eMedicine Specialties > Dermatology > Psychocutaneous Diseases

Neurotic Excoriations: Treatment & Medication

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

Updated: Feb 18, 2008

Treatment

Medical Care

In 2005, Krishnan and Koo5 reported that the pathology of the opioid neurotransmitter system and the central nervous system is the neurological basis for neurotic excoriations and thus psychiatric medications that can normalize nervous system pathology can abate neurotic excoriations.

In the treatment of NEs, studies have shown that the serotonergic effect of SSRIs consistently produces the strongest antipruritic effect. The relief of pruritus is unrelated to changes in the patient's mood and happens faster than would be expected for antidepressant effects.

For its sedating and antipsychotic effects, doxepin (10-25 mg PO qhs) is a useful medication in treating NEs.

Dereli et al6  found that gabapentin is a useful treatment for recalcitrant chronic prurigo nodularis.

Consultations

Consult a psychiatrist and a psychologist. NEs can be associated with psychopathology. Social stressors may be well hidden because of shame or a delusional belief system. Suppression, inappropriate channeling, and repression of aggression can be a result of unmet emotional needs. Conflicts can result from past or current situations. Resolving these issues alone can be difficult. NEs can be associated with anxiety disorders, low self-confidence, generalized apprehension, meticulousness, depressive mood, and hypersensitivity to perceived self-negativism. Thus, the intervention of a psychiatrist or other trained mental health care professionals can be useful. Patients can benefit from psychotherapy and other forms of counseling.

Medication

NEs are treated with a variety of psychotropic medications. The doses can be lower than those used in treating depression, and the medications can act more quickly.

Using hypnosis to facilitate resolution of psychogenic excoriations in acne excoriée has been reported.

Olanzapine may be an effective adjunctive therapy in the management of acne excoriée.7

Paroxetine was reportedly effective in a case of psychogenic pruritus and NEs.8

Antipsychotic agents

Decrease the urge to scratch and relieve anxiety.


Doxepin (Sinequan)

Inhibits histamine and acetylcholine activity and has proven useful in the treatment of various forms of depression associated with chronic and neuropathic pain.

Adult

10-25 mg PO qhs

Pediatric

Not commonly used
<12 years: Not recommended
>12 years: 10 mg qhs

Decreases antihypertensive effects of clonidine but increases effects of sympathomimetics and benzodiazepines; effects of desipramine increase with phenytoin, carbamazepine, and barbiturates

Documented hypersensitivity; urinary retention; acute recovery phase following myocardial infarction; glaucoma

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

Caution in cardiovascular disease, conduction disturbances, seizure disorders, urinary retention, and hyperthyroidism; caution in patients receiving thyroid replacement

Antianxiety agents

Used to reduce the level of anxiety in patients who experience pruritus.


Buspirone (BuSpar)

A 5-HT1 agonist with serotonergic neurotransmission and some dopaminergic effects in CNS. Has anxiolytic effect but may take up to 2-3 wk for full efficacy.

Adult

15 mg PO qd/tid

Pediatric

Not established

Toxicity is increased with MAOIs, phenothiazines, and CNS depressants; increases toxicity of digoxin and haloperidol

Pregnancy

B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals

Precautions

Caution in hepatic or renal impairment

Antidepressant agents

May be used to improve mood and to restore normal sleep patterns in patients who experience pruritus.


Fluoxetine (Prozac)

Selectively inhibits presynaptic serotonin reuptake with minimal or no effect in the reuptake of norepinephrine or dopamine.

Adult

20 mg PO qd

Pediatric

<18 years: Not established; initial doses of 20 mg/d in children 6-14 y have been used
>18 years: Administer as in adults

Increases toxicity of diazepam and trazodone by decreasing clearance; also increases toxicity of MAOIs and highly protein bound drugs; serotonin syndrome (ie, myoclonus, rigidity, confusion, nausea, hyperthermia, autonomic instability, coma, eventual death) occurs with simultaneous use of other serotonergic agents (eg, anorectic agents, tramadol, buspirone, trazodone, clomipramine, nefazodone, tryptophan); discontinue other serotonergic agents at least 2 wk prior to SSRIs

Documented hypersensitivity; concurrently taking MAOIs or have taken them in the last 2 wk

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

Caution in hepatic impairment and history of seizures; discontinue MAOIs at least 14 d before initiating therapy

Topical cortisone agents

Have anti-inflammatory properties and cause profound and varied metabolic effects. Corticosteroids modify the body's immune response to diverse stimuli.


Triamcinolone topical (Aristocort)

Treats inflammatory dermatosis that is responsive to steroids. Decreases inflammation by suppressing the migration of polymorphonuclear leukocytes and reversing capillary permeability.

Adult

Apply thin film bid/tid until favorable response obtained

Pediatric

Apply as in adults with caution

Documented hypersensitivity; fungal, viral, and bacterial skin infections

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

Do not use in decreased skin circulation; prolonged use, applying over large areas, and using potent steroids and occlusive dressings may result in systemic absorption; systemic absorption may cause Cushing syndrome, reversible HPA-axis suppression, hyperglycemia, and glycosuria

Antiepileptic agents

Decrease impulsiveness.


Topiramate (Topamax)

Sulfamate-substituted monosaccharide with broad spectrum of antiepileptic activity that may have state-dependent sodium channel blocking action. Potentiates inhibitory activity of GABA. May block glutamate activity.
Not necessary to monitor plasma concentrations to optimize therapy. On occasion, addition of topiramate to phenytoin may require phenytoin dose adjustment to achieve optimal clinical outcome.

Adult

50 mg/d and titrate by 50 mg/d at 1-wk intervals to target a dose of 200 mg bid; not to exceed 1600 mg/d

Pediatric

Not established

Phenytoin, carbamazepine, and valproic acid can significantly decrease levels; reduces digoxin and norethindrone levels when administered concomitantly; concomitant use with carbonic anhydrase inhibitors may increase risk of renal stone formation and should be avoided

Documented hypersensitivity; use with extreme caution when administering concurrently with CNS depressants because may have an additive effect in CNS depression and other cognitive or neuropsychiatric adverse events

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

Risk of developing kidney stones increased 2-4 times that of untreated population; risk may be reduced by increasing fluid intake; caution in renal or hepatic impairment; patients should seek immediate medical attention if they experience blurred vision or periorbital pain; continued usage after symptoms develop, can lead to glaucoma; primary treatment is discontinuation; if left untreated, serious sequelae, including permanent vision loss, may occur

More on Neurotic Excoriations

Overview: Neurotic Excoriations
Differential Diagnoses & Workup: Neurotic Excoriations
Treatment & Medication: Neurotic Excoriations
Follow-up: Neurotic Excoriations
Multimedia: Neurotic Excoriations
References
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References

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

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

  3. Setyadi HG, Cohen PR, Schulze KE, Mason SH, Martinelli PT, Alford EL, et al. Trigeminal trophic syndrome. South Med J. Jan 2007;100(1):43-8. [Medline].

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

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

  6. 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].

  7. 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].

  8. 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].

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

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

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

  12. Gupta MA, Lanius RA, Van der Kolk BA. Psychologic trauma, posttraumatic stress disorder, and dermatology. Dermatol Clin. Oct 2005;23(4):649-56. [Medline].

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

  14. Koblenzer CS. Psychocutaneous disease. Clin Dermatol. 1985;4:1-14.

  15. Shapira NA, Lessig MC, Murphy TK, Driscoll DJ, Goodman WK. Topiramate attenuates self-injurious behaviour in Prader-Willi Syndrome. Int J Neuropsychopharmacol. Jun 2002;5(2):141-5. [Medline].

  16. Usatine RP, Saldana-Arregui MA. Excoriations and ulcers on the arms and legs. J Fam Pract. Sep 2004;53(9):713-6. [Medline].

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Further Reading

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Keywords

NE, picker's nodules, prurigo nodularis, repetitive scratching, unconscious picking at the skin, uncontrollable picking at lesions

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Contributor Information and Disclosures

Author

Noah S Scheinfeld, MD, JD, FAAD, Assistant Clinical Professor, Department of Dermatology, Columbia University; Consulting Staff, Department of Dermatology, St Luke's Roosevelt Hospital Center, Beth Israel Medical Center, 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: Nothing to disclose.

Medical Editor

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.

Pharmacy Editor

David F Butler, MD, Professor of Dermatology, Texas A&M University College of Medicine; Director, Division of Dermatology, Scott and White Clinic; Director Dermatology Residency Training Program, Scott and White 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: 3M Pharmaceutical Grant/research funds Other; Graceway Pharmaceuticals Grant/research funds Other

Managing Editor

Rosalie Elenitsas, MD, 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 Society of Dermatopathology
Disclosure: Nothing to disclose.

CME Editor

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 None; Genentech Consulting fee Consulting; Centocor Consulting fee Consulting; Centocor Grant/research funds None; Covance Consulting fee Consulting; Shire  Consulting

Chief Editor

Dirk M Elston, MD, Director, Department of Dermatology, Geisinger Medical Center
Dirk M Elston, MD is a member of the following medical societies: American Academy of Dermatology
Disclosure: Nothing to disclose.

 
 
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