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The lesions on this 41-year-old African-American woman’s skin have waxed and waned over the years—but they’re always on her mind. They are most prominent on her arms and trunk but crop up almost anywhere on her body.
When they manifest—for no apparent reason—they itch, creating an irresistible urge for the patient to pick at them. This provides some relief, both from the itching and from her feeling that there is “something in there” that she needs to remove. Fairly often, her digging (with fingernails) results in “finding” white bumps at the ends of tiny hairs.
As these small excoriations heal, the wounds itch—compelling her to pick the site open again. She knows she is caught in a vicious cycle but doesn’t know how to stop. Selective serotonin reuptake inhibitors have been tried, with little to no effect.
EXAMINATION
The patient’s type IV skin is covered with dark brown, maculopapular lesions that are so numerous and large (average diameter, 2 to 3 cm) that they are impossible to ignore. Her palms, soles, face, and midback are spared.
Only a few of the newer lesions are palpable, showing faint signs of central excoriation. Previous biopsies failed to show significant pathology.
The patient appears ill at ease during history-taking. She admits to picking her skin for many years but doesn’t believe she is inhabited by any kind of bug. The skin on her wrists and between her fingers is clear. Her 3-year-old daughter’s skin is free of notable changes.
What is the diagnosis?
Known in the DSM-5 and ICD-10 as skin-picking disorder, this condition has also been called dermatillomania. For unknown reasons, its incidence is far greater among women than men.
While it has been posited as a form of obsessive compulsive disorder (OCD), dermatillomania responds poorly, if at all, to standard OCD treatments. It is considered by others to more closely resemble addiction because, despite knowing its harm, patients persistently pick at the skin and often report a subsequent sense of relief.
This patient’s type IV skin lent itself to postinflammatory hyperpigmentation upon injury. Although she knew this, she still felt that she could somehow pick the darkness away.
Bloodwork was done to rule out other conditions, such as porphyria, hematologic disease, and renal or liver disease. Had a recent biopsy not been performed, this would have been included to rule out systemic disease.
The patient was given a topical steroid cream to put on any itchy lesions and counseled to avoid picking or scratching them, since this was the only way her skin could ever clear.
TAKE-HOME LEARNING POINTS
- One common term for this patient’s disorder is dermatillomania, though the DSM-5 and ICD-10 refer to it as skin-picking disorder.
- This patient experienced postinflammatory hyperpigmentation, which caused her considerable embarrassment.
- Many affected patients have unresolved underlying psychologic issues that contribute to their problem.
- The solution (which may require extensive counseling): Stop picking, and the dark lesions will eventually resolve.
The lesions on this 41-year-old African-American woman’s skin have waxed and waned over the years—but they’re always on her mind. They are most prominent on her arms and trunk but crop up almost anywhere on her body.
When they manifest—for no apparent reason—they itch, creating an irresistible urge for the patient to pick at them. This provides some relief, both from the itching and from her feeling that there is “something in there” that she needs to remove. Fairly often, her digging (with fingernails) results in “finding” white bumps at the ends of tiny hairs.
As these small excoriations heal, the wounds itch—compelling her to pick the site open again. She knows she is caught in a vicious cycle but doesn’t know how to stop. Selective serotonin reuptake inhibitors have been tried, with little to no effect.
EXAMINATION
The patient’s type IV skin is covered with dark brown, maculopapular lesions that are so numerous and large (average diameter, 2 to 3 cm) that they are impossible to ignore. Her palms, soles, face, and midback are spared.
Only a few of the newer lesions are palpable, showing faint signs of central excoriation. Previous biopsies failed to show significant pathology.
The patient appears ill at ease during history-taking. She admits to picking her skin for many years but doesn’t believe she is inhabited by any kind of bug. The skin on her wrists and between her fingers is clear. Her 3-year-old daughter’s skin is free of notable changes.
What is the diagnosis?
Known in the DSM-5 and ICD-10 as skin-picking disorder, this condition has also been called dermatillomania. For unknown reasons, its incidence is far greater among women than men.
While it has been posited as a form of obsessive compulsive disorder (OCD), dermatillomania responds poorly, if at all, to standard OCD treatments. It is considered by others to more closely resemble addiction because, despite knowing its harm, patients persistently pick at the skin and often report a subsequent sense of relief.
This patient’s type IV skin lent itself to postinflammatory hyperpigmentation upon injury. Although she knew this, she still felt that she could somehow pick the darkness away.
Bloodwork was done to rule out other conditions, such as porphyria, hematologic disease, and renal or liver disease. Had a recent biopsy not been performed, this would have been included to rule out systemic disease.
The patient was given a topical steroid cream to put on any itchy lesions and counseled to avoid picking or scratching them, since this was the only way her skin could ever clear.
TAKE-HOME LEARNING POINTS
- One common term for this patient’s disorder is dermatillomania, though the DSM-5 and ICD-10 refer to it as skin-picking disorder.
- This patient experienced postinflammatory hyperpigmentation, which caused her considerable embarrassment.
- Many affected patients have unresolved underlying psychologic issues that contribute to their problem.
- The solution (which may require extensive counseling): Stop picking, and the dark lesions will eventually resolve.
The lesions on this 41-year-old African-American woman’s skin have waxed and waned over the years—but they’re always on her mind. They are most prominent on her arms and trunk but crop up almost anywhere on her body.
When they manifest—for no apparent reason—they itch, creating an irresistible urge for the patient to pick at them. This provides some relief, both from the itching and from her feeling that there is “something in there” that she needs to remove. Fairly often, her digging (with fingernails) results in “finding” white bumps at the ends of tiny hairs.
As these small excoriations heal, the wounds itch—compelling her to pick the site open again. She knows she is caught in a vicious cycle but doesn’t know how to stop. Selective serotonin reuptake inhibitors have been tried, with little to no effect.
EXAMINATION
The patient’s type IV skin is covered with dark brown, maculopapular lesions that are so numerous and large (average diameter, 2 to 3 cm) that they are impossible to ignore. Her palms, soles, face, and midback are spared.
Only a few of the newer lesions are palpable, showing faint signs of central excoriation. Previous biopsies failed to show significant pathology.
The patient appears ill at ease during history-taking. She admits to picking her skin for many years but doesn’t believe she is inhabited by any kind of bug. The skin on her wrists and between her fingers is clear. Her 3-year-old daughter’s skin is free of notable changes.
What is the diagnosis?
Known in the DSM-5 and ICD-10 as skin-picking disorder, this condition has also been called dermatillomania. For unknown reasons, its incidence is far greater among women than men.
While it has been posited as a form of obsessive compulsive disorder (OCD), dermatillomania responds poorly, if at all, to standard OCD treatments. It is considered by others to more closely resemble addiction because, despite knowing its harm, patients persistently pick at the skin and often report a subsequent sense of relief.
This patient’s type IV skin lent itself to postinflammatory hyperpigmentation upon injury. Although she knew this, she still felt that she could somehow pick the darkness away.
Bloodwork was done to rule out other conditions, such as porphyria, hematologic disease, and renal or liver disease. Had a recent biopsy not been performed, this would have been included to rule out systemic disease.
The patient was given a topical steroid cream to put on any itchy lesions and counseled to avoid picking or scratching them, since this was the only way her skin could ever clear.
TAKE-HOME LEARNING POINTS
- One common term for this patient’s disorder is dermatillomania, though the DSM-5 and ICD-10 refer to it as skin-picking disorder.
- This patient experienced postinflammatory hyperpigmentation, which caused her considerable embarrassment.
- Many affected patients have unresolved underlying psychologic issues that contribute to their problem.
- The solution (which may require extensive counseling): Stop picking, and the dark lesions will eventually resolve.