Approach Considerations
The patient’s denial of psychic distress and the possible negative feelings aroused in health care personnel make management of excoriation (skin-picking) disorder difficult. It is has been estimated that about 20% of patients with excoriation (skin-picking) disorder look for treatment. This is thought to be due to the belief that the condition is untreatable or considering it a “bad habit” or due to fear of social embarrassment. A dermatologist rather than a psychiatrist or psychologist often first sees those that do seek treatment. [1]
Setting limits for the protection of both the physician and patient; creating an accepting, empathic, and nonjudgmental environment; and closely supervising symptomatic dermatologic care permit the development of a therapeutic relationship in which psychological issues may be gradually introduced, which may occasionally permit referral to a psychiatrist. Issues of etiology should be sidestepped because confrontation is counterproductive.
If the patient refuses referral to a psychiatrist, psychotropic drug therapy prescribed by dermatologists is helpful and appropriate. The upper dose range of selective serotonin reuptake inhibitors (SSRIs) or low-dose atypical antipsychotic agents may be effective.
Using hypnosis to facilitate resolution of psychogenic excoriations in acne excoriée has been reported.
Pharmacologic Therapy
There is currently no medication approved by the US Food and Drug Administration approved for the treatment of excoriation (skin picking) disorder. [17] Attempts to treat it with a variety of psychotropic medication classes include antipsychotic agents, antianxiety agents, antidepressant agents, topical cortisone agents, and antiepileptic agents.
In 2005, Krishnan and Koo reported that pathology of the opioid neurotransmitter system and the central nervous system (CNS) is the neurologic basis for neurotic excoriations, which suggested that psychiatric medications that can normalize CNS pathology can abate neurotic excoriations. [18] In line with this, glutamate, an excitatory CNS neurotransmitter, has been reported as being potentially helpful for treating picking disorders when other conventional therapies fail. [19] A two-center randomized, double-blind trial with 66 adults with excoriation disorder assessed N-acetylcysteine against placebo for 12 weeks, with 47% of N-acetylcysteine group reporting improvement compared to 19% receiving placebo. N-acetylcysteine, an amino acid that appears to restore extracellular glutamate concentration in the nucleus accumbens, has been shown to significantly reduce skin-picking symptoms, and it is well tolerated. [17]
Studies have shown that the serotonergic effect of SSRIs produces an antipruritic effect. [20, 21] The relief of pruritus is unrelated to changes in the patient’s mood and happens faster than would be expected for antidepressant effects.
Olanzapine may be an effective adjunctive therapy in the management of acne excoriée. [22] Paroxetine was reportedly effective in a case of psychogenic pruritus and neurotic excoriations. [23] Lithium has been used to treat neurotic excoriations, but further study is needed. [24] Dereli et al found that gabapentin is a useful treatment for recalcitrant chronic prurigo nodularis. [25]
Hypnosis
In a study by Shenefelt, hypnotic suggestion successfully alleviated the behavioral picking aspect of acne excoriée des jeunes filles in a pregnant woman who had been picking at the acne lesions on her face for 15 years. [26] Acne excoriée is a subset of psychogenic or neurotic excoriation. Conventional topical antibiotic treatment was used to treat the acne. Compared with other treatments for uncomplicated acne excoriée, hypnosis is relatively brief and cost-effective and is nontoxic in pregnancy.
Consultations
A meta analysis of 9 studies examined the efficacy of various psychiatric treatments available for excoriation disorder including cognitive-behavioral therapy (CBT), acceptance and commitment therapy (ACT), and habit reversal training (HRT). The overall findings suggest that behavioral treatments were associated with large reductions in severity of excoriation disorder from baseline to post treatment. [27] CBT involves psychoeducation, relapse prevention, and cognitive restructuring. HRT, which is used to treat a variety of repetitive behavior problems, involves competing response training. ACT entails acceptance and mindfulness strategies as well as commitment and behavior change strategies. [1]
A psychiatrist and a psychologist should be consulted. Neurotic excoriations 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 consequences of unmet emotional needs. Conflicts can result from past or current situations. Resolving these issues alone can be difficult.
Excoriation disorder 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. [28]
Long-Term Monitoring
Lesions can be kept to a minimum, the patient can be protected from unnecessary and intrusive studies, and society can be protected from escalating and unnecessary expenditure of medical resources if, rather than discharging the patient, the dermatologist continues to see the patient on an ongoing basis for supervision and support, regardless of whether lesions are present.
Patients with neurotic excoriations can be seen by psychiatrists and benefit from follow-up care to encourage the maintenance of treatment. As outpatients, patients with neurotic excoriations can be treated with low-dose psychotropic medications and cortisone creams.
Prevention
Physical barriers (eg, an Unna sleeve) can be an effective treatment for neurotic excoriations. [29]
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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.
