Psychogenic excoriation

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Psychogenic excoriation

Jillian W. Wong Millsop and John Y.M. Koo

Evidence Levels:  A Double-blind study  B Clinical trial ≥ 20 subjects  C Clinical trial < 20 subjects  D Series ≥ 5 subjects  E Anecdotal case reports

image

Psychogenic excoriation is a psychodermatologic condition in which patients participate in destructive scratching and picking of normal skin or skin with minor surface irregularities. Such behaviors may cause self-inflicted ulcers, abscesses, or scars that can ultimately become disfiguring. Although traditionally called ‘neurotic excoriation,’ the authors prefer the term ‘psychogenic excoriation’ since the underlying psychopathology may not be neurosis and may range from depression to obsessive compulsive disease to even psychosis. The traditional term, ‘neurotic excoriation,’ does our specialty a disservice, making dermatologists feel as if we know what is going on with the patient psychologically when the reality is that there is no way we can know what the underlying psychopathology is without carefully interviewing the patient regarding his or her mental status. Therefore, the authors recommend the following approach.

First, do not be fooled by the term ‘neurotic excoriation’; go beyond the skin to clearly ascertain the nature of the underlying psychopathology. Patient behavior may be associated with underlying depression, anxiety, obsessive compulsive disorder, psychosis or borderline personality disorder. Psychogenic excoriations may also be precipitated by emotional stress.

Second, before diagnosing a patient with psychogenic excoriation, it is important to rule out other psychodermatologic disorders, such as dermatitis artefacta (often associated with damage done with sharp objects rather than just fingernails, characteristic secrecy about the etiology of lesions and often associated with demanding and manipulative personality), or delusions of parasitosis (associated with delusional ideation, particularly the strongly held belief of organisms infesting the skin).

Finally, the appropriate treatment strategy can be determined based on the nature of the underlying psychopathology.

Management strategy

Because psychogenic excoriation is primarily a psychiatric disorder, for a dermatologist without time or training for psychotherapy, psychopharmacology could be the most feasible line of therapy.

If depression or anxiety is the underlying psychopathology, antidepressants and anti-anxiolytics are considered first-line treatment. One of the author’s (J.K.) preferred medication is the tricyclic antidepressant doxepin. There is an insufficient number of clinical trials demonstrating its efficacy in this condition, but doxepin is often useful due to its combined antidepressant and antihistaminic/antipruritic activity, which may be critical in disrupting the itch–scratch cycle. Doxepin is usually started at 10–25 mg at bedtime, with a gradual increase in dose of 10–25 mg every 2 to 4 weeks until the patient is taking up to 100 mg every evening, which is the typical effective antidepressant dose, particularly if the underlying psychopathology is major depression. If the patient requires even higher dosages, a maximum of up to 300 mg daily may be used, provided there are no side effects. Since doxepin can prolong the QT interval, a screening ECG is recommended for patients over age 55 or any patient with a past history of cardiac dysrhythmia. Sedation, syncope, seizures, weight gain, and orthostatic hypotension are other potential side effects.

Selective serotonin reuptake inhibitors (SSRIs) also have been shown in several reports to be effective in patients with psychogenic excoriation. These antidepressant drugs have better safety profiles than doxepin as they are less associated with sedation and cardiac conduction abnormalities. Other tricyclic antidepressants, such as clomipramine and amitriptyline, and various benzodiazepines are third-line therapies that should only be considered if the patient does not respond to more conventional treatments or cannot tolerate the side effects.

For treatment of underlying psychosis, antipsychotics can be effective. Pimozide, a traditional antipsychotic, olanzapine, an atypical antipsychotic, aripiprazole, a second-generation antipsychotic, and naltrexone, an opioid antagonist, may have a role for these patients with psychogenic excoriation.

As for borderline personality as the underlying psychopathology, psychotherapy is recommended. Psychotherapy and cognitive behavioral techniques, including aversion therapy and habit reversal treatments, have been reported in certain cases to be effective for this disorder, and can be used as adjunctive therapy for other underlying psychopathologies including those discussed above. There are two case reports of the efficacy of cognitive psychotherapy with laser irradiation of disfiguring skin lesions, as well as a case report on the efficacy of hypnosis to alleviate psychogenic excoriation.

There are other strategies for treatment which may further enhance systemic pharmacological treatments and psychotherapy. Treating associated infection and pruritus through the prudent use of antibiotics and antihistamines (oral or topical), respectively, and using topical corticosteroids may provide additional symptomatic benefit for patients with psychogenic excoriation. Lastly, a recent study demonstrated narrowband ultraviolet (NB-UVB) phototherapy may be helpful for psychogenic excoriation.

Specific investigations

Third-line therapies

image Fluoxetine A
image Fluvoxamine C
image Venlafaxine E
image Escitalopram D
image Clomipramine E
image Amitriptyline E
image Benzodiazepines E
image Pimozide E
image Olanzapine D
image Aripiprazole E
image Naltrexone E
image Psychotherapy D
image Cognitive behavioral therapy E
image Hypnosis E
image Narrowband ultraviolet light C

[/level-membership-for-dermatology-category][not-level-membership-for-dermatology-category]

Psychogenic excoriation

Jillian W. Wong Millsop and John Y.M. Koo

Evidence Levels:  A Double-blind study  B Clinical trial ≥ 20 subjects  C Clinical trial < 20 subjects  D Series ≥ 5 subjects  E Anecdotal case reports

image

Psychogenic excoriation is a psychodermatologic condition in which patients participate in destructive scratching and picking of normal skin or skin with minor surface irregularities. Such behaviors may cause self-inflicted ulcers, abscesses, or scars that can ultimately become disfiguring. Although traditionally called ‘neurotic excoriation,’ the authors prefer the term ‘psychogenic excoriation’ since the underlying psychopathology may not be neurosis and may range from depression to obsessive compulsive disease to even psychosis. The traditional term, ‘neurotic excoriation,’ does our specialty a disservice, making dermatologists feel as if we know what is going on with the patient psychologically when the reality is that there is no way we can know what the underlying psychopathology is without carefully interviewing the patient regarding his or her mental status. Therefore, the authors recommend the following approach.

First, do not be fooled by the term ‘neurotic excoriation’; go beyond the skin to clearly ascertain the nature of the underlying psychopathology. Patient behavior may be associated with underlying depression, anxiety, obsessive compulsive disorder, psychosis or borderline personality disorder. Psychogenic excoriations may also be precipitated by emotional stress.

Second, before diagnosing a patient with psychogenic excoriation, it is important to rule out other psychodermatologic disorders, such as dermatitis artefacta (often associated with damage done with sharp objects rather than just fingernails, characteristic secrecy about the etiology of lesions and often associated with demanding and manipulative personality), or delusions of parasitosis (associated with delusional ideation, particularly the strongly held belief of organisms infesting the skin).

Finally, the appropriate treatment strategy can be determined based on the nature of the underlying psychopathology.

Management strategy

Because psychogenic excoriation is primarily a psychiatric disorder, for a dermatologist without time or training for psychotherapy, psychopharmacology could be the most feasible line of therapy.

If depression or anxiety is the underlying psychopathology, antidepressants and anti-anxiolytics are considered first-line treatment. One of the author’s (J.K.) preferred medication is the tricyclic antidepressant doxepin. There is an insufficient number of clinical trials demonstrating its efficacy in this condition, but doxepin is often useful due to its combined antidepressant and antihistaminic/antipruritic activity, which may be critical in disrupting the itch–scratch cycle. Doxepin is usually started at 10–25 mg at bedtime, with a gradual increase in dose of 10–25 mg every 2 to 4 weeks until the patient is taking up to 100 mg every evening, which is the typical effective antidepressant dose, particularly if the underlying psychopathology is major depression. If the patient requires even higher dosages, a maximum of up to 300 mg daily may be used, provided there are no side effects. Since doxepin can prolong the QT interval, a screening ECG is recommended for patients over age 55 or any patient with a past history of cardiac dysrhythmia. Sedation, syncope, seizures, weight gain, and orthostatic hypotension are other potential side effects.

Selective serotonin reuptake inhibitors (SSRIs) also have been shown in several reports to be effective in patients with psychogenic excoriation. These antidepressant drugs have better safety profiles than doxepin as they are less associated with sedation and cardiac conduction abnormalities. Other tricyclic antidepressants, such as clomipramine and amitriptyline, and various benzodiazepines are third-line therapies that should only be considered if the patient does not respond to more conventional treatments or cannot tolerate the side effects.

For treatment of underlying psychosis, antipsychotics can be effective. Pimozide, a traditional antipsychotic, olanzapine, an atypical antipsychotic, aripiprazole, a second-generation antipsychotic, and naltrexone, an opioid antagonist, may have a role for these patients with psychogenic excoriation.

As for borderline personality as the underlying psychopathology, psychotherapy is recommended. Psychotherapy and cognitive behavioral techniques, including aversion therapy and habit reversal treatments, have been reported in certain cases to be effective for this disorder, and can be used as adjunctive therapy for other underlying psychopathologies including those discussed above. There are two case reports of the efficacy of cognitive psychotherapy with laser irradiation of disfiguring skin lesions, as well as a case report on the efficacy of hypnosis to alleviate psychogenic excoriation.

There are other strategies for treatment which may further enhance systemic pharmacological treatments and psychotherapy. Treating associated infection and pruritus through the prudent use of antibiotics and antihistamines (oral or topical), respectively, and using topical corticosteroids may provide additional symptomatic benefit for patients with psychogenic excoriation. Lastly, a recent study demonstrated narrowband ultraviolet (NB-UVB) phototherapy may be helpful for psychogenic excoriation.

Specific investigations

Neurotic excoriations and dermatitis artefacta.

Koblenzer CS. Dermatol Clin 1996; 14: 447–55.

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