI should be tried, increasing the dosage by gradual increments.

The “itch-scratch” cycle induces mast cell degranulation and cytokines that may respond to antihistamines. Doxepin (Sinequan) is an antidepressant with antihistaminic properties. Doxepin is highly sedating, 10 to 30 mg at bedtime is usually sufficient.

Other published reports ²⁹ support trials of tricyclic antidepressants, antihistamines and naloxone (Narcan) in some cases, but these agents have more side effects and less consistent efficacy.

A dermatologic approach to neurotic excoriations may include the use of antibiotics, topical steroids or lubricants:

• If there is significant crusting and secondary bacterial infection of the erosions, antibiotic therapy (e.g., erythromycin or a first-generation cephalosporin) is indicated.
• Steroids applied twice daily can be effective. Low-potency (group 5) topical steroids should be tried first, gradually progressing to high-potency steroids (group 1) if there is little or no response ²¹.
• Patients can also try substituting ritualistic application of lubricants for the ritual of digging. It is helpful to recommend using only mild soaps and decreasing the frequency of washing.

Complementary or alternative medicine

Other approaches may include hypnosis ¹³ for direct intervention in the itch-scratch cycle, acupuncture ³⁰ and supportive and family therapy to reduce underlying stressors.

Neurotic excoriation prognosis

Except in mild transient neurotic excoriation cases triggered by an immediate stress, the prognosis for neurotic excoriation cure is poor. Neurotic excoriation tends to wax and wane with the circumstances of the patient’s life. Often, however, neurotic excoriation disorder can be controlled if the underlying psychological illness is controlled. Patients need intervention but sometimes have difficulty in changing the habit of picking. Without medical and psychiatric treatment, neurotic excoriation disorder tends to be a chronic condition. Untreated neurotic excoriations can result in scarring or infection, or tissue damage that may require antibiotics or surgery. Rarely, synovisits has been reported in the wrists due to chronic picking ¹⁵.

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