'Look beyond skin': psychogenic excoriation - a series of five cases.

Psychogenic excoriation is a condition where the patient picks the skin repetitively to produce excoriations. Treating this clinical entity is challenging as these patients often have an associated psychological abnormality. The five cases in this case series include two children and three adults. They presented with skin lesions ranging from excoriations and ulcers to scars and pigmentation. Detailed evaluation was done by clinical psychologist. Two cases had anxiety traits, one had alcohol dependence, one had difficult temperament and one had depressive symptoms. Habit reversal was introduced. Psychiatry referral was given for three cases and started on selective serotonin reuptake inhibitors. On follow-up, the urge to scratch reduced substantially and skin lesions were also improving. It is important to identify the underlying psychological disorder accounting for skin picking behavior. Incorporating psychotherapeutic techniques into clinical practice will improve the quality of life of many of these patients.

What was known?

1. Psychogenic excoriations are highly associated with psychological co-morbidities.

2. Dermatologists must elicit a psychiatric history to treat these patients effectively.

3. Behavioral techniques like habit reversal have been used to reduce the skin picking compulsion.

Introduction

Psychogenic excoriation is a condition characterized by repetitive or compulsive picking of skin to the point of causing tissue damage.[1] This entity affects approximately 2% of patients attending dermatology outpatient department and can coexist with other primary skin conditions like acne. It causes significant distress and disfigurement to the patients. Other terms used include: Neurotic excoriation, self-injurious skin picking, self-mutilation, compulsive picking, acne excoriée, dermatotillomania, primary excoriation and pathological skin picking.[2] We report our experience in the Psycho-dermatology clinic with a series of five patients who developed disfiguring lesions resulting from uncontrollable skin picking.

Case Reports

Case 1

History

A 20-year-old girl presented with scratching and picking of lips, face and arms of 3 years duration which increased with stress. She did not realize that she was picking but became aware only when it started bleeding or when others pointed it out. She also had sad mood, crying spells and increased irritability since 2 months.

Evaluation and therapy

On examination, numerous excoriated lesions and hyperpigmented macules were present over face, lips and forearms [Figure 1]. On evaluation by clinical psychologists the patient was found to have depressive symptoms. Excoriations were treated with topical antibiotics. Supportive therapy was initiated. Relaxation training with 5 sessions of Jacobson's progressive muscle relaxation was started and was advised to continue. The scratching behavior was managed behaviorally by habit reversal, awareness training and competing response.

Figure 1

Excoriations and acne over cheek

Outcome

At six month follow-up, the skin picking scale[3] score reduced from 15/24 to 9/24. She noted a transient reduction in irritability and gradually achieved control over her picking behavior over the period. She also solved her interpersonal issues with friends and made new friends.

Case 2

An 11-year-old school boy presented with pigmentation over face and extremities of 4 month duration. He had intense urge to scratch his face following stress at school and relief after the act. It was followed by excoriations which resolved with hyperpigmentation.

There were multiple hyper pigmented macules over face, upper chest, forearms and dorsa of hands [Figure 2]. On psychological evaluation, he was found to have anxiety traits. 3 sessions of behavioral management with reinforcement was done. Distraction techniques and habit reversal were introduced. These were explained to parents and he was asked to practice it at home. Psychiatrist opinion was sought and the patient was started on oral escitalopram 10 mg/day. Skin hyperpigmentation was treated with topical demelanizing cream.

Figure 2

Hyper pigmented macules over face

In the initial few days of therapy, patient continued to report of recurrent urge to scratch but they decreased with psychological therapies and psychotropic medication. Skin picking scale score reduced from 20/24 to 0/24 at 6-month follow-up and skin hyper pigmentation was also found to have improved considerably.

Case 3

A 14-year-old girl studying in 10th standard reported itching and scratching on the shin for three years which gradually involved other parts of the body like hands, face, neck, chest and abdomen. The scratching increased during her leisure time.

There were excoriated plaques predominantly over shin and extensor surface of forearms [Figure 3]. Interview with the girl and her parents revealed that she had a difficult temperament. The family relations were disturbed as father had alcohol dependence and there were frequent quarrels at home between the parents. Habit reversal seemed most appropriate as she had inability to control the urge. Interpersonal conflicts in the family were also dealt with as a part of psychological intervention. Psychiatrist treated her with oral dothiepin 50 mg/day and we treated her excoriations with topical anti-bacterial cream with steroids.

Figure 3

Excoriated plaques over shin

Patient was maintaining well following behavior techniques at 6-month follow-up and was educated regarding need for adherence to therapies. However, her father's alcohol dependence continued to be a constant stressor.

Case 4

The father of the girl (Case 3) is a 43-year-old man who also reported scratching of fore arms and legs of 13 years duration.

Dermatological examination revealed excoriations and hyperpigmentation over legs and forearms [Figure 4]. A detailed evaluation revealed alcohol dependence for the past 20 years. He used to consume alcohol daily and had quarrels with his wife in front of children. 4 sessions of habit reversal was taught. Alcohol dependence and inter personal conflicts with wife were dealt with. The psychiatrist started him on oral dothiepin 25 mg/day and topical anti-bacterial cream was given for skin lesions.

Figure 4

Excoriations and hyperpigmentation over legs

Alcohol dependence continued at 6 month follow-up and he was taken up for motivation enhancement therapy. He claimed adherence to the behavioral techniques taught but his skin lesions did not improve much and he also developed new lesions.

Case 5

A 35-year-old lady presented with complaints of scratching of face, arms, chest and upper back of ten years duration. The urge to scratch the face, arms, chest and upper back increased when she was idle.

Excoriations and scarring were present over more accessible areas including back, chest and extremities [Figure 5]. There was a history of depression and suicide in her brother. She used to get recurrent thoughts of her demised brother and was found to have anxiety traits. Oral doxepin 25 mg/day was started and habit reversal technique was taught.

Figure 5

Excoriations and scarring over back

Patient was maintaining well at 2-month follow-up. She was recording the urge to pick in a diary and was practicing habit reversal at home.

Discussion

Patients with psychogenic excoriation resulting in disfiguring lesions pose a true challenge to the treating dermatologist. Psychogenic excoriation commonly exists along with at least one psychological condition rendering multimodal treatment viz. psychological, psychiatric and dermatologic therapies a necessity. The lifetime frequency of comorbid psychological conditions is estimated to be 100%. Mood disorders form the majority constituting about 80% of it.[4] Table 1 shows the associated psychological condition in our series of 5 cases.

Table 1

Cases and their associated psychological condition

While psychotherapy is sufficient in the management of most patients, it may fall short in conditions where neuro-chemical imbalance in the brain plays a part.[5] In these cases, combination therapy with drugs is essential.

Behavioral techniques such as habit reversal and eclectic psychotherapy programs with insight-oriented components can mitigate the skin picking urge. The four steps involved in habit reversal include:[6]

Awareness training (frequency and duration of each episode of picking is recorded by the patient at home)

Practice of competing response (patient has to adopt a behavior that is physically in compatible with the movements involved in the habit until the urge has passed)

Habit control motivation (includes habit inconvenience review, social support and public display procedures)

Generalization training (patient has to be taught how to control the habit in everyday situations)

Conclusions

When treating a patient with psychogenic excoriation, it is important to identify any underlying psychological disorder that could account for the skin picking behavior. Combined management with clinical psychologists and psychiatrists is ideal for improving treatment outcomes. Due to lack of liaison services in most places, dermatologists must become familiar with use of atleast a few selected psychotherapeutic interventions and psychotropic agents.

Early institution of psychotherapeutic intervention is essential for the effective management of this condition. Incorporating these techniques into clinical practice will improve the quality of life of many patients and dermatologists should develop the ability to see beyond skin in psychogenic excoriation.

What is new?

1. Indian literature on psychogenic excoriation is less as dermatologists tend to overlook the psychological aspect underlying the skin condition.

2. There was an associated psychological disorder in all 5 of our patients.

3. This article signifies the importance of holistic treatment of the patient by taking account of the psychiatric and psychological issues.