Neurotic Excoriation

A 42-year-old woman sought medical advice for a facial rash of 4 weeks' duration. She denied any drug allergies, changes in her routine, or use of new laundry products.

In addition to the facial lesions, examination disclosed ascites and pedal edema. No other part of her body was affected by the rash. The workup ruled out connective tissue disease.

The patient's history was significant for cirrhosis, ascites, and depression. She also revealed that she scratched her face. A diagnosis of neurotic excoriation was made. Twice daily applications of a group I topical corticosteroid was prescribed. The rash resolved completely after 2 weeks of treatment.

Drs Vinod Patel and Vincent Thompson of the State University of New York at Buffalo report that these linear excoriations are caused when patients dig at their skin to relieve itching or to extract imaginary pieces of material that they believe are embedded in or extruding from the skin. The itching and digging become compulsive rituals. Most patients are aware that they create the lesions.

As many as several hundred excoriations can be made by the repetitive scratching and digging; all the lesions have a similar size and shape. The excoriations tend to be grouped in areas of the body that are easily reached, such as the arms, legs, and upper back. Recurrent picking at crusts may delay healing.

An equally effective alternative to the regimen used for this patient is application of a group V topical corticosteroid covered with plastic wrap and systemic antibiotic therapy. When the lesions have healed, encourage your patient to use a mild soap, wash infrequently, and apply a lubricant often. A practitioner's supportive, empathic approach has been reported to be more effective in treating persons with neurotic excoriations than insight-oriented psychotherapy, which may lead to exacerbation of symptoms.¹

REFERENCE:1. Habif TP. Clinical Dermatology: A Colorful Guide to Diagnosis and Therapy. 3rd ed. St Louis: Mosby; 1996.