History
Patients with excoriation (skin-picking) disorder give a history of picking, digging, or scraping their skin. Sometimes an inciting incident is the cause, and sometimes no inciting incident is present. Patients might note that they do not scratch themselves consciously; rather, they pick and then notice that they are picking. Cyr and Dreher have provided an excellent summary of neurotic excoriations and their historical and clinical findings and manifestations. [11] Ultimately, neurotic excoriations are a diagnosis of exclusion. [12]
An French survey of neurotic excoriations in 10 patients found that most patients linked their initial excoriations with personal problems; 4 of the patients noted abuse in childhood or in adolescence. [13] This study appeared to suggest that skin picking was an impulsive reaction rather than an obsessive-compulsive disorder; however, the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5), currently classifies excoriation disorder among the obsessive-compulsive and related disorders. [2]
Patients can have a psychiatric history that includes a comorbid mental disorder. Most patients with excoriation disorder do not have any particular psychopathology; however, psychiatric diagnoses to be considered include the following:
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Somatoform disorders (eg, facial dermatitis, somatization, or hypochondriasis)
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Borderline personality disorder (self-mutilation)
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Delusions of parasitosis (may be part of a larger diagnostic group, such as schizophrenia)
Patients pick at areas until they can pull material from the skin. This may be referred to as "pulling a thread from the skin."
Setyadi et al noted that trigeminal trophic syndrome can result in ulcerations on the nose (in the nasal ala and paranasal locations), most commonly manifesting in older women after therapy for trigeminal neuralgia. [14]
Young women who pick at their faces may have a history of mild acne. Such cases are referred to as acne excoriée. This condition is not discussed in this article. The erosions can heal slowly because of recurrent picking.
It is helpful to ask patients which came first, the lesion or the urge to itch. When closely questioned, most patients say that they first scratched their skin and then saw a lesion. The lesions of neurotic excoriations have a component of an itch-scratch cycle, whereby the urge to scratch generates an even greater urge to scratch.
Because a variety of physical conditions can cause itching and then lesions, these must be excluded or, at least, established as being relatively unlikely before a firm diagnosis of excoriation disorder can be made. Such conditions include the following:
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Renal disease
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Cocaine use
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Opiate use
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Medication reactions
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Multiple sclerosis
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Hepatic disease
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Lymphoma
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Pregnancy
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Internal cancers
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Uremia
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Carcinoid
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Delirium
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Diabetes mellitus
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Hypothyroidism
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Iron deficiency anemia
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Hyperthyroidism
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Xerosis
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Intestinal parasitosis
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Myeloma may be noted
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Patients may report headache or menstrual disorders
Physical Examination
Often, right-handed persons tend to pick at their left side, left-handed people at their right side. The erosions and scars tend to have angulated borders. The quantity of erosions and scars is variable. Several lesions to hundreds of lesions can be present. Erosions, crusts, and scars are located only where the patient can pick. Lesions can be either crusted or noncrusted (see the images below).
Erosions can vary in morphology and can sometimes evolve into frank ulcers. Dug-out erosions or ulcers, crusted erosions, and ulcers can be present. Sometimes, erythema and scars are present around the erosions and the ulcers.
In dermatitis artefacta, the patient creates skin lesions to satisfy an internal psychological need, usually a need to be taken care of. The clinical presentation is characteristic, and it differs from that of excoriation disorder, delusional disorders, malingering, and Munchausen syndrome. Munchausen syndrome by proxy is a form of dermatitis artefacta.
Except when the lesions mimic another disease, those that do not conform to descriptions of known dermatoses are shrouded in mystery, appearing fully formed on accessible skin, within the context of a characteristic psychological constellation. The patient is friendly but bewildered, and relatives may be angry and frustrated.
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A picker's nodules with no crust and a scarred appearance.
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A picker's nodule with crusted lesions.
