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ANSWER
The correct answer is neurotic excoriations (choice “d”), a chronic condition thought to be a psychologic process with dermatologic manifestations, consciously created by repetitive scratching and rubbing. Focally, it can manifest with skin alterations very similar to lichen simplex chronicus (choice “a”; also known as neurodermatitis), but the latter refers to very limited, localized processes and does not involve the psychiatric overlay seen with neurotic excoriations.
Patients with dermatitis artefacta (choice “b”; formerly called factitial dermatitis) consciously create their lesions for secondary gain, often using sharp objects such as nail files, kitchen utensils, or even shards of broken glass. Dermatitis artefacta lesions, which are relatively sparse and bizarre in appearance, can also be created by the application of caustic chemicals, or even by injection of foreign substances.
The differential rightly includes any number of skin conditions such as bullous pemphigoid (choice “c”). However, this was effectively ruled out by the biopsy and also by the morphology and extended chronicity of the patient’s complaint.
DISCUSSION
Neurotic excoriations (NE) are usually created by unconscious picking, scratching, or rubbing. There may be a precipitating minor skin pathology (eg, insect bite, folliculitis or acne), but it can develop independent of any such process. Its origins can often be tied to upsetting life events, such as divorce, death, or early dementia.
More history taking from this patient and her family revealed that her skin problems began after her husband died in an accident, after which, according to her children, “she has never been the same.” Her picking accelerated when she moved to an assisted living setting.
Because patients create neurotic excoriations, their lesions have the quality of an “outside job,” with clean linear erosions, crusts, and scars that can be hypopigmented or hyperpigmented, depending on the patient’s skin type. Similar in size and shape, the lesions tend to be bilaterally and symmetrically distributed and confined to areas within easy reach, such as the extensor surfaces of the arms and the upper part of the back.
The vast majority of NE patients are adult women, though it is also seen in children as a manifestation of comorbid psychopathology or other psychosocial stressor.
TREATMENT
As one might expect, treatment of NE is difficult, particularly since many patients find it impossible to accept the role their mental state plays in the creation and perpetuation of their condition. In the best of all possible scenarios, the patient would be seen and followed by a psychiatrist, who would probably prescribe psychoactive medication.
Failing that—or even in addition to that treatment—one could, at a minimum, find ways to distract the patient, trim her nails as much as possible, and/or place barriers between the offending nails and the skin in question.
Topical medications, such as steroid creams, are of very limited usefulness, as are oral antibiotics and antihistamines.
ANSWER
The correct answer is neurotic excoriations (choice “d”), a chronic condition thought to be a psychologic process with dermatologic manifestations, consciously created by repetitive scratching and rubbing. Focally, it can manifest with skin alterations very similar to lichen simplex chronicus (choice “a”; also known as neurodermatitis), but the latter refers to very limited, localized processes and does not involve the psychiatric overlay seen with neurotic excoriations.
Patients with dermatitis artefacta (choice “b”; formerly called factitial dermatitis) consciously create their lesions for secondary gain, often using sharp objects such as nail files, kitchen utensils, or even shards of broken glass. Dermatitis artefacta lesions, which are relatively sparse and bizarre in appearance, can also be created by the application of caustic chemicals, or even by injection of foreign substances.
The differential rightly includes any number of skin conditions such as bullous pemphigoid (choice “c”). However, this was effectively ruled out by the biopsy and also by the morphology and extended chronicity of the patient’s complaint.
DISCUSSION
Neurotic excoriations (NE) are usually created by unconscious picking, scratching, or rubbing. There may be a precipitating minor skin pathology (eg, insect bite, folliculitis or acne), but it can develop independent of any such process. Its origins can often be tied to upsetting life events, such as divorce, death, or early dementia.
More history taking from this patient and her family revealed that her skin problems began after her husband died in an accident, after which, according to her children, “she has never been the same.” Her picking accelerated when she moved to an assisted living setting.
Because patients create neurotic excoriations, their lesions have the quality of an “outside job,” with clean linear erosions, crusts, and scars that can be hypopigmented or hyperpigmented, depending on the patient’s skin type. Similar in size and shape, the lesions tend to be bilaterally and symmetrically distributed and confined to areas within easy reach, such as the extensor surfaces of the arms and the upper part of the back.
The vast majority of NE patients are adult women, though it is also seen in children as a manifestation of comorbid psychopathology or other psychosocial stressor.
TREATMENT
As one might expect, treatment of NE is difficult, particularly since many patients find it impossible to accept the role their mental state plays in the creation and perpetuation of their condition. In the best of all possible scenarios, the patient would be seen and followed by a psychiatrist, who would probably prescribe psychoactive medication.
Failing that—or even in addition to that treatment—one could, at a minimum, find ways to distract the patient, trim her nails as much as possible, and/or place barriers between the offending nails and the skin in question.
Topical medications, such as steroid creams, are of very limited usefulness, as are oral antibiotics and antihistamines.
ANSWER
The correct answer is neurotic excoriations (choice “d”), a chronic condition thought to be a psychologic process with dermatologic manifestations, consciously created by repetitive scratching and rubbing. Focally, it can manifest with skin alterations very similar to lichen simplex chronicus (choice “a”; also known as neurodermatitis), but the latter refers to very limited, localized processes and does not involve the psychiatric overlay seen with neurotic excoriations.
Patients with dermatitis artefacta (choice “b”; formerly called factitial dermatitis) consciously create their lesions for secondary gain, often using sharp objects such as nail files, kitchen utensils, or even shards of broken glass. Dermatitis artefacta lesions, which are relatively sparse and bizarre in appearance, can also be created by the application of caustic chemicals, or even by injection of foreign substances.
The differential rightly includes any number of skin conditions such as bullous pemphigoid (choice “c”). However, this was effectively ruled out by the biopsy and also by the morphology and extended chronicity of the patient’s complaint.
DISCUSSION
Neurotic excoriations (NE) are usually created by unconscious picking, scratching, or rubbing. There may be a precipitating minor skin pathology (eg, insect bite, folliculitis or acne), but it can develop independent of any such process. Its origins can often be tied to upsetting life events, such as divorce, death, or early dementia.
More history taking from this patient and her family revealed that her skin problems began after her husband died in an accident, after which, according to her children, “she has never been the same.” Her picking accelerated when she moved to an assisted living setting.
Because patients create neurotic excoriations, their lesions have the quality of an “outside job,” with clean linear erosions, crusts, and scars that can be hypopigmented or hyperpigmented, depending on the patient’s skin type. Similar in size and shape, the lesions tend to be bilaterally and symmetrically distributed and confined to areas within easy reach, such as the extensor surfaces of the arms and the upper part of the back.
The vast majority of NE patients are adult women, though it is also seen in children as a manifestation of comorbid psychopathology or other psychosocial stressor.
TREATMENT
As one might expect, treatment of NE is difficult, particularly since many patients find it impossible to accept the role their mental state plays in the creation and perpetuation of their condition. In the best of all possible scenarios, the patient would be seen and followed by a psychiatrist, who would probably prescribe psychoactive medication.
Failing that—or even in addition to that treatment—one could, at a minimum, find ways to distract the patient, trim her nails as much as possible, and/or place barriers between the offending nails and the skin in question.
Topical medications, such as steroid creams, are of very limited usefulness, as are oral antibiotics and antihistamines.
At her daughters’ insistence, this 69-year-old woman requests referral to dermatology for a skin condition that has been present for at least 20 years. During that time, she has seen many medical providers (including dermatologists) and has tried many different treatments (eg, creams, oral antibiotics, oral steroids, and antihistamines). While some of these helped a bit, most did not help at all—nor did the constant nagging at the patient by family and caregivers. Nonetheless, her daughters feel strongly that their mother is perpetuating the problem with her “scratching and picking.” They have observed that when she is able to leave her arms alone, the improvement in her skin is dramatic. For example, years ago, she broke her wrist and was placed in a cast for six weeks; when it was removed, the affected arm was completely clear (except for multiple old scars). Everyone, including the patient, was ecstatic—but a week later, the lesions returned. The extensor aspects of both arms and hands are covered with linear excoriations, scars, and scabs, with focal hyperpigmentation in many of the excoriated areas. Overall, the skin in these areas is re-markably thickened and focally shiny. Her skin elsewhere—such as her palms and the volar aspects of her arms—is relatively clear. Throughout the examination, the patient’s hands never stop rubbing and scratching her arms, even as she weakly denies doing so. “Whatever happens, I’m not going to see a shrink,” she says. Clearly, a biopsy is in order, with a sample taken from a typical section of her forearm. The results show minimal changes but demonstrate hyperkeratosis. Blood work, including a complete metabolic profile and complete blood count, fail to show any evidence of systemic disease.
