SKINIPEDIA - Skin Diseases: Neurotic Skin Excoriations

Neurotic Skin Excoriations by: 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

lPatients consciously create neurotic excoriations by repetitive scratching of their skin. 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.

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 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.

Pathophysiology

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

Frequency in the 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.

Neurotic Skin Excoriations, Clinical Study, Part II

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