Neurotic Excoriations and Dermatitis Artefacta

Neurotic Excoriations and Dermatitis Artefacta
Caroline S. Koblenzer, MD,* and Rishu Gupta, BS†
Neurotic Excoriations is a psychocutaneous disorder that is characterized by an uncontrollable urge to pick at normal skin or skin with mild irregularities. Dermatitis Artefacta is
another psychocutaneous disorder that consists of self-induced skin lesions often involving
a more elaborate method for damaging the skin, such as the use of a sharp instrument. Both
neurotic excoriations and dermatitis artefacta cause significant disfigurement and anxiety
for the patient. Since patients often present to dermatologists first, it is important for
dermatologists to be aware of the nature of each condition and the available treatment
options. This article provides an update on the clinical features, diagnosis, and treatment
options for neurotic excoriations and dermatitis artefacta.
Semin Cutan Med Surg 32:95-100 © 2013 Frontline Medical Communications
KEYWORDS neurotic excoriations, dermatitis artefacta, psychodermatology, psychocutaneous
disorder, pathological skin picking, acne excoriée, impulse control disorder, factitial dermatitis
T
here are 6 clinical conditions in which self-induced lesions cause the patient to consult the dermatologist. Patients with neurotic excoriations, patients with delusional
disorders, and those who cut their wrists frankly acknowledge the part that they play in creating lesions. However,
those with dermatitis artefacta, those who malinger, and
those with Munchausen’s Syndrome completely deny their
part.1 This chapter will discuss one syndrome from each
group: neurotic excoriations and dermatitis artefacta.
Neurotic Excoriations
Clinical Picture
The patient with neurotic excoriations has an irresistible and uncontrollable urge to pick the skin.2-4 Picking is episodic and may be
triggered by anxiety or stress, a focal itching sensation, a pre-existing
skin condition, or by the hand encountering an irregularity as it
moves unconsciously over the surface of the skin.2,5-7 Once picking
is started, there is a build-up of tension, which is relieved only when
every lesion has been picked.2,8 Picking is most often accomplished
by the fingernails. But it may also be carried out with needles, tweezers, or whatever instrument may come to hand.3,7,9,10
*Private Practice, Moorestown, New Jersey.
†Keck School of Medicine, University of Southern California, Los Angeles.
Disclosures: The authors have completed and submitted the ICMJE form for
disclosure of potential conflicts of interest and none were reported.
Correspondence: Rishu Gupta, BS, Department of Dermatology, University of
California, 515 Spruce Street, San Francisco, CA 94118. E-mail:
[email protected]
1085-5629/13/$-see front matter © 2013 Frontline Medical Communications
DOI: 10.12788/j.sder.0008
Lesions are confined to areas within reach of the hands,
appearing most numerously on the extensor aspect of the
forearms, shoulders, upper back, breasts; buttocks, and the
anterior aspect of the thighs. Sparing of the unreachable inter-scapular area in the mid-back, the “butterfly sign” is characteristic.3,10 Lesions may number from one to dozens. Morphologically, active lesions may be round or linear, clean or
crusted, scooped-out ulcers (Figure 1). The margins of the
older lesions may be thickened from repeated picking. Secondary infection may also occur.3,10 Prurigo nodules may be
seen when the condition is ongoing. In the established case,
lesions are present in every stage of development (ie, small,
newly opened or crusted ulcers, larger and deeper ulcerations with a nodular component, and circular or linear
sharply demarcated hypopigmented scars).3,8
Neurotic excoriations can significantly impair the patient’s
quality of life.7,11 Time may be spent worrying about picking,
resisting the urge to pick, and finally experiencing shame and
embarrassment after picking.7 There is a broad spectrum of
picking behaviors. For some patients, it occurs almost automatically when the mind is otherwise occupied, while
reading, watching television, or driving the car. For others, it may become a daily ritual and may take place behind
closed doors for many hours at a time.4,12 Shame and
embarrassment usually accompanies this behavior, leading patients to wait many years before seeking treatment.10
Incidence
Diagnostic criteria for neurotic excoriations have not yet been
delineated by the American Psychiatric Association, making
95
C.S. Koblenzer and R. Gupta
96
Figure 1 Neurotic Excoriations. Lesions have classic morphology
and area of distribution for neurotic excoriations.
it difficult to determine the true incidence rates.13,14 Indeed,
picking is considered to be a part of normal grooming behavior. Children frequently outgrow the common habit of picking insect bites. So it is difficult to determine at what stage the
picking behavior should be considered pathological.15 Certainly, it is pathological when it impacts the quality of life.7
Despite this difficulty, studies suggest that there is an incidence of 2%-5% in dermatology patients, with a female to
male ratio of 3:1.9,16,17 The average age of onset is reported
between the ages of 15 and 35 years in psychiatric literature.
In dermatology, we see a second group between 40 and 60
years who are primarily women.3,6,10,16,18,19 Patients complain that an intense focal sensation of itching or burning
develops.3 This occurs most frequently in the evening and
can be relieved only by picking the exact spot. This then
generates an entire cycle of picking.3,20 Unlike the patient
with delusions, these patients do not know the cause; they
merely seek relief.3,16
Etiology
Neurotic excoriations is a psychiatric disorder that most often presents to a dermatologist rather than a psychiatrist.20
The condition has long been considered a part of the obsessive-compulsive spectrum of behaviors. But more recently,
because of the absence of an obsessive component, impulsecontrol disorder has been deemed a more accurate diagnosis.4,7,21 Indeed, neuropsychiatric findings would tend to
support this diagnosis22 as there is frequent comorbidity with
other impulse-control disorders (ie, nail-biting or trichotillomania).4,7,12,23,24
Anxiety and depression are frequently present. The condition is also more common in those who have a family history
of similar symptoms of neurotic excoriations.3,6,10 Picking is
considered to be a part of normal grooming, which is usually
outgrown in childhood. When this is not the case, there have
been emotional difficulties in very early childhood. There
may also be ongoing stress in the home or school,15 a sign
declared in the form of acne excoriée (the uncontrollable urge
to pick acne lesions), picking insect bites, or patches of eczema (Figure 2).7,15,25,26
Figure 2 Acne Excoriee. Patient with a form of neurotic excoriations
consisting of an uncontrollable urge to pick at acne lesions.
Diagnosis
The clinical picture is usually diagnostic. However, it is important to consider possible triggers. This means ruling out
any underlying primary skin disorder that would generate
itching; irregularities in the surface of the skin; or a systemic
disorder that may draw attention to the skin by creating an
altered sensation.2,3 With this in mind, anemia, hepatic disease, renal disease, thyroid dysfunction and lymphoma
should be ruled out. The cultures should be taken to rule out
a secondary infection.7 A biopsy should be considered if there is
any question of an underlying skin disorder or to reassure a
worried patient.2,3,20
Since neurotic excoriations is a psychiatric disorder, it is
important to assess the emotional state of the patient. Is the
patient experiencing anxiety or depression? Is the patient
under significant stress? How is the condition impacting the
patient’s life? Is there social withdrawal or isolation? Is the
patient able to work? Has the patient had thoughts of hurting
himself or others? These issues must be assessed and addressed for the treatment to be successful.27
Treatment
A supportive doctor-patient relationship is crucial to help the
patient bring the condition under control. A successful relationship cannot be hurried; one cannot become impatient or
defensive. Empathize with the patient’s physical discomfort,
the embarrassment and the shame that the patient feels, and
with the time and expense of treatment. Support the patient’s
strengths. Give positive reinforcement for even the smallest
advances. See the patient frequently at first to show interest
and support. Perhaps see the patient weekly for the first
month. Then decrease frequency as their response to treatment allows.28,29
Because the skin is the focus of attention, it is important to
prescribe intensive topical treatments that include positive
measures to replace the prior destructive activity.28 Depending on the degree of involvement, saline compresses that
contain one teaspoon of table salt to one pint of water or
soaking for 15 minutes twice daily using a product that
Neurotic excoriations and dermatitis artefacta
reduces redness, itching, scaling and inflammation (ie, Clorox or Cu៮ tar) are helpful. These can be followed by gentle
debridement of the softened crusts with a gauze square. Topical antibiotic ointments, such as a triple antibiotic ointment
or a combined antibiotic and steroid ointment (betamethasone, 0.5% with neomycin; or hydrocortisone, 0.5% with
neomycin and polymyxin) can then be applied to open areas.1,28 Areas where there is lichenification or nodule formation can be injected with a slow-release suspension of triamcinolone, 10 mg/ml, monthly as needed. When lesions are
few, advanced-healing blister band-aids can be applied and
left in place until healing has taken place.28 Oral antibiotics
should be prescribed as needed, according to the culture
findings. Topical retinoids are helpful both in the treatment
of acne excoriée and to reduce scarring.25,28
Anxiety and depression should be addressed. Though rare, a
multispecialty clinic is ideal for this. If one can help the patient to
acknowledge the negative impact of the problem and recognize
the presence of anxiety or depression, there is a possibility that
they will agree to a psychiatric referral.2,29 The current psychiatric treatments of choice are habit-reversal therapy, cognitivebehavioral therapy or one of the specific serotonin re-uptake
inhibitors (SSRI’s).2,19,22,30-34 Sometimes a very low dose of an
atypical antipsychotic may be added to boost the impact of the
SSRI; and while the oral antihistamines are seldom helpful, opiate antagonists such as naltrexone may help to reduce any altered sensation in the skin.2,35,36
Course and Prognosis
Frequently, there is significant improvement in response to
the physician’s empathy and interest even after the first visit.
If the patient follows instructions and keeps regular appointments, a slow but steady improvement can be expected. The
patient should be advised to call at once should any unexpected change take place. They must also be advised never to
stop medication unilaterally.
Despite positive results when a patient adheres to the regimen, a flare-up may occur during a time of particular stress
or peri-menstruation. Some studies in the psychological literature suggest that up to 40% of young people (below the
age of 18 years) may continue to pick for the rest of their
lives.2,15 From experience in dermatology, this would seem to
be an unusually high percentage.6
Dermatitis Artefacta
Clinical Picture
Dermatitis artefacta refers to a condition in which the patient
creates destructive lesions on his or her own skin, secretly
and mysteriously, while assiduously denying any part in their
creation.37-40 It falls within the spectrum of factitious disorders. The unconscious goal is to gain attention and to be
taken care of.14,41-43 The condition generates neither material
gain nor avoidance of responsibility; this helps separate it
from malingering.14,42,44
Lesions may be single or multiple and are often bilaterally symmetric. The morphology of individual lesions is
97
Figure 3 Dermatitis Artefacta. Patient with severe self-induced lesions.
determined by the particular technique by which they are
created and are not reconcilable with any known dermatosis.38,45-53 Patients are quite original in their choice of
modality. Indeed, lesions may result from picking, gouging, cutting, burning, application of pressure, the pouring
on of corrosive liquids, or by any method that one might
imagine. Lesions are angulated, geometric or linear; or in
the case of burning or suction, they will show the changes
characteristic of those injuries. Irregular linear burns, together with the drop sign, may result from the application
of caustic liquids. Factitial lesions may be extraordinarily
destructive; but the margins of each lesion will be quite
distinct with normal surrounding skin (Figure 3).38
What has been termed a “hollow history” is a part of the
clinical picture.54 The patient can give no description of the
evolution of the lesions. It is as if they had mysteriously
appeared, fully formed, perhaps overnight, or during a brief
break, and a careful examination will invariably fail to find
incipient, early or evolving lesions.38,54,55
When one is consulted by a patient with dermatitis artefacta, an interesting interpersonal dynamic can usually be
noted. Despite extensive and often very disfiguring tissue
destruction flagrantly exposed, the patient appears remarkably unconcerned, friendly, out-going, and seemingly without great anxiety.56 On the other hand, family members are
clearly very anxious, often openly angry and confronting.
Most often patients and their family members have consulted
a number of physicians in a variety of specialties. The patient
has had numerous and repeated tests. But because there have
not yet been any answers and no improvement in the patient’s condition, they have a sense that their concerns are
unheeded.57-59 In the end, they feel that physicians are incompetent or uncaring and medicine has let them down.
A condition called dermatitis artefacta-by-proxy occurs
when the lesions are created by one person on the skin of
another. The dyad is usually a mother who elicits needed
attention by creating lesions on her young child.60-66
Another variant of dermatitis artefacta is pathomimicry in
which the patient creates lesions that mimic those of a known
dermatosis. They do so either by perpetuating with artificial
C.S. Koblenzer and R. Gupta
98
lesions a condition that the patient has previously experienced or by reproducing artificially those encountered on a
relative or friend.38,45-53
Incidence
The incidence of dermatitis artefacta is difficult to determine
as there are few reliable controlled studies, and undoubtedly
many cases that are never diagnosed. Accurate diagnostic
criteria are not always applied. As a result, confusion with
neurotic excoriations and Munchausen’s syndrome sometimes takes place. The condition is significantly more common in women and ratios anywhere from 3:1 to 20:1 are
quoted.58
The onset is most commonly in adolescence or early adult
life. But short-lived cases may occur in younger patients,
which may be triggered by a recent psychosocial
stress.37,40,41,67,68 Dermatitis artefacta can also develop in
older patients who are predominantly male.58,59,68 It is a common finding that either the patient or a close relative has, or
has had, a close relationship with some aspect of the healthcare field. Frequently the patient is a nurse.38,40,56
Etiology
Dermatitis artefacta is a primary psychiatric disorder with
secondary skin manifestations. The skin lesions are known as
a “defense” in that they distract the patient from the underlying psychiatric problem. Most frequently the psychiatric
diagnosis is a personality disorder with borderline, paranoid
or hysterical features.14,69 These patients usually experience
emotional deprivation during childhood, resulting in an unstable body image, a blurring of physical and emotional
boundaries, and a need to be cared for.48,70,71 The production
of lesions helps to affirm the physical boundary of the self and
the need to be cared for.47,66,72-74
The onset of dermatitis artefacta may be triggered by a
current psychosocial stress. It is unclear if the patient is aware
of creating or perpetuating lesions.74 Some patients apparently create lesions unconsciously, while in a dissociated
state. In others, the production of lesions is believed to be a
part of the obsessive-compulsive spectrum.75
Diagnosis
The clinical picture of the patient with dermatitis artefacta is
so characteristic as to raise one’s suspicions. The emotional
atmosphere as one first walks into the room—the hollow
history, the relative indifference of the patient given the destructive lesions, the bizarre morphology of the lesions, and
the sheaf of papers documenting prior studies and prior medications that accompany the patient—should immediately
alert the physician.56,57,76
It is important to obtain copies of those prior studies, not
to repeat those that are already available. Specific dermatologic diagnostic considerations in each case will be determined by the morphology, distribution of the lesions, and by
those prior reports.76 Reportedly, the most common serious
considerations are vasculitis, pyoderma gangrenosum, deep
fungal infection, arthropod bites and collagen vascular dis-
ease.38,52,77-79 One must be alert also to the possibility of
pathomimicry.50
Dermatitis artefacta falls under the rubric of somatizing
disorders. In this group of patients, comorbidity with other
somatizing disorders such as chronic fatigue syndrome, fibromyalgia, irritable bowel disease, is common, as is comorbidity with anxiety and/or depression.13,80 As these patients
are disturbed by their body image, it is understandable that
other body-image disorders such as an eating disorder or
body dysmorphic disorder may also be present.81,82
Dermatitis artefacta is distinguished from malingering because, unlike the malingerer, the patient’s goal is neither
material gain nor the avoidance of unpleasant duties, such as
perhaps serving in the armed forces.14,44 It is also to be distinguished from Munchausen’s syndrome, which is characterized by peregrination (travelling from doctor to doctor for
the treatment of a fabricated condition) and pseudologia fantastica (fabrication of a complex past personal, family, and
medical history).58,59,83 Patient’s with this syndrome create
false identities and sensational stories about fake symptoms.
They also peregrinate from doctor to doctor and from hospital to hospital as they sense that their deceit has been suspected. Occasionally, the patient may undergo unnecessary
repeated hospitalizations and major surgical procedures.68
The psychopathology here is a personality disorder with antisocial features.42,68
Treatment
As for neurotic excoriations, the treatment of dermatitis artefacta falls into 3 parts: the doctor-patient relationship, topical
treatment, and systemic treatment. As with neurotic excoriations, a supportive and trusting relationship is needed for
any type of treatment to succeed. Because dermatitis artefacta
is a psychiatric disorder, the hope is that one’s approach may
ultimately permit either a psychiatric referral or referral to a
multi-specialty clinic.58,59,77,84
To prevent further doctor shopping and begin on a path toward treatment, the development of a trusting relationship cannot be hurried. By simply sitting down and making eye contact,
one expresses commitment and interest.54 This can be reinforced by looking carefully at the sheaf of papers that the patient
brings and documenting what has been done to date.58,85 While
taking a careful history, one can empathize with the various
aspects of the patient’s prior experience that generates anger and
frustration: the expense in time and money of the numerous
fruitless consultations and worthless treatments; the negative
impact on the quality of life; and the disappointment with seemingly uncaring physicians.39,58,84
See the patient weekly for at least the first month and then
extend the interval between visits as the relationship allows.37,40 Be in touch with one’s own feelings and do not
permit impatience or defensiveness to emerge in response to
the patient’s behavior. Do permit the patient to experience
one’s caring through gentle touch. Express a positive attitude
and support the patient’s strengths. Stress the need to follow
all treatment instructions and to keep appointments.58
Neurotic excoriations and dermatitis artefacta
Bearing in mind that the destructive behavior serves as a
defense mechanism, it is important not to arouse anxiety by
confronting the patient. Anxiety is frequently expressed in
anger and may result in further tissue-destruction. However,
with children, if one sees the patient separate from the parents, it is sometimes possible to generate a more frank discussion.86
Since the skin is the focus of attention, topical treatment
can be instituted in hope that it will take the place of the prior
destructive activity. This will be adapted to the specific lesions and may consist, for example, of compresses followed
by antibiotic ointment, the packing of deep ulcers with
gauze, enzymatic debridement of sloughs, and stimulation of
granulation tissue with the application of 10-X sugar. The use
of occlusive dressings can permit healing. However, as a
treatment, it may result in the appearance of a new lesion at a
different site.58,59
Systemic treatment is both dermatologic and psychiatric.
Oral antibiotics and anti-fungal agents are prescribed on the
basis of culture and laboratory findings, antihistamines (if
pruritus is described), and appropriate supplements (ie, iron
or B-12).58 Anxiety is common and can be addressed with
one of the SSRI family of antidepressants with either buspirone or benzodiazepine. Depression also may be treated with
an SSRI, a serotonin and norepinephrine reuptake inhibitor
or bupropion. Sometimes it is helpful to add a very low dose
of one of the atypical antipsychotics such as aripiprazole,
which also has some antidepressant action.58,87
When prescribing one of the psychotropic drugs, it is important to explain to the patient that the drug is not approved
by the Federal Drug Administration for this indication — it is
an off-label use. It is also important to discuss possible side
effects. But during the discussion, stress the positive aspects
while putting adequate but not too much emphasis on the
possible negatives.
Prognosis
There are few longitudinal studies of patients with dermatitis
artefacta. Therefore, accurate measures of the prognosis are
unavailable. However, except in childhood, where the condition may be a transient response to a current psychosocial
stress, most observers report a poor prognosis for cure, suggesting that the condition appears to wax and wane with the
circumstances of the patient’s life.58,59,71,73,85,88,89
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