Are You Confident of the Diagnosis?
The term neurotic excoriations (NE) refers to a condition in which the patient picks at his or her own skin, and freely acknowledges that he or she is creating the lesions. NE is not to be confused with dermatitis artefacta, in which the lesions appear mysteriously and the patient stridently denies any part in their genesis. NE is also not to be confused with cutaneous delusions infestation or Morgellons disease, in which the patient freely acknowledges that he or she picks the skin, but in those cases it is an attempt to “dig out” foreign agents believed to be hidden there.
NE is primarily a psychiatric disorder with cutaneous manifestations. Some degree of picking is a part of normal grooming behavior, and at what point this picking becomes N.E. is unclear. Many children pick insect-bites or scabs as a habit, which most commonly is outgrown. Many quite normal people pick irregularities in the skin surface when the mind is otherwise occupied, or if there is a minor itch (e.g., many drivers pick the scalp, when stopped at a red-light). This minor picking is within the spectrum of normal behavior unless it cannot be controlled, causes significant tissue damage and emotional distress, or interferes with normal functioning. Patients who pick the skin may have other impulse-driven or compulsive behaviors such as nail-biting, alcohol dependence, trichotillomania, body dysmorphic disorder or an eating disorder.
Psychiatric researchers employ rather rigid diagnostic criteria for NE. The patients that are described in the psychiatric literature are at the more severe end of the spectrum. These patients pick normal skin uncontrollably and consistently.
In dermatology, we see a rather broader spectrum of patients. Dermatology patients with NE are using skin-picking to defend against the recognition that they have psychological issues. The picking is uncontrollable but episodic. It may occur on entirely normal skin, on skin that has previously been picked, or within an area already affected by a skin disease, such as acne or eczema. The picking causes tissue destruction, emotional distress— shame, embarrassment— and impaired quality of life.
Characteristic features on physical examination
The primary lesions of NE are clean, scooped-out or linear, open or crusted ulcerations, in every stage of development (Figure 1, Figure 2, Figure 3). Lesions are slow to heal because of repeated picking. They are of roughly equivalent size, but vary in number from three or four to perhaps several dozen. Lesions are confined to areas within reach of the hands. The face, scalp, extensor forearms and arms are usually picked, but, the shoulders, and the upper back are the most common sites (Figure 3). The breasts, buttocks, and anterior thighs are also often involved, but the “butterfly” area between the scapulae and out of reach of the hands is spared.
Picking may be with the fingers, tweezers, knife-points, or other convenient instruments, and leads to scarring, with dyspigmentation, atrophy, lichenification or prurigo nodules (Figure 4).
There is a broad spectrum of picking behavior: Episodes are associated with depression, anger, anxiety, or situational stress. A focal altered sensation may draw attention to a specific spot and precede picking.
Small blemishes such as acne lesions, hyperkeratosis, or lesions of keratosis pilaris may be sought out to pick. Patients with body dysmorphic disorder pick the skin to remove what is perceived to be abnormal, irregular, or ugly.
Some pick uncontrollably at a particular time of day and behind closed doors. There may be complicated and time-consuming rituals. Picking may take from minutes to many hours at a time. At an emotional level, much time may be spent in thinking about picking, resisting the urge, giving in, and subsequently berating the self for having done so.
Episodes can be preceded by a build-up of tension which is relieved by picking, and may be followed by transient happiness. Severe picking causes emotional distress, shame and embarrassment. These feelings can interfere in every aspect of the patient’s life. Though the patient believes that picking will improve appearance, at the same time he or she knows this is not so.
The clinical picture of NE is diagnostic. If there is focal dysesthesia in the absence of evident underlying skin disease, hepatic, renal and thyroid disease, viral infection, anemia, lymphoma, and occult malignancy should be ruled out by appropriate tests. Skin biopsy is seldom necessary for diagnosis, but may be indicated to reassure the patient.
Early lesions show loss of tissue without inflammatory changes. Depending on the depth and the age of the lesion, there may be serous exudation or scab formation, evidences of secondary infection, or lichenification. If there is an underlying skin disease, pertinent changes of that disease will also be evident.
Who is at Risk for Developing this Disease?
Although NE is classified as a psychiatric disorder, psychiatric and dermatologic factors combine to trigger NE.
Remember, when the dermatologist is consulted the patient is unconsciously using the skin to express unacceptable psychiatric issues that may not have been recognized. Anxiety disorder, mood disorders (depression), alcohol-abuse/dependence, recreational drugs, obsessive-compulsive personality disorder, and borderline personality disorder are common comorbidities in patients with NE. Approximately 45% of patients with body dysmorphic disorder pick their skin. The incidence of skin-picking is greater in patients who have a family history of obsessive-compulsive disorder.
Since dermatologists in general are not comfortable with prescribing psychotropic drugs, patients with NE who do not also see a psychiatrist are at risk of not receiving the best treatment. In addition to those who pick completely normal skin, patients with undertreated pruritic dermatoses or with insect bites, dry scaly skin, acne, keratosis pilaris and other cutaneous irregularities are at risk of picking, should there be stress in their lives.
Stress is shown to be associated with the release of neuropeptides in the skin that may cause or intensify itching and lead to picking. Once started, the scratching itself perpetuates itching while secondary changes in the skin cause surface irregularities that are tempting to pick off.
In many published epidemiological studies, the subjects are recruited from psychiatry clinics, psychology students, or from open questionnaires on the Internet. Unlike most dermatology patients, many of these subjects are aware that they have psychiatric issues and seek consultation. Many are also computer-literate. These factors may bias the findings. To date there are no comparable dermatologic studies.
These studies report that 2-5% of dermatology patients have NE. There is a female:male ratio of 75:25. The average age at onset is15-35 years. Because of shame and embarrassment, patients may delay seeking treatment for as long as 10 years. Forty-four percent of patients report a perimenstrual flare. In 30-90% of patients, picking episodes are triggered by acknowledged psychosocial stress.
From a dermatologic perspective the studies are simplistic. They take no note of the broad range of picking behaviors seen in dermatology, nor of pathologic changes that may take place in the skin that influence picking behavior. It is difficult to interpret these psychiatric findings in the context of a dermatology practice.
Experience in dermatology suggests that there are two peaks of increased picking activity. Children and adolescents pick insect bites, acne lesions, or keratosis pilaris as an ongoing habit. This picking is of very variable severity. It is frequently outgrown over a variable period of time. That 40% of young people continue pathologic picking into adulthood, as reported, seems a very high estimate. It would seem that the level of severity at which picking is deemed pathologic in these studies is very low.
In those children or adolescents for whom picking is severe and persistent, there is a history of emotional or separation difficulties in very early life, or there is stress in the home or in school. For these children, picking provides a release for anger, anxiety, and feelings of diminished self-esteem, or may even serve to affirm body boundaries.
There is a second group in which we see increased levels of picking in dermatology patients: These are women of 40-60 years of age or even older. Depression in this group is common, and psychosocial stress prevalent. Picking is chronic and debilitating and may lead to impaired personal and occupational functioning and social isolation.
A common pattern of picking is noted in these patients. An intense but quite focal itch occurs towards the end of the day when the mind is not otherwise occupied. The urge to pick is uncontrollable, and picking starts.
From the primary site, picking extends to every old excoriation or irregularity in the skin that can be found. Ritualization is common in this group. The discomfort is relieved only when each focal itch is picked out. Unlike the delusional patient, this patient has no concern about cause, but merely wants relief.
Between these two groups there are patients who may or may not have had skin disease, but in whom there is ongoing chronic picking that waxes and wanes with the exigencies of the patient’s life.
What is the Cause of the Disease?
Recognized psychosocial stress precedes picking in 30-90% of patients. Stress as a trigger is common in those who have anxiety, depression, impulse-control issues or one of the personality disorders. Each of these may underlie the picking behavior. Stress triggers the release of neuropeptides and other agents in the skin that are associated with cutaneous dysesthesia.
The American Psychiatric Association no longer recognizes the impulse control disorders as an entity, and NE is included in the Obsessive-Compulsive spectrum of diseases. The ritualization that we see in some patients is consistent with obsessive-compulsive pathology, and that there is a higher incidence of NE in patients with a family history of obsessive-compulsive disorder would also support that as an etiology. There is evidence also to support involvement of dopamine and opioid pathways.
Systemic Implications and Complications
It is important to ensure that there is not an underlying skin disorder, or systemic disease. One must rule out hepatic, renal and thyroid disease, anemia and lymphoma, and on the basis of the findings, make appropriate referrals.
A biopsy should be taken, should there be any question as to diagnosis, or if it is necessary in order to reassure the patient. This is a matter of judgment. Bacterial cultures should be taken as indicated. Infection is the most common complication, and may lead to cellulitis, abscesses and hospitalization.
Be alert to the possibility of deepening depression, or worsening emotional issues, as normal functioning may be impaired, and suicide is reported. Increased use of alcohol, recreational drugs or tobacco may be resorted to in an attempt to relieve the burden of the disease.
It is crucial that one develop a supportive doctor-patient relationship.
Try to effect a psychiatric referral.
Appropriate oral antibiotics.
Measures to promote healing:
Topical and intralesional steroids
Incision and draining as indicated.
Habit reversal therapy (HRT).
Cognitive behavioral therapy (CBT).
Specific serotonin reuptake Inhibitors. (SSRIs)
Optimal Therapeutic Approach for this Disease
THE DOCTOR-PATIENT RELATIONSHIP
A trusting doctor-patient relationship is crucial to success. Treatment must be a team effort. Patients generally feel that no one listens, and that doctors are ill-informed about their problem. Assure the patient that you understand the nature of the condition, that the picking is not voluntary, that it would not happen if the patient could avoid it and that the patient is not “crazy.” Empathize with the patient’s feelings of shame and embarrassment. Shame, because the patient, though not wishing to pick, has no ability to stop, and the physical appearance is unacceptable.
Weekly visits, which may be quite short, are needed to establish rapport, provide support, and demonstrate interest. Try to gauge the patient’s level of anxiety and depression. How well is the patient functioning? What does NE stop the patient from doing? Has the patient had thoughts of hurting him or herself, or of hurting others? Assure the patient that he or she is not unique, that you have seen similar patients before, and that there are effective treatments available.
Stress the fact that patient cooperation is essential. Help the patient to understand that he or she must be constantly aware, and must try to identify triggers that promote picking. Offer substitute ways to occupy the hands, to focus attention and try to release tension. A fidget ring, or beads can be very helpful. Regular encouragement is vital. Praise every small success, and empathize when things do not go well. If the patient is a child, the parents must be a part of the team and help the patient in similar ways at home, but without being judgmental or punitive. Gradually, as the relationship evolves, gently point out the ways that NE is impacting the patient’s life, and gradually introduce the value of a psychiatric referral and psychotherapy.
Prescribe oral antibiotics consistent with culture findings. The skin is the focus of attention. Maintain that focus, but offer positive action instead of the negative picking. Cool saline compresses (1 teaspoon of table-salt to 1 pint of cool water) are helpful. These can be applied twice daily for 5 -10 minutes, followed by a topical antibiotic (mupuricin ointment, 2.0 %, or equivalent) to any open areas. Apply a topical steroid cream (0.5 % betamethasone) to any thickened areas twice daily.
A retinoid (tretinoin, 0.05 % cream) can be introduced very gradually, to help to reduce scarring. Tretinoin is applied once daily at bedtime. It is helpful initially to mix the tretinoin cream with in equal amount of moisturizer, and perhaps start with alternate night application to ensure that there is no irritation. As the skin adjusts to the application, the tretinoin may be increased to nightly use, and the moisturizer can then gradually be withdrawn. Protective dressings of gauze or a nonstick material covered by an elastic bandage will provide protection to any open area, and may help to prevent ongoing picking.
Injections of a triamcinolone suspension (up to 40 mg/ml, depending on the degree of hypertrophy) may be injected at monthly intervals into any areas of hypertrophic scarring, or prurigo nodules. An oral antihistamine such as fexofenadine, 180 mg may be helpful, and will not make the patient sleepy during the day.
Any abscessed areas should be treated by incision and drainage. The possibility of cosmetic surgical procedures should be considered only if the condition is stable psychiatrically and if there is no longer any picking. Nonsurgical cosmetic routines may be considered initially, in preparation for surgery. The resulting improvement in the skin texture may help to discourage the patient from picking further.
Surgical intervention is not appropriate for any patient with body dysmorphic disorder.
In order that a psychopharmacologic drug be tolerated, it is important to start with the lowest dose and increase gradually to therapeutic levels. If the drug is to be discontinued, it should be tapered down in similar fashion. Common side effects can be expected to decrease over time. Because low-dose schedules of most psychotropic drugs are effective, significant side effects are unusual.
It is important to advise the patient that there is no drug that has been approved by the FDA for the treatment of NE, but that there are many that are very helpful. Advise the patient also, that the drug may take 4-6 weeks to be effective, and that the patient should not become impatient. If overnight cure is anticipated, trust will be lost, and treatment a failure.
The psychiatric treatments of choice for NE currently are HRT and CBT, or one of the SSRIs. Both HRT and CBT are relatively short-term, and are designed to help the patient to be aware of situations where picking may occur, to recognize and assess the associated feelings and to change the behavior. There is some evidence to suggest that HRT or CBT supplemented by an SSRI is superior to either treatment alone.
Insight-oriented therapy may also be effective, but currently is recommended less often. This therapy is directed towards uncovering underlying reasons for the self-destructive behavior, reasons of which the patient is not consciously aware. Therapy of this type is of much longer duration, sometimes many years, and for many patients the cost is prohibitive.
If psychiatric referral is rejected, the dermatologist can start treatment by prescribing one of the SSRIs. The SSRIs are effective in treating anxiety, depression, and obsessive-compulsive disorder, so they cover all the bases in the treatment of NE. SSRIs are well-tolerated and have an acceptable side effect profile. If one drug is not effective or not tolerated, then another drug in the same class may be prescribed. Side effects can be expected to diminish over time. These include nausea, somnolence or insomnia, headache, cholinergic effects, and a diminished sex drive. The drugs are best given with food to avoid nausea. In children there are occasional reports of deepening depression, and one must be alert to this possibility.
Any one of the SSRIs may prove effective in treating NE, but drugs for which there is evidence, include :
Fluvoxamine (Luvox, 50 mg. once daily at bedtime. Increase by 50 mg once each month as needed, to a total dose of 300 mg, divided and given twice daily).
Sertraline (Zoloft, 50 mg once daily in the morning increasing by 50 mg once each month to a total of 200 mg given as a single dose, once daily).
Citalopram (Celexa, 20 mgs once daily, increasing by 20 mg. once each month, to a total of 60 mg once daily, given as a single dose).
If the SSRIs alone are not effective, the addition of a small dose of one of the atypical antipsychotics is often helpful. Options that have been found effective are:
Pimozide (Orap. 0.5-4.0 mg once daily in the morning). Because pimozide is also a potent antipruritic, it is often very effective. Start with 0.5 mg, and increase by increments of 0.5 mg every 5-7 days, as needed. Pimozide may be given as a single dose either at bed-time or in the morning depending on response.
Risperidone (Risperdal 0.5 mg given once daily at bedtime. This may be increased by 0.5 mg every 5-7 days, up to a total of 2.0-4.0 mg, given once daily at bedtime.) Experience suggests that 1.0-2.0 mg is usually adequate to achieve the desired effect.
Aripiprazone (Abilify, 2.0-10.00 mg once daily) at bedtime.
Significant side effects are unusual in the doses prescribed in dermatology and drug interactions are likewise unusual. Extrapyramidal side effects can be counteracted by diphenhydramine hydrochloride (Benadryl, 25 mg up to 3 times daily), or benztropine myselate (Cogentin, 1.0-2.0 mg up to 4 times daily). Unlike diphenhydramine, benztropine is not sedating and may be the better choice. Other possible side effects of the antipsychotics include drowsiness or insomnia, agitation, headache, dizziness, nausea, and possible weight gain.
Tardive dyskinesia (TD), which may result from prolonged use of a relatively high dose of an antipsychotic, has not to date been convincingly reported in the dermatology literature, perhaps because of the low doses that are usually effective. TD is a condition in which there is involuntary and uncontrollable movement of the mouth, tongue, face and neck, and chorioathetoid movements of the extremities. Reversible in the very early stages, unfortunately there is no effective treatment for the established disorder at this time.
Potentially pimozide can prolong the Q-T interval, but the risk is low, and it is suggested in the literature that baseline and follow-up electrocardiograms are not required if the dose is less than 10.0 mg per day. Seldom in dermatology is a dose higher than 6.0 mg per day required. The patients who consult us about altered sensation in the skin are often a little paranoid and suspicious of any medication that we might suggest, so unless there is a medical reason, it may be advisable to avoid any unnecessary testing in relation to proposed treatment.
Since opioid activity has now been identified in patients with NE. The antiopioid Naltrexone has been added to our armamentarium. A dose of 50 mg once to twice daily is appropriate. Naltrexone has been shown effective in prurigo nodularis, with the minimal side effects of dizziness and nausea.
Given the distress, and physical and psychological impairment that can result from NE, the advantages of any of these medications far outweighs the possible risks.
Usually there is remarkable improvement after even the first visit. This is because one has listened and empathized, and because one seems to know what to do. Weekly visits are important initially, but once trust is established the intervals between visits may gradually be extended to 1 month, and then to 3 months, with the understanding that the patient must call at once, should any change occur.
One’s goal continues to be to effect a successful psychiatric referral. It is helpful to point out, whenever pertinent, the circumstances under which the NE intensifies. One can stress the impact that the condition has on the quality of life of the patient and the patient’s family, and urge a consultation on those grounds. Continue to provide emotional support and encouragement, praise every modest success, and ask the patient never to discontinue medication unilaterally.
After several months free of symptoms, medication may be gradually tapered. It is a matter of judgment when tapering may be considered. For some patients treatment may be a life-time project, for others it may be indicated intermittently, according to the exigencies of the patient’s life, while for some there may be complete resolution of the problem.
Ensure that the patient understands that NE may be a chronic problem and that it can return at any time. If referral still cannot be effected, it is helpful to find a friendly neighborhood psychiatrist with whom one can consult.
Unusual Clinical Scenarios to Consider in Patient Management
Two possible scenarios that it is important to keep in mind. First, There may be an underlying systemic disease, such as renal or hepatic disease, anemia or polycythemia vera, autoimmune disease such as dermatomysitis, or an occult neoplasm, particularly a lymphoma, which may not declare itself until as long as 10 years after the picking has begun. Second, given the patient’s life-circumstances, there is always the possibility of deepening depression. Try to make an unofficial assessment of the patient’s level of functioning and emotional status at each meeting.
What is the Evidence?
Harris, SS, Kuchon, D, Benedetto, E. “Pathologic grooming behavior : facial dermatotillomania”. Cutis. vol. 87. 2011. pp. 14-18. (This is a very nice and detailed case report with follow-up. Successful treatment with an SSRI and maintained improvement is encouraging.)
Millard, LG, Millard, J, Burns, T, Breathnach, S, Cox, N, Griffiths. “Pathological skin-picking”. Rook's textbook of dermatology. 2010. pp. 64.27-29. (Nice description with good references.)
Koblenzer, CS. “Psychocutaneous disease”. Orlando FA. 1987. pp. 138-140. (In addition to a description of the clinical picture and treatment, many earlier papers are included in the references.)
Gupta, MA, Gupta, AK, Haberman, HF. “Neurotic excoriations: A review and some new perspectives”. Comp. Psychiatr. vol. 27. 1986. pp. 381-86. (Review and case reports from a more psychiatric perspective, stressing the need for psychiatrists as well as dermatologists to be informed.)
Tucker, PTP, Woods, DW, Flessner, CA, Franklin, SA, Franklin, ME. “The skin-picking impact project: phenomenology, interference and treatment utilization of pathological skin picking in a population-based study”. J Anx Disorders.. vol. 25. 2011. pp. 88-95. (This paper gives a summary of recent statistical studies on skin-picking followed by the report of a new study comprised of over 1600 subjects recruited from a variety of self-help Internet sites. These subjects differ from most of our patients in that the subjects were already seeking self-help, though only half had sought medical treatment. However it gives an account of the demographics, associated psychopathology, modes, severity, location and duration of picking, the use of resources, and the psychosocial impact of the disorder. The study confirms the need for informed medical treatment.)
Keuthen, NJ, Deckersbach, T, Wilhelm, S, Hale, E, Fraim, C, Baer, L, O’ Sullivan, RL, Jenike, MA. “Repetitive skin-picking in a student population and comparison with a sample of self-injurious skin-pickers. 2000”. Psychosomatics. vol. 41. May-June. pp. 210-15. (A study that demonstrates how common nonclinical picking is in young adults.)
Spiegel, DR, Finklea, L. “The recognition and treatment of pathological skin-picking. A potential neurobiological underpinning of the efficacy of pharmacotherapy in impulse control disorders”. Psychiatr. (Edgmont). vol. 6920. 2009; (Feb). pp. 38-42. (A discussion about the pathophysiology of impulse-control disorders and obsessive-compulsive disorder, the neuropeptides involved and a rationale as to choice of drugs.)
Deckersbach, T, Wilhelm, S, Keuthen, J, Baer, L, Jenike, MA. “Cognitive – Behavior therapy for self-injurious skin picking: a case-series”. Behav Modif. vol. 26. 2002. pp. 361-377. (Gives a description of the process of C-B.T. for the dermatologist, with encouraging results.)
Lee, CS, Koo, JYM, Koo, JYM, Lee, CS. “The use of psychotropic drugs in dermatology”. Psychocutaneous disease. 2003. pp. 427-51. (A simple and reassuring guide to the safe use of psychotropic drugs, for the dermatologist.)
Wlkaitis, J, Mulvihill, T, Nasrallah, HA. “Classic antipsychotic medications”. Textbook of psychopharmacology. 2004. (Pimozide is a wonderfully effective and reliable drug, but it has received negative press over recent years with regard to possible cardiac side effects. This standard text is reassuring with respect to these possible side effects: moderate drowsiness, low insomnia, moderate extrapyramidal effects, but only a low incidence of possible cardiac side effects.Habit-Reversal Therapy [HRT], and Cognitive-Behavioral Therapy [CBT]. Both of these psychotherapies are relatively short-term, and are designed to help the patient to be aware of situations where picking may occur, to recognise and assess the associated feelings and to change the behavior. Insight-oriented therapy may also be effective, but currently is recommended less often. This therapy is directed towards uncovering underlying reasons for the self-destructive behavior, reasons of which the patient is not consciously aware. Therapy of this type is of much longer duration, sometimes many years, and for many patients the cost is prohibitive.)
“The Diagnostic and Statistical Manual of Mental Disorders”. 2013. pp. 254-257. (This section for the first time gives the psychiatrically recognized diagnostic criteria for what is now referred to in the psychiatric literature as "The Skin-picking Disorder". It gives a very concise summary of the syndrome from a psychiatric perspective, but does not go into the different manifestations encountered in dermatology practice.)
Grant, JE, Odlaug, BL, Chamberlain, SR, Keuthen, NJ, Lochner, C, Stein, DJ. “Skin Picking Disorder”. Am J Psychiatry.. vol. 169. 2012. pp. 1143-1149. (This is a very comprehensive paper which, in addition to the clinical picture, epidemiology, evaluation and treatment of neurotic excoriations, describes some of what is known of the pathophysiology, from a neuropsychiatric perspective.)
Misery, L, Chastaing, M, Touboul, S, Callot, V, Schollhammer, M, Young, P, Feton-Danau, N, Dutray, S. “Psychogenic Skin Excoriations: Diagnostic Criteria, Semiological Analysis and Psychiatric Profiles”. Acta Derm Venereol. vol. 92. 2012. pp. 416-418. (The condition from a European perspective.)
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