Are You Confident of the Diagnosis?
What you should be alert for in the history
The history is marked by a tendency to pick at skin lesions or “imperfections.”
Characteristic findings on physical examination
Characteristic findings include excoriated acne lesions ranging from superficial excoriated lesions to deep excoriations and scarring (Figure 1). Angulated configuration from fingernails are often evident in deeper excoriations.
Rule out dermatologic disorders such as excoriated lesions of folliculitis, acne necrotica, Dowling-Degos disease, or chloracne. From a psychogenic perspective, consider a more generalized pattern of neurotic excoriations (picking of normal skin in addition to or instead of acne lesions), delusions of parasitosis, factitious lesions, drug abuse causing pruritus, or repetitive behaviors.
Who is at Risk for Developing this Disease?
Persons with extremely symptomatic acne (pruritic or painful), obsessive-compulsive disorder (OCD), anxiety disorders, borderline and narcissistic personality disorders, and family history of “picking” are at risk. It Occurs predominantly in young females. Occurrence peaks in adolescence and in 35-45-year–olds.
What is the Cause of this Disease?
Postulated causes include underlying psychopathology, genetic-learned familial behavior, and sporatic habit.It can be an expression of anger, rebellion, or self loathing.
Systemic Implications and Complications
There is a substantial risk of scarring and pigmentary alteration. Other risks are secondary infection and social rejection and stigmatization.
Data are mostly case reports and small nonrandomized trials without a placebo control group. Medication suggestions are off label.Assess the extent of excoriation: superficial picking versus deep excoriation to determine aggressiveness of treatment plan. Is there evidence of other self destructive behavior? Examine for the degree of damage to the integument (ie, scarring, pigmentary alteration). Assess for insight and motivation.
-physician support, local and internet support groups
-teaching or encouraging alternative behaviors
-more effective acne treatments, including isotretinoin. Give them nothing to pick at!
-Selective serotonin reuptake inhibitors (SSRIs (ie, sertraline 50-150mg daily, fluoxetine 20-60mg daily, paroxetine 10-40mg daily). Potential for rare risk of mania and increased suicidality
-Short-term use of anxiolytics. Alprazolam 0,.25-0.5mg twice daily, Lorazepam 0.5mg twice daily, Clonazepam 0.25-0.5mg twice daily, Buspirone 7.5–15mg twice daily. Benzodiazepines can pose risk for dependence.
-Beta blockers (ie, propranolol 20mg twice daily)
-Atypical antipsychotics for severe refractory disease (ie, Olanzapine 2.5-5mg once daily , Risperidone 0.5-2mg once daily.) Risk for tardive dyskinesia.
Optimal Therapeutic Approach for this Disease
Assess patient motivation and insight: Are they aware and admitting that they pick and do they want to control picking?If not, why? Is it a familial power struggle, anger, depression, borderline personality disorder, or drug use?Assess the degree of distress/dysphoria. Are they at imminent risk and/or in need of emergent psychiatric referral?
Assess the extent of excoriation, including the presence of scarring: Increase level of intervention accordingly. It is important to differentiate symptomatic from asymptomatic lesions. Ask the patient if acne lesions cause sensations. Most patients with acne excoriee are asymptomatic.
If symptomatic (itch, burning, tender, formications), it is important to control symptoms with topical agents (ie, corticosteroids, 5% doxepin cream, 10% amitriptyline cream, 2-5% lidocaine cream or gel).
Offer perspective. Explain the ubiquitious tendency of humans and all higher functioning animals to groom and manipulate the skin.
Give hope and offer control. Most patients have heard “don’t pick” ad nauseum. They need concrete control techniques, not admonitions, to give them “nothing to pick at.” Offer camouflage. for greater social acceptance and possibly less picking (out of sight, out of mind). Recommend anxiety and depression reduction programs, behavior modification, and/or cognitive behavioral psychotherapy.
– isotretinoin to remove the stimulus to pick Some will continue picking and need additional treatment.
-hypnosis, guided imagery.
-SSRI or SNRI (serotonin-norepinephrine reuptake inhibitor) medications
-short-term use of anxiolytics
-adding a beta blocker if tension or anxiety is associated with picking.
Atypical antipsychotics may be valuable for severe refractory disease.
Monitor associated emotional states; anxiety, depression,or OCD. Assess disease impact on the patient’s functional status. Observe eye contact, animation in voice, and follow clincally for a decrease in the extent and severity of excoriations.
Unusual Clinical Scenarios to Consider in Patient Management
Acne excoriee by proxy (parent or significant other picking or otherwise manipulating lesions) has been observed.
What is the Evidence?
Fried, RG. “Picking apart the picker: Toward a better classification of patients with excoriated skin”. Cutis. vol. 71. 2003. pp. 291-8. (This article provides a classification and specific management strategies for patients with skin excoriations.)
Shah, KN, Fried, RG. “Factitial dermatoses in children”. Curr Opin Pediatr. vol. 18. 2006. pp. 403-9. (A good review of these entities and an overall approach to the patient.)
Shenefelt, PD. “Using hypnosis to facilitate resolution of psychogenic excoriations in acne excoriée”. Am J Clin Hypn. vol. 46. 2004. pp. 239-45. (Documents the efficacy of hypnotherapy.)
Fried, RG. “Nonpharmacologic treatments in psychodermatology”. Dermatol Clin. vol. 20. 2002. pp. 177-85. (Presents an overview of available nondrug interventions for psychodermatologic disorders.)
Gupta, MA, Gupta, AK. “Olanzapine may be an effective adjunctive therapy in the management of acne excoriée: a case report”. J Cutan Med Surg. vol. 5. Jan-Feb 2001. pp. 25-7. (Illustrates that atypical antipsychotics may be effective in severe cases.)
Gupta, MA, Gupta, AK. “Fluoxetine is an effective treatment for neurotic excoriations: case report”. Cutis. vol. 51. May 1993. pp. 386-7. (Documents efficacy of SSRI for skin excoriation.)
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