Dermatotillomania
Dermatotillomania
Definition
Dermatotillomania, also called psychogenic excoriation (skin removal), neurotic excoriation, acne excorié, and pathological or compulsive skin picking, is characterized by excessive picking, scratching, or squeezing of skin. This syndrome is not formally included in Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision (DSM-IV-TR), although dermatotillomania is hypothesized to be an impulse control disorder related to obsessive-compulsive disorder (OCD) and/or to depression . Dermatotillomania can therefore be distinguished from other dermatological diseases that are influenced by psychological factors (e.g., psoriasis or alopecia) because it is a dermatological manifestation of a psychiatric syndrome.
Description
Behaviors associated with dermatotillomania include excessive excoriation of skin at multiple sites that are easily reachable. Excoriation may occur at sites of skin lesions (e.g., acne, scabs, insect bites) or in response to skin sensations such as dryness, tingling, or pain. The face is the most common site of excoriation that is usually performed with the fingers or fingernails but may involve the teeth or other instruments. Excoriation may occur in brief bouts or for extended periods and is usually worse in the evening.
Impulse control disorders are characterized by irresistible impulses to commit acts that may be harmful to one’s self or others. Feelings of tension or anxiety may precede these acts that may then be followed by pleasure or gratification following the performance of the act. Guilt or regret may, or may not, be felt subsequent to the act. A person experiencing dermatotillomania is likely to be under substantial distress and may feel embarrassed about the excoriating behavior. Social functioning may be decreased, especially those functions in which skin lesions will be exposed. Excoriation may result in varied medical complications including bleeding, ulcers, infections, and temporary or permanent disfigurement.
Causes and symptoms
Causes
Co-occurring psychiatric conditions, especially mood and anxiety disorders , are common in patients with dermatotillomania. Mood disorders such as major depression and obsessive-compulsive disorder, as well as anxiety disorders including panic disorder , social and simple phobias, post-traumatic stress disorder , and generalized anxiety disorder are frequently seen in individuals with dermatotillomania. Depressive disorders are the most common co-occuring psychiatric diagnoses in people with dermatotillomania, suggesting that the underlying pathophysiology in people with dermatotillomania may be major depression.
Symptoms
The most prominent symptoms are excessive picking, scratching, or squeezing of skin. The duration of each episode and the total daily duration are variable. Episodes may be more frequent during the evening hours. Skin excoriation is performed throughout the duration of the disorder.
Demographics
The mean age of onset for dermatotillomania is between 15 and 40 years. The mean duration of symptoms is between five and 21 years. This syndrome is thought to have an incidence of 2% of patients seen in dermatological clinics, with women affected more often than men.
Diagnosis
The diagnosis of dermatotillomania is made by history and interview in the absence of formal inclusion in DSM-IV-TR. The behaviors associated with dermatotillomania are heterogeneous. Co-occuring impulse control and/or depression symptoms coupled with the prominent dermatological features allow for diagnosis. Several related disorders have features of dermatotillomania, including trichotillomania (compulsive hair pulling) and body dysmorphic disorder (concerns about appearance, especially related to the skin or hair in which obsessions are related to any aspect of the skin, such as color, marks, veins, pores, wrinkles, stretch marks, or sagging). It is possible that an underlying dermatological condition produces the observed symptoms although the lack of obsessive or compulsive-impulsive behavior would rule out dermatotillomania in these cases.
Treatments
Medications
Case reports and small trials have examined the efficacy of various types of drugs for dermatotillomania: antidepressants , including selective serotonin reuptake inhibitors (SSRIs , such as fluvoxamine ) and tricyclics (e.g., doxepin and clomipramine ), opiate antagonists (naltrexone ), typical antipsychotics (pimozide ), and atypical antipsychotics (olanzapine, aripiprazole ). In some cases (for example, the SSRI fluoxetine ), there appeared to be a separation in the efficacy of the drug on skin excoriation and a comorbid symptom (depression or anxiety), suggesting that the drug may have a primary effect on skin excoriation.
Alternative therapies
Behavioral treatments, including psychotherapy and hypnosis, have been examined for effectiveness in dermatotillomania. Small-scale studies or case reports have suggested that habit-reversal therapy, in which a program of self-monitoring is paired with competing response practice, and psychotherapy, in which behavioral and emotional as well as topical therapies are practiced, can be effective.
Prognosis
Large-scale outcome studies are lacking, although it has been suggested that presentation to a dermatologist prior to experiencing symptoms for one year results in a better prognosis. Complications from lesion infection are possible and chronic rebuilding of lesioned tissues has been suggested to be a potential causative factor for skin cancer.
Prevention
Obsessive-compulsive disorders and depression are major psychiatric disorders whose underlying pathophysiology involves alterations in neurotrans-mission. Since dermatotillomania is a dermatologic manifestation of one, or both, of these disorders, its elimination is dependent on curing the underlying illness.
Resources
BOOKS
American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders 4th ed., Text rev. Washington, D.C.: American Psychiatric Association, 2000.
PERIODICALS
Arnold, L. M., M. B. Auchenbach, and S. L. McElroy. “Psychogenic Excoriation. Clinical Features, Proposed Diagnostic Criteria, Epidemiology and Approaches to Treatment.” CNS Drugs 15.5 (2001): 351–59.
Arnold, L. M., and others. “An Open Clinical Trial of Fluvoxamine Treatment of Psychogenic Excoriation.” Journal of Clinical Psychopharmacology 19.1 (February 1999): 15–18.
Blanch, J., F. Grimalt, G. Massana, and V. Navarro. “Efficacy of Olanzapine in the Treatment of Psychogenic Excoriation.” British Journal of Dermatology 151.3 (September 2004): 714–16.
Calikusu, C., B. Yucel, A. Polat, and C. Baykal. “The Relation of Psychogenic Excoriation with Psychiatric Disorders: A Comparative Study.” Comprehensive Psychiatry 44.3 (May-June 2003): 256-61,
Carter, W.G., III, and S. D. Shillcutt. “Aripiprazole Augmentation of Venlafaxine in the Treatment of Psychogenic Excoriation.” Journal of Clinical Psychiatry 67.8 (August 2006): 1311.
Osaba, O., and G. Mahr. “Psychogenic Excoriation and Cancer.” Psychosomatics 43.3 (May-June 2002): 251–52.
Andrew J. Bean, PhD