Neurotic Excoriations 

  • Author: Noah S Scheinfeld, MD, JD, FAAD; Chief Editor: Dirk M Elston, MD   more...
 
Updated: Aug 3, 2011
 

Background

Patients consciously create neurotic excoriations by repetitive scratching. Neurotic excoriations should be distinguished from dermatitis artefacta, in which patients create lesions for secondary gain. Neurotic excoriations can be initiated by some minor skin pathology, such as an insect bite, folliculitis, or acne, but it can also be independent of any pathology. Because no significant underlying pathology is present in the skin, neurotic excoriations are really a psychologic process with dermatologic manifestations. Many doctors lack an extensive understanding of neurotic excoriations and its treatment.[1] The complex interplay of the mind and urge to create a neurotic excoriation even in 2010 continues to recieve explication.[2] Dermatologists are aware of this complex dynamic and continue to grapple with it.[3]

Because patients create neurotic excoriations, the lesions have the quality of "an outside job," that is, clean, linear erosions, crusts, and scars that can be hypopigmented or hyperpigmented. The erosions and scars of neurotic excoriations often have irregular borders and are usually similar in size and shape. They occur on areas that the patient can scratch, particularly the extensor surfaces of the extremities, the face, and the upper part of the back. The distribution is bilateral and symmetric.

The manifestations of neurotic excoriations vary widely from unconscious picking at the skin to uncontrollable picking at lesions to remove imaginary foreign bodies. Picking is usually episodic and irregular, but it can be constant. The picking can have the quality of a ritual and may take place in a state of dissociation.

In 2006, Shah and Fried[4] reported that neurotic excoriations are among the most common factitial skin diseases observed in children. They further noted that factitial skin disease is less common in children and can often be linked to comorbid psychiatric diagnoses or a psychosocial stressor that can be identified.

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Pathophysiology

Neurotic excoriations are due either to an underlying psychopathology or to the formation of habit. As such, its pathophysiology is poorly understood.

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Epidemiology

Frequency

United States

Neurotic excoriations are thought to be common and underreported. The rate of neurotic excoriations among patients at dermatologic clinics is 2%. The rate of neurotic excoriations in patients with pruritus is 9%.

Mortality/Morbidity

Scars often remain on patients with this condition.

Sex

In studies, 52-92% of patients with neurotic excoriations are female.

Age

Most studies report a mean patient age at onset of 30-45 years. Andreoli et al suggest that adolescence is the most common age at which patients pick their skin.[5]

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Contributor Information and Disclosures
Author

Noah S Scheinfeld, MD, JD, FAAD  Assistant Clinical Professor, Department of Dermatology, Columbia University College of Physicians and Surgeons; Consulting Staff, Department of Dermatology, St Luke's Roosevelt Hospital Center, Beth Israel Medical Center, and New York Eye and Ear Infirmary; Private Practice

Noah S Scheinfeld, MD, JD, FAAD is a member of the following medical societies: American Academy of Dermatology

Disclosure: Optigenex Consulting fee Independent contractor

Specialty Editor Board

Shyam Verma, MBBS, DVD, FAAD  Adjunct Clinical Assistant Professor, Department of Dermatology, University of Virginia, State University of New York at Stonybrook, Penn State University

Shyam Verma, MBBS, DVD, FAAD is a member of the following medical societies: American Academy of Dermatology

Disclosure: Nothing to disclose.

David F Butler, MD  Professor of Dermatology, Texas A&M University College of Medicine; Chair, Department of Dermatology, Director, Dermatology Residency Training Program, Scott and White Clinic, Northside Clinic

David F Butler, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Dermatology, American Medical Association, American Society for Dermatologic Surgery, American Society for MOHS Surgery, Association of Military Dermatologists, and Phi Beta Kappa

Disclosure: Nothing to disclose.

Rosalie Elenitsas, MD  Herman Beerman Associate Professor of Dermatology, University of Pennsylvania School of Medicine; Director, Penn Cutaneous Pathology Services, Department of Dermatology, University of Pennsylvania Health System

Rosalie Elenitsas, MD is a member of the following medical societies: American Academy of Dermatology and American Society of Dermatopathology

Disclosure: Lippincott Williams Wilkins Royalty Textbook editor; DLA Piper Consulting fee Consulting

Joel M Gelfand, MD, MSCE  Medical Director, Clinical Studies Unit, Assistant Professor, Department of Dermatology, Associate Scholar, Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania

Joel M Gelfand, MD, MSCE is a member of the following medical societies: Society for Investigative Dermatology

Disclosure: AMGEN Consulting fee Consulting; AMGEN Grant/research funds Investigator; Genentech Grant/research funds investigator; Centocor Consulting fee Consulting; Abbott Grant/research funds investigator; Abbott Consulting fee Consulting; Novartis investigator; Pfizer Grant/research funds investigator; Celgene Consulting fee DMC Chair; NIAMS and NHLBI Grant/research funds investigator

Chief Editor

Dirk M Elston, MD  Director, Ackerman Academy of Dermatopathology, New York

Dirk M Elston, MD is a member of the following medical societies: American Academy of Dermatology

Disclosure: Nothing to disclose.

References

  1. Jafferany M, Vander Stoep A, Dumitrescu A, Hornung RL. The knowledge, awareness, and practice patterns of dermatologists toward psychocutaneous disorders: results of a survey study. Int J Dermatol. Jul 2010;49(7):784-9. [Medline].

  2. Brodin MB. Neurotic excoriations. J Am Acad Dermatol. Aug 2010;2:341-2. [Medline].

  3. Jafferany M, Vander Stoep A, Dumitrescu A, Hornung RL. The knowledge, awareness, and practice patterns of dermatologists toward psychocutaneous disorders: results of a survey study. Int J Dermatol. Jul 2010;7:784-9. [Medline].

  4. Shah KN, Fried RG. Factitial dermatoses in children. Curr Opin Pediatr. Aug 2006;18(4):403-9. [Medline].

  5. Andreoli E, Finore ED, Provini A, Paradisi M. [Self-inflicted dermatitis: a case in pediatric age]. Minerva Pediatr. Jun 2008;60(3):355-9. [Medline].

  6. Cyr PR, Dreher GK. Neurotic excoriations. Am Fam Physician. Dec 15 2001;64(12):1981-4. [Medline].

  7. Setyadi HG, Cohen PR, Schulze KE, et al. Trigeminal trophic syndrome. South Med J. Jan 2007;100(1):43-8. [Medline].

  8. Shenefelt PD. Using hypnosis to facilitate resolution of psychogenic excoriations in acne excoriée. Am J Clin Hypn. Jan 2004;46(3):239-45. [Medline].

  9. Koblenzer CS. Neurotic excoriations and dermatitis artefacta. Dermatol Clin. Jul 1996;14(3):447-55. [Medline].

  10. Krishnan A, Koo J. Psyche, opioids, and itch: therapeutic consequences. Dermatol Ther. Jul-Aug 2005;18(4):314-22. [Medline].

  11. Fellner MJ, Majeed MH. Tales of bugs, delusions of parasitosis, and what to do. Clin Dermatol. Jan-Feb 2009;27(1):135-8. [Medline].

  12. Dereli T, Karaca N, Inanir I, Oztürk G. Gabapentin for the treatment of recalcitrant chronic prurigo nodularis. Eur J Dermatol. Jan-Feb 2008;18(1):85-6. [Medline].

  13. Paley K, Prevost N, English JC 3rd. Unna sleeve for neurotic excoriations. Cutis. Mar 2010;85(3):149-52. [Medline].

  14. Fried RG. Nonpharmacologic treatments in psychodermatology. Dermatol Clin. Jan 2002;20(1):177-85. [Medline].

  15. Gupta MA, Gupta AK. Olanzapine may be an effective adjunctive therapy in the management of acne excoriée: a case report. J Cutan Med Surg. Jan-Feb 2001;5(1):25-7. [Medline].

  16. Biondi M, Arcangeli T, Petrucci RM. Paroxetine in a case of psychogenic pruritus and neurotic excoriations. Psychother Psychosom. May-Jun 2000;69(3):165-6. [Medline].

  17. Gupta MA, Gupta AK. Fluoxetine is an effective treatment for neurotic excoriations: case report. Cutis. May 1993;51(5):386-7. [Medline].

  18. Fried R. Psychodermatology. Dialogues in Dermatology. American Academy of Dermatology. Available at http://www.aad.org/Marketplace/Catalog/dialogues.html. Accessed 2003.

 
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A picker's nodules with no crust and a scarred appearance.
A picker's nodule with crusted lesions.
 
 
 
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