Acta Dermatovenerol Croat 2015 ;23(2):87-95

Professor Aleksandra Basta-Juzbašić, MD, PhD, Department of Dermatology and Venereology, University Hospital Centre Zagreb, University of Zagreb School of Medicine, Šalata 4, 10000 Zagreb, Croatia;

Primary psychiatric disorders where skin changes appear most frequently include: delusions of parasitosis, body dysmorphic disorder, neurotic excoriations, dermatitis artefacta, and trichotillomania. In all these diseases the primary pathologic condition is of psychiatric nature, and the skin changes are secondary and self-induced. In this review we wanted to present the epidemiology, clinical pictures, and treatment options for these disorders. Read More

Adv Psychosom Med 2015 30;34:123-34. Epub 2015 Mar 30.

University of Arizona, College of Medicine, Tucson, Ariz., USA.

Psychodermatology is an underappreciated field that studies psychocutaneous disorders, which are conditions that have both dermatologic and psychiatric characteristics. Underlying psychiatric comorbidity is estimated to occur in up to one-third of dermatologic patients, and psychiatric illness may either be the cause or the consequence of dermatologic disease. Psychodermatologic patients lack insight and often do not recognize a psychiatric etiology for their symptoms and therefore comprise some of the most challenging cases to treat. Read More

Int Wound J 2016 Oct 14;13(5):860-2. Epub 2015 Jan 14.

Department of Pathology, Dental School, University of São Paulo, São Paulo, Brazil.

Obsessive-compulsive-related cutaneous disease most often includes trichotillomania, neurotic excoriations and nail biting. In this report, we present two cases of self-inflicted severe wounds that were diagnosed as secondary to obsessive-compulsive behaviour. Patients were middle-aged females who presented with deep cutaneous ulcers that were acknowledgedly maintained through repetitive manipulation. Read More

Innov Clin Neurosci 2014 Jan;11(1-2):29-31

Mr. Turner is a third year medical student, Ms. Sutton is a fourth year medical student, and Dr. Sharma is Associate Professor of Consult/Liaison Psychiatry; all from University of Nebraska Medical Center, Psychiatry Department, Omaha, Nebraska.

We present a case of a 21-year-old woman with excoriation disorder that was resistant to currently reported treatment options. Severe lesions were present on multiple sites of her body. The skin picking appeared to be associated with anxiety surrounding her current medical stay and medical condition. Read More

Clin Rheumatol 2014 Jul 14;33(7):1009-13. Epub 2014 Jan 14.

Department of Dermatology, Mayo Clinic, 200 First St SW, Rochester, MN, 55905, USA.

The aim of this study was to determine the common dermatologic diagnoses and skin-related symptoms in a cohort of patients with fibromyalgia seen in a tertiary referral center. A retrospective chart review was performed of all patients with a fibromyalgia diagnosis from January 1 to December 31, 2008, whose diagnosis was confirmed in the Fibromyalgia and Chronic Fatigue Clinic at Mayo Clinic in Rochester, Minnesota. Charts were reviewed for dermatologic conditions and cutaneous symptoms. Read More

Semin Cutan Med Surg 2013 Jun;32(2):95-100

Keck School of Medicine, University of Southern California, Los Angeles, USA.

Neurotic Excoriations is a psychocutaneous disorder that is characterized by an uncontrollable urge to pick at normal skin or skin with mild irregularities. Dermatitis Artefacta is another psychocutaneous disorder that consists of self-induced skin lesions often involving a more elaborate method for damaging the skin, such as the use of a sharp instrument. Both neurotic excoriations and dermatitis artefacta cause significant disfigurement and anxiety for the patient. Read More

Indian J Dermatol 2013 Jan;58(1):44-8

School of Medicine, University of Utah, Salt Lake City, UT, San Francisco, California ; Department of Dermatology, University of California, San Francisco, California, USA.

Primary psychiatric conditions encountered in dermatology include dermatitis artefacta, trichotillomania (TTM) and neurotic excoriations. For these disorders, the primary pathologic condition involves the psyche; therefore, any cutaneous findings are self-induced. Herein, we review common primary psychiatric conditions in dermatology - dermatitis artefacta, neurotic excoriations and TTM - and examine their epidemiology, clinical presentation, differential diagnosis and treatment strategies. Read More

Acta Derm Venereol 2013 Jan;93(1):4-12

Department of Psychosomatic Medicine, Justus Liebig University, Giessen, Germany.

The terminology, classification, diagnosis and treatment of self-inflicted dermatological lesions are subjects of open debate. The present study is the result of various meetings of a task force of dermatologists, psychiatrists and psychologists, all active in the field of psychodermatology, aimed at clarifying the terminology related to these disorders. A flow chart and glossary of terms and definitions are presented to facilitate the classification and management of self-inflicted skin lesions. Read More

Clin Dermatol 2013 Jan-Feb;31(1):110-7

Department of Psychiatry, Schulich School of Medicine and Dentistry, University of Western Ontario, 585 Springbank Dr, Suite 101, London, ON, N6J 1H3, Canada.

The self-induced dermatoses (such as trichotillomania, pathologic skin picking or neurotic excoriations, dermatitis artefacta, onychophagia and onychotillomania), which are caused as a result of excessive manipulation of the skin, hair, and nails by the patient, can contribute to significant morbidity and can even complicate the course of a primary dermatologic condition such as acne (eg, in acne excoriée) and some pruritic dermatoses. Reports on the self-induced dermatoses in the past decade have tended to focus upon the specific motor behaviors involved in self-inducing the lesions (ie, skin picking or hair pulling) rather than address the common psychopathologic factors underlying the self-injurious behaviors. In the current psychiatric nosology (Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision) the self-induced dermatoses are classified as Impulse Control Disorders and Stereotypic Movement Disorders, and this classification does not adequately consider the fact that in most patients with self-induced dermatoses, the frequency and severity of the self-injurious behaviors are directly related to acute or chronic problems with emotional regulation and dissociation. Read More

Eurasian J Med 2012 Aug;44(2):68-72

Department of Plastic Surgery, Faculty of Medicine, Inonu University, Malatya, Turkey.

Objective: Macromastia can cause psychiatric disorders, such as anxiety and depression, and decreases in self-esteem and self-confidence. These problems often externalize themselves on the skin, causing lesions characterized by various degrees of excoriations and lichenified plaques. Mammaplasty operations are very effective in the treatment of neurotic excoriations and similar skin lesions as well as any underlying psychiatric disorders. Read More

Zh Nevrol Psikhiatr Im S S Korsakova 2012 ;112(1):14-25

Hypochondria sine materia is a disorder with physical complains corresponding to no any somatic diagnosis. Hypochondria sine materia is a more complicated psychopathological condition compared to hypochondria cum materia. Hypochondria sine materia could be diagnosed not only in psychiatry, but mainly in general medicine. Read More

J Clin Aesthet Dermatol 2012 Feb;5(2):63-4

The Ohio State University Medical Center, Division of Dermatology, Columbus, Ohio.

Patients with psychiatric disease may use the skin as a means of communication during times of increased emotional distress. Furthermore, a high incidence of skin disorders among patients with a primary psychiatric condition, including depression, schizophrenia, and anxiety, has been demonstrated, with neurotic excoriation being one of the most commonly diagnosed. Despite the strong association and incidence of psychogenic excoriation in patients with a primary psychiatric disorder, it is important for primary care physicians and dermatologists alike to realize that these patients may have true dermatological disease. Read More

Acta Derm Venereol 2012 Jul;92(4):416-8

Department of Dermatology, European University of Brittany, University of Brest, University Hospital, FR-29609 Brest, France.

Psychogenic excoriations are also called neurotic excoriations, dermatillomania or skin picking syndrome. We proposed diagnostic criteria and then performed a study of the psychiatric profiles of outpatients with psychogenic excoriations and the circumstances around the creation of these excoriations. Although the results must be interpreted with caution because the study was performed with only 10 patients, interesting data is provided about the onset of psychogenic excoriations, the behaviour of picking, and comorbidity. Read More

J Am Acad Dermatol 2010 Aug;63(2):341-2

Int J Dermatol 2010 Jul;49(7):784-9

Department of Psychiatry & Behavioral Sciences, Division of Child & Adolescent Psychiatry, University of Washington School of Medicine, Seattle, WA, USA.

Background: To assess the level of training in, and awareness and attitude about, psychocutaneous disorders among dermatologists.

Methods: A mail-in survey was sent to all members of Washington State Dermatology Society, who were requested to provide information on demographic variables; level of training, skills, and degree of comfort in managing psychodermatologic disorders; referral patterns, knowledge of patient and family resources on psychodermatology; and interest in continuing medical education on psychocutaneous disorders.

Results: Of 237 mailed surveys, 102 were returned for analysis. Read More

Cutis 2010 Mar;85(3):149-52

Department of Dermatology, University of Pittsburgh, Pennsylvania 15213, USA.

Neurotic excoriations are self-induced skin lesions produced because of compulsive scratching or picking. We present the successful use of the venerable technique of an Unna boot used as an Unna sleeve for neurotic excoriations of the upper extremities. Read More

Int J Dermatol 2009 Dec;48(12):1395-6

The Skin Clinic, 12 Meadow Street, Williamstown, MA 01267, USA.

There is a group of cutaneous disorders for which we have an inadequate understanding of their etiology and which frustrates us as therapists. This includes conditions such as the dynias, neurotic excoriations, postherpetic neuralgia, prurigo nodularis, and others. Herein, we review a recent article in the New Yorker magazine which postulates a new way to look at these puzzling entities. Read More

Minerva Pediatr 2008 Jun;60(3):355-9

Istituto Dermopatico dell'Immacolata IDI, IRCCS Roma, Rome.

The skin is an organ that has a primary function in the tactile receptivity and also reacts significantly to emotional stimuli. The high visibility of the dermatological diseases makes the skin a privileged target for feelings and actions that reflect behavioural problems. The tendency to self-harm can be expressed with remarkable frequency through dermatological lesions; among them neurotic excoriations are a clinical frame in which patients, unlike for other ''similar'' pathologies, succeed however in recognizing their own role in the development of the cutaneous lesions. Read More

South Med J 2007 Jan;100(1):43-8

Baylor College of Medicine, USA.

Ulceration of the nose may be inadvertently induced by the patient. Although trigeminal trophic syndrome is an uncommon cause of chronic ulcers, healthcare providers should consider the possibility of this disorder when encountering a patient with nasal ulcerations. Trigeminal trophic syndrome most commonly occurs in older women following therapy for trigeminal neuralgia. Read More

Curr Opin Pediatr 2006 Aug;18(4):403-9

Section of Pediatric Dermatology, Children's Hospital of Philadelphia, PA 19104, USA.

Purpose Of Review: Factitial skin diseases are characterized by unusual patterns of skin lesions that do not conform to any known dermatologic condition and that are consciously or subconsciously fabricated by the patient. This review summarizes the current literature regarding the diagnosis and management of factitial dermatoses in children.

Recent Findings: Neurotic excoriations, acne excoriee and trichotillomania are the most common factitial skin diseases seen in children. Read More

Dermatol Ther 2005 Jul-Aug;18(4):314-22

Department of Medicine, University of California, San Francisco (USCF), CA, USA.

A patient's psychological condition can substantially affect the presence and severity of pruritus, a phenomenon thought to be mediated by the central nervous system's (CNS) opioid neurotransmitter system. Specific psychodermatologic disorders associated with psychogenic pruritus, including depression, anxiety, chronic tactile hallucinations, delusions of parasitosis, neurotic excoriations, and other cutaneous compulsions are likely controlled by this pathway. Therefore, in treating these conditions, medications specifically directed at the CNS can be the most effective therapies, whereas topical and supportive therapy may be important adjuncts in targeting the associated pruritus. Read More

Dermatol Clin 2005 Oct;23(4):649-56

Department of Psychiatry, University of Western Ontario, London, Ontario, Canada.

Psychologic trauma refers to events (such as sexual assault, major earthquake, or plane crashes) that overwhelm an individual's capacity to cope. Psychologic trauma can result in chronic and recurring dermatologic symptoms that persist after the trauma subsides. Examples are cutaneous sensory flashbacks (which may be fragments of the sensory component of the traumatic experience), autonomic hyperarousal (with symptoms such as profuse sweating or flare-up of an underlying stress-reactive dermatosis), conversion symptoms (such as numbness, pain, or other medically unexplained cutaneous symptoms), and cutaneous self-injury (manifesting in many forms, including trichotillomania, dermatitis artefacta, and neurotic excoriations--tension-reducing behaviors in patients who have posttraumatic stress disorder). Read More

J Fam Pract 2004 Sep;53(9):713-6

University of Texas Health Sciences Center at San Antonio, Dept of Family and Community Medicine, MC 7794, 7703 Floyd Curl Drive, San Antonio, TX 78229-3900, USA.

Am J Clin Hypn 2004 Jan;46(3):239-45

Division of Dermatology and Cutaneous Surgery, MDC 079, College of Medicine, University of South Florida, 12901 Bruce B. Downs Blvd., Tampa, Florida 33612, USA.

Hypnotic suggestion successfully alleviated the behavioral picking aspect of acne excoriée des juenes filles in a pregnant woman who had been picking at the acne lesions on her face for 15 years. Acne excoriée is a subset of psychogenic or neurotic excoriation. Conventional topical antibiotic treatment was used to treat the acne. Read More

Int J Neuropsychopharmacol 2002 Jun;5(2):141-5

Department of Psychiatry, Evelyn F and William L McKnight Brain Institute of the University of Florida, Gainsville 32610-0256, USA.

Self-injurious behaviour (SIB), most notably skin picking, has been described by various terms in the literature ranging from neurotic/psychogenic excoriations to compulsive/pathological skin picking. Prader-Willi Syndrome (PWS) is a neurogenetic multisystem disorder characterized by infantile hypotonia, mental retardation, short stature, hypogonadism, dysmorphic features, and hyperphagia with a high risk of obesity. Psychiatric manifestations include SIBs in the form of skin picking, nail biting and rectal gouging. Read More

Dermatol Clin 2002 Jan;20(1):177-85

The author believes that psychocutaneous medicine has indeed come of age and is being incorporated into mainstream medical practice. Patients presenting to dermatologists today are more sophisticated and are frequently dissatisfied with traditional medical therapies. They actively seek alternative approaches and adjuncts to standard treatments. Read More

J Eur Acad Dermatol Venereol 2001 Nov;15(6):512-8

Department of Psychiatry, University of Western Ontario, London, Canada.

This paper provides an updated review of the use of antidepressant drugs in dermatology. Some of the psychiatric disorders that are usually comorbid with dermatological disorders and respond to antidepressants include major depressive disorder, obsessive compulsive disorder, body dysmorphic disorder, social phobia and post-traumatic stress disorder usually secondary to trauma and abuse during early life. Cutaneous symptoms may be the feature of a primary psychiatric disorder, e. Read More

Am Fam Physician 2001 Dec;64(12):1981-4

Department of Family Practice, Maine Medical Center, Portland 04102, USA.

Neurotic excoriations are self-inflicted skin lesions produced by repetitive scratching. Because there is no known physical problem of the skin, this is a physical manifestation of an emotional problem. The classic lesions are characterized by clean, linear erosions, scabs and scars that can be hypopigmented or hyperpigmented. Read More

Am J Clin Dermatol 2000 Jan-Feb;1(1):47-55

Thomas Jefferson University, Philadelphia, Pennsylvania, USA.

In dermatitis artefacta, the patient creates skin lesions to satisfy an internal psychological need, usually a need to be taken care of. The clinical presentation is characteristic, and differs from that of neurotic excoriations, delusional disorders, malingering, and Munchausen's syndrome. Munchausen's syndrome by proxy is a form of dermatitis artefacta. Read More

J Cutan Med Surg 2001 Jan-Feb;5(1):25-7

Department of Psychiatry, University of Western Ontario, London, Canada.

Background: The self-inflicted dermatoses such as acne excorieé and neurotic excoriations are often chronic, recurring, and resistant to standard dermatologic therapies.

Objective: We present a 28-year-old woman with longstanding acne excorieé, whose acne started at age 14 years and was followed by acne excorieé at age 16 years. The patient reported that her acne and self-excoriative behavior were exacerbated by psychological stress. Read More

Psychother Psychosom 2000 May-Jun;69(3):165-6

Am J Ophthalmol 1999 Feb;127(2):196-201

Department of Ophthalmology, Mayo Clinic and Mayo Foundation, Rochester, Minnesota 55905, USA.

Purpose: To describe the clinical appearance of factitious (or self-inflicted) lesions on periocular skin and face.

Methods: All patients with factitious cutaneous disease who were examined at Mayo Clinic, Rochester, Minnesota, between 1985 and 1997 were identified. For patients with lesions on the face and periocular skin, the demographic features, clinical descriptive characteristics of their lesions, associated psychopathology, and treatments were ascertained. Read More

Int J Dermatol 1997 Sep;36(9):650-2

Department of Dermatology, Arar Central Hospital, Saudi Arabia.

Background: Asian domestic house-helpers in Saudi Arabia come from a different socioeconomic setting with a different disease pattern from that of their host country. This study reports the incidence of skin and treponemal diseases in this group seen at a referral hospital in northern Saudi Arabia.

Methods: The study was based on the analysis of the dermatologic and serologic examinations of 1520 domestic house-helpers during resident permit issue, and a retrospective study of clinical records of house-helpers with skin disorders. Read More

Dermatology 1997 ;195(1):74

Cutis 1997 Jan;59(1):19-20

Seattle Dermatology Center, Washington, USA.

Dermatophagia is a neurodermatitis akin to onychophagia, onychotillomania, trichotillomania, dermatothlasia, neurotic excoriations, and other conditions in which persons have a neurotic habit or compulsion to self-multilate their skin or its appendages. Dermatophagia is a habit or compulsion, consciously or subconsciously, to bite one's own skin. We believe "dermatophagia" is a more appropriate term for this disorder than the descriptive term "wolf-biter". Read More

Dermatol Clin 1996 Jul;14(3):447-55

Department of Dermatology, University of Pennsylvania School of Medicine, Philadelphia, USA.

Patients with different psychiatric disorders produce artefacts on the skin, each requiring a different therapeutic approach. These different disorders are outlined briefly. The clinical picture, pathology, psychopathology, differential diagnosis, treatment, course, and prognosis of dermatitis artefacta and neurotic excoriations are reviewed in greater detail. Read More

Arch Dermatol 1996 May;132(5):589-90

J Am Acad Dermatol 1995 Feb;32(2 Pt 1):296-7

J Am Acad Dermatol 1994 Apr;30(4):669-70

Division of Dermatology, Royal Victoria Hospital, Montreal, Quebec, Canada.

Cutis 1993 May;51(5):386-7

Department of Psychiatry, University of Michigan Medical School, Ann Arbor.

A fifteen-year-old girl with a two-year history of severe neurotic excoriations and an obsessive-compulsive disorder experienced a dramatic improvement of her neurotic excoriations after a six-week course of fluoxetine 20 mg per day. This is in contrast to most previously reported treatments, which typically were only moderately effective. The neurobiological basis for the efficacy of fluoxetine, an antidepressant that is a potent serotonin reuptake inhibitor, in the treatment of neurotic excoriations associated with an obsessive-compulsive disorder, is reviewed. Read More

Br J Oral Maxillofac Surg 1993 Feb;31(1):41-2

Department of Oral and Maxillofacial Surgery, Morriston Hospital, Swansea.

A case is described in which division of the great auricular nerve during parotidectomy was complicated by perichondritis of the ear cartilage following self-inflicted injury. The desirability of preserving the posterior branch of the nerve whenever possible is stressed. Read More

Contact Dermatitis 1992 Oct;27(4):272-3

Dermatology Clinic, Aalborg, Denmark.

Dermatol Nurs 1992 Aug;4(4):285-6

Dermatol Clin 1992 Jul;10(3):641-5

University of California, Medical Center, San Francisco.

In this article, the use of selected psychopharmacologic medications was explained in detail. If a patient who is obviously suffering from a psychiatric component of his or her disorder that can be responsive to psychopharmacotherapy refuses to accept a referral to a psychiatrist or other mental health professional, the dermatologist must decide whether to use these medications. If he or she decides to use these medications, it should always be remembered that the choice of psychopharmacologic treatment depends on the nature of the underlying psychopathology-anxiety, psychosis, depression, or compulsion-rather than on the dermatologic label such as neurotic excoriations. Read More

Int J Dermatol 1991 Apr;30(4):262-5

Department of Psychiatry, Odense University Hospital, Denmark.

During the period from 1979 to 1985, 22 patients with the primary forms of neurotic excoriations (NE) accepted referral to the author. Twenty of them completed a psychotherapy program which was eclectic in form and allowed for individual weighting of its single elements. At the follow-up, on average after 5 years, valid evidence was found of a positive effect of goal-directed psychotherapy in NE patients. Read More

Int J Dermatol 1991 Mar;30(3):198-203

Department of Psychiatry, Odense University Hospital, Denmark.

This article sketches the planning of psychotherapy as a treatment for neurotic excoriations (NE). The program is developed on the basis of information collected in an investigation of 63 consecutive, first-time referrals of NE patients to a dermatology department, and the findings from a follow-up after 1 to 5 years. The offer of social advice and support, but not psychotherapy, was included in the investigation program. Read More

Int J Dermatol 1991 Feb;30(2):136-8

Department of Dermatology, Metropolitan Hospital Center, New York Medical College, Valhalla 10029.

Indian J Dermatol Venereol Leprol 1989 May-Jun;55(3):183-184

A 35 year old female presented with a pruritic plague on the dorsum of the left forearm. During follow-up it came to light that the lesion self-inflicted and served as a means to seek help for the underlying psycho-social problem in the patient's life. Read More

J Am Acad Dermatol 1989 May;20(5 Pt 1):860-1

Int J Dermatol 1987 Oct;26(8):541-3

Department of Medicine (Dermatology), University of Florida College of Medicine, Gainesville.

Two patients with 6- to 7-year histories of neurotic excoriations refractory to the usual dermatologic management were referred for evaluation. Both had symptoms and signs of depression associated with the onset and persistence of the skin condition. Doxepin, a tricyclic antidepressant therapy with potent antihistamine properties, was used in oral doses of 30-75 mg daily for our patients. Read More