ORLANDO – In what might be the first success of its kind, dermatologists at the University of Texas report treating a case of neurotic excoriations with onabotulinumtoxinA.
A 36-year-old man presented with multiple excoriated, crusted erosions on his face and scalp and also complained of tension headaches and an inability to relax.
Images courtesy Dr. Jennifer Gordon
Before treatment, neurotic excoriations are seen on the patient’s face and scalp.
In an attempt to relieve his headaches, Dr. Jennifer Gordon and her colleagues injected his glabella and forehead with 56 units of onabotulinumtoxinA (Botox and Botox Cosmetic).
To their surprise, in 3 weeks he was not only relieved of his headaches, but also of his excoriations.
The patient has been free of symptoms for the past year and receives maintenance injections every 4-6 months, said Dr. Gordon, a second-year dermatology resident at the University of Texas, Austin.
Neurotic excoriations (NE), also known as psychogenic excoriation, dermatillomania, or skin picking syndrome, are the result of compulsive skin picking and scratching. The condition occurs in the absence of a physical pathology and is usually associated with psychological and medical conditions that cause psychological distress.
Some studies suggest that roughly 2% of the patients at dermatology clinics have NE, and there’s a 9% prevalence of NE in patients with pruritus (itching). Researchers believe, however, that the incidence and prevalence of the condition are underreported.
Current treatments for NE include antidepressants and cognitive-behavioral therapy.
Treatment with botulinum resolved the excoriations.
Dr. Gordon, who presented a poster at the Orlando Dermatology Aesthetic and Clinical Conference, reported that her patient described "hairs" coming out of his skin, and that twisting his body caused the hairs to coil and pull. As a result, he would pick at these areas on his face and scalp. He also complained of frequent tension headaches.
His lab values were within normal limits, Dr. Gordon reported. He was first treated for folliculitis and was given wound care instructions. He was later started on citalopram, which eliminated complaints about the hairs, but the excoriations persisted. The patient already had been treated for delusions, "and we don’t hesitate to send [the patients] for psych treatment if they need it," said Dr. Gordon, who published the poster with Dr. Jason S. Reichenberg, a faculty member at the university.
The investigators said that they believed the onabotulinumtoxinA might have induced remission in the patient by eliminating tension headaches, which could have been a trigger for his picking. The treatment also might have helped his underlying depression.
Although some statistics show that as many as one-third of NE patients also have tension or migraine headaches and gynecologic symptoms related to menstruation, it is unclear whether this treatment would work on other patients with symptoms similar to this particular patient. It’s also not yet known whether the treatment would work on other sites of the body, or on patients who do not have tension headaches, Dr. Gordon said.
The key to treatment of NE, she said, "is finding the underlying trigger."
Dr. Gordon said that she had no disclosures.
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