Neurotic Excoriation

Aka: Neurotic Excoriation, Psychogenic Excoriation, Dermatotillomania, Compulsive Skin Picking

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II. Symptoms

  1. Pruritus (intense at times)
    1. Itching awakens person from sound sleep
    2. Scabies and Rhus Dermatitis prevent getting to sleep
  2. Patient digs at skin
    1. Digs to relieve itch
    2. Digs to extract imaginary embedded materials in skin
  3. Rash
    1. Rash does not appear until after scratching starts
    2. Rash may appear spontaneously

III. Signs

  1. Often in localized areas within reach of hand
    1. Occiput and Neck
    2. Shoulders
    3. Forearms
    4. Shins
    5. Spares middle of back
  2. Characteristics
    1. Linear excoriations, scabs and scars
    2. Scattered ulcerations

IV. Differential Diagnosis

  1. See Pruritus Causes
  2. Substance Use Disorder (esp. Cocaine, Methamphetamine) are common causes of Compulsive Skin Picking
  3. Other psychogenic skin disorders
    1. Neurodermatitis
    2. Delusions of Parasitosis
    3. Trichotillomania
    4. Dermatitis Artifacta
      1. Excoriation in patient who denies scratching

V. Complications

  1. Lichen Simplex Chronicus
  2. Prurigo Nodularis
  3. Impetigo

VI. Associated Conditions

  1. Obsessive-Compulsive Disorder

VII. Management

  1. Similar management to Neurodermatitis
  2. See Pruritus Management
  3. Frequent application of Skin Lubricants
    1. Replaces the habit of scratching
  4. Bedtime Antihistamines
    1. Doxepin (Sinequan) 10 to 30 mg qhs
  5. Topical antipruritics
    1. Zonalon (topical Doxepin)
      1. Risk of drowsiness if widespread use
      2. Risk of contact allergy
    2. Menthol and Phenol (Sarna lotion)
    3. Pramoxine (PrameGel, Pramosone)
  6. Selective Serotonin Reuptake Inhibitors (SSRI)
    1. Very effective in Pruritus of Neurotic Excoriation
    2. Effect immediate and independent of Antidepressant
  7. Olanzapine (Zyprexa) has been used with some success
    1. Blanch (2004) Br J Derm 151:714-5 [PubMed]
  8. Consider mental health counseling
  9. Topical Corticosteroids
    1. Indicated for inflammatory dermatitis

VIII. References

  1. Habif (1996) Clinical Dermatology, Mosby, p. 72
  2. Cyr (2001) Am Fam Physician 64(12):1981-4 [PubMed]
  3. Tennyson (2001) Dermatol Clin 19(1):179-97 [PubMed]

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