Excoriation Disorder 

Updated: Jul 10, 2018
Author: Roxanne Graham, MD; Chief Editor: Dirk M Elston, MD 

Overview

Practice Essentials

Excoriation (skin-picking) disorder, also known as psychogenic excoriation, dermatillomania or neurotic excoriation, is characterized by the conscious repetitive picking of skin that leads to skin lesions and significant distress or functional impairment. [1]  Neurotic excoriations can be initiated by some minor skin pathology (eg, insect bite, eczema, folliculitis, or acne), but it can also be independent of any pathology. See the image below.

A picker's nodules with no crust and a scarred app A picker's nodules with no crust and a scarred appearance.

Signs and symptoms

Findings from the history may include the following:

  • History of picking, digging, or scraping the skin

  • Presence or absence of an inciting incident

  • Personal problems (eg, history of abuse)

  • Psychiatric history that includes a comorbid mental disorder

  • Nasal ulcerations

  • Facial acne

Psychiatric and medical diagnoses that should be considered include the following:

  • Depression

  • Trichotillomania

  • Anxiety

  • Tic disorder

  • Obsessive-compulsive disorder (OCD)

  • Body dysmorphic disorder

  • Somatoform disorders

  • Borderline personality disorder

  • Delusions of parasitosis

  • Scabies

See DDx for more detail.

Physical findings may include the following:

  • Crusted or noncrusted lesions

  • Erosions and scars with angulated borders

  • Variable quantity of erosions and scars (from several to hundreds)

  • Occasional evolution into frank ulcers

See Presentation for more detail.

Diagnosis

Specific DSM-5 criteria for excoriation disorder are as follows:

  • Recurrent skin-picking, resulting in lesions

  • Repeated attempts to decrease or stop skin picking

  • The skin picking causes clinically significant distress or impairment in important areas of functioning

  • The skin picking cannot be attributed to the physiologic effects of a substance or another medical condition

  • The skin picking cannot be better explained by the symptoms of another mental disorder

Diagnostic studies that may be considered for ruling out other conditions include the following:

  • Complete blood count (CBC) with differential

  • Chemistry profile

  • Determination of thyrotropin levels

  • Fasting plasma glucose level

  • Cancer workup

  • Chest radiography

  • Skin biopsy

See Overview  for more detail.

Management

General management principles include the following:

  • Setting limits for the protection of both the physician and patient

  • Creating an accepting, empathic, and nonjudgmental environment

  • Closely supervising symptomatic dermatologic care

  • Attempting to develop a therapeutic relationship in which psychological issues may be addressed and which may permit referral to a psychiatrist as appropriate

  • Avoidance of issues of etiology (confrontation is counterproductive)

Pharmacotherapy may include the following:

  • Antipsychotic agents

  • Antianxiety agents

  • Antidepressants

  • Topical cortisone agents

  • Antiepileptic agents

Other treatment methods that may be considered are as follows:

  • Hypnosis

  • Physical barriers (eg, an Unna sleeve)

See Treatment and Medication for more detail.

Background

Excoriation (skin-picking) disorder involves the conscious creation of neurotic excoriations by means of repetitive scratching (although acts of rubbing skin, lancing, squeezing or biting can also be used and individuals may use tweezers, fingernails or other objects).[2]  Neurotic excoriations should be distinguished from dermatitis artefacta, in which patients create lesions for secondary gain. Neurotic excoriations can be initiated by some minor skin pathology, such as an insect bite, folliculitis, callouses, scabs, or acne, but it can also be independent of any pathology. Triggers include emotions such as stress, anger, and anxiety, and sedentary activities such as watching television, reading, boredom, and feeling tired.[1]

Because no significant underlying pathology is present in the skin, neurotic excoriations are best understood as a psychological process with dermatologic manifestations. Many doctors lack an extensive understanding of neurotic excoriations and their treatment.[3] The complex dynamic underlying the urge to create a neurotic excoriation is yet to be fully explained.[4] Dermatologists are aware of this complex dynamic and continue to grapple with it.[3]

Because patients create neurotic excoriations, the lesions have the quality of an "outside job"—that is, clean, linear erosions, crusts, and scars that can be hypopigmented or hyperpigmented. The erosions and scars of neurotic excoriations often have irregular borders and are usually similar in size and shape. They occur on areas that the patient can scratch, particularly the extensor surfaces of the extremities, the face, and the upper part of the back. The distribution is bilateral and symmetric.

The manifestations of neurotic excoriations vary widely, ranging from unconscious picking at the skin to uncontrollable picking at lesions to remove imaginary foreign bodies. Picking is usually episodic and irregular, but it can be constant. The picking can have the quality of a ritual and may take place in a state of dissociation.

The inability to stop picking despite efforts to do so can lead to feelings of shame, anxiety, and depression. Individuals often spend a large amount of time on repetitive picking and/or camouflaging (taking up several hours per day in severe cases). They often avoid situations where skin lesions can be detected that could lead to social embarrassment, or have loss of productivity at school or work due to this avoidance behaviors. Medical sequelae such as infections, scarring, and even serious physical disfigurement can occur. Excoriation (skin picking) disorder is also associated with other comorbidities including other body-focused repetitive behavior disorders – with trichotillomania being the most common. Obsessive–compulsive disorder (OCD) and body dysmorphic disorder (BDD) are also more prevalent in individuals with excoriation disorder than in the general population. Mood and anxiety disorders are also common.[1]

Pathophysiology and Etiology

Neurotic excoriations are due either to an underlying psychopathology or to the formation of habit. Accordingly, their pathophysiology is poorly understood.

Shah and Fried found neurotic excoriations to be among the most common factitious skin diseases in children; they further noted that factitious skin disease is less common in children and can often be linked to comorbid psychiatric diagnoses or a psychosocial stressor that can be identified.[5] Subsequently, a task force of dermatologists, psychiatrists, and psychologists worked to place neurotic excoriations in their proper category in dermatology and psychology, finding that mental disorders with pathologic activities could underline the disease.[6]

The causes of neurotic excoriations are manifold and can relate to picking as a means of resolving stress or, as noted, to some underlying psychopathology.[7] Some believe neurotic excoriations to be a physical manifestation of obsessive-compulsive disorder (OCD).

Epidemiology

Skin-picking is more common than expected, and thought to be underreported, with prevalence ranging between 1.4% and 5.4%.[1]  The rate of neurotic excoriations among patients at dermatologic clinics is 2%. The rate of neurotic excoriations in patients with pruritus is 9%. Most studies have found the mean patient age at onset to be in the range of 30–45 years although onset often occurs during adolescence.[8]  There is variability among studies regarding gender prevalence; one study found nearly equal gender distribution in those with excoriation (skin-picking) disorder with women perceiving themselves as less attractive and men having more alcohol consumption.[9]

In other studies, 52–92% of patients with neurotic excoriations have been female.[2]  Excoriation (skin-picking) disorder is more commonly found in individuals with first-degree relatives who have the disorder or in individuals with obsessive-compulsive disorder. Studies have found that trichotillomania and excoriation disorder co-occur more often than expected. Both disorders have substantial similarities in clinical characteristics and overlapping risk factors.[1]

Prognosis

Except in mild transient cases triggered by an immediate stress, the prognosis for cure is poor. The condition tends to wax and wane with the circumstances of the patient’s life. Often, however, excoriation disorder can be controlled if the underlying psychological illness is controlled. Patients need intervention but sometimes have difficulty in changing the habit of picking. Without medical and psychiatric treatment, excoriation disorder tends to be a chronic condition. Untreated excoriations can result in scarring or infection, or tissue damage that may require antibiotics or surgery. Rarely, synovisits has been reported in the wrists due to chronic picking.[2]

 

Presentation

History

Patients with excoriation (skin-picking) disorder give a history of picking, digging, or scraping their skin. Sometimes an inciting incident is the cause, and sometimes no inciting incident is present. Patients might note that they do not scratch themselves consciously; rather, they pick and then notice that they are picking. Cyr and Dreher have provided an excellent summary of neurotic excoriations and their historical and clinical findings and manifestations.[10] Ultimately, neurotic excoriations are a diagnosis of exclusion.[11]

An French survey of neurotic excoriations in 10 patients found that most patients linked their initial excoriations with personal problems; 4 of the patients noted abuse in childhood or in adolescence.[12] This study appeared to suggest that skin picking was an impulsive reaction rather than an obsessive-compulsive disorder; however, the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5), currently classifies excoriation disorder among the obsessive-compulsive and related disorders.[2]

Patients can have a psychiatric history that includes a comorbid mental disorder. Most patients with excoriation disorder do not have any particular psychopathology; however, psychiatric diagnoses to be considered include the following:

  • Depression

  • Trichotillomania

  • Anxiety

  • Tic disorder

  • Obsessive-compulsive disorder (OCD)

  • Body dysmorphic disorder

  • Somatoform disorders (eg, facial dermatitis, somatization, or hypochondriasis)

  • Borderline personality disorder (self-mutilation)

  • Delusions of parasitosis (may be part of a larger diagnostic group, such as schizophrenia)

Patients pick at areas until they can pull material from the skin. This may be referred to as "pulling a thread from the skin."

Setyadi et al noted that trigeminal trophic syndrome can result in ulcerations on the nose (in the nasal ala and paranasal locations), most commonly manifesting in older women after therapy for trigeminal neuralgia.[13]

Young women who pick at their faces may have a history of mild acne. Such cases are referred to as acne excoriée. This condition is not discussed in this article. The erosions can heal slowly because of recurrent picking.

It is helpful to ask patients which came first, the lesion or the urge to itch. When closely questioned, most patients say that they first scratched their skin and then saw a lesion. The lesions of neurotic excoriations have a component of an itch-scratch cycle, whereby the urge to scratch generates an even greater urge to scratch.

Because a variety of physical conditions can cause itching and then lesions, these must be excluded or, at least, established as being relatively unlikely before a firm diagnosis of excoriation disorder can be made. Such conditions include the following:

  • Scabies

  • Dermatitis herpetiformis

  • Renal disease

  • Cocaine use

  • Opiate use

  • Medication reactions

  • Multiple sclerosis

  • Hepatic disease

  • Lymphoma

  • Pregnancy

  • Internal cancers

  • Uremia

  • Carcinoid

  • Delirium

  • Polycythemia vera

  • Diabetes mellitus

  • Hypothyroidism

  • Iron deficiency anemia

  • Hyperthyroidism

  • Xerosis

  • Urticaria

  • Intestinal parasitosis

  • Myeloma may be noted

  • Patients may report headache or menstrual disorders

Physical Examination

Often, right-handed persons tend to pick at their left side, left-handed people at their right side. The erosions and scars tend to have angulated borders. The quantity of erosions and scars is variable. Several lesions to hundreds of lesions can be present. Erosions, crusts, and scars are located only where the patient can pick. Lesions can be either crusted or noncrusted (see the images below).

A picker's nodules with no crust and a scarred app A picker's nodules with no crust and a scarred appearance.
A picker's nodule with crusted lesions. A picker's nodule with crusted lesions.

Erosions can vary in morphology and can sometimes evolve into frank ulcers. Dug-out erosions or ulcers, crusted erosions, and ulcers can be present. Sometimes, erythema and scars are present around the erosions and the ulcers.

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 it differs from that of excoriation disorder, delusional disorders, malingering, and Munchausen syndrome. Munchausen syndrome by proxy is a form of dermatitis artefacta.

Except when the lesions mimic another disease, those that do not conform to descriptions of known dermatoses are shrouded in mystery, appearing fully formed on accessible skin, within the context of a characteristic psychological constellation. The patient is friendly but bewildered, and relatives may be angry and frustrated.

 

DDx

Diagnostic Considerations

In addition to the conditions listed in the differential diagnosis, other problems (both psychiatric and medical) to be considered include the following:

  • Anxiety

  • Body dysmorphic disorder

  • Borderline personality disorder

  • Carcinoid

  • Cocaine use

  • Delirium

  • Depression

  • Dermatitis artefacta

  • Dermatitis herpetiformis

  • Diabetes mellitus

  • Hepatic disease

  • Hyperthyroidism

  • Hypothyroidism

  • Internal cancers

  • Intestinal parasitosis

  • Iron deficiency anemia

  • Lymphoma

  • Medication reactions

  • Multiple sclerosis

  • Obsessive-compulsive disorder

  • Opiate use

  • Polycythemia vera

  • Pregnancy

  • Renal disease

  • Somatoform disorders

  • Tic disorder

  • Trichotillomania

  • Trigeminal trophic syndrome

  • Uremia

  • Urticaria

  • Xerosis

 

Differential Diagnoses

 

Workup

Approach Considerations

A scale for evaluating skin picking, the Skin Picking Reward Scale (SPRS), helps to define a patient's "wanting" and "liking" of skin picking. Initial findings validate the scale as a psychometrically sound measure.[14]

To rule out systemic disease, the following tests are indicated:

  • Complete blood count (CBC) with differential

  • Chemistry profile

  • Determination of thyrotropin levels

  • Fasting plasma glucose level

The appropriate workup for cancer can be performed if indicated by the patient’s history. A chest radiograph can help to rule out suspected lymphoma. Patients can be assessed for contact dermatitis or food allergies. A skin biopsy can be helpful to rule out other pathologic conditions.

Diagnosis

Diagnostic criteria (DSM-5)

The American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5), places excoriation (skin-picking) disorder in the category of obsessive-compulsive and related disorders and notes that it is characterized by recurrent body-focused repetitive behavior (skin picking) and repeated attempts to decrease or stop the behavior.

The specific DSM-5 criteria for excoriation (skin-picking) disorder are as follows[2] :

  • Recurrent skin-picking, resulting in skin lesions

  • Repeated attempts to decrease or stop skin picking

  • The skin picking causes clinically significant distress or impairment in social, occupational, or other important areas of functioning

  • The skin picking cannot be attributed to the physiologic effects of a substance (eg, cocaine) or another medical condition (eg, scabies)

  • The skin picking cannot be better explained by the symptoms of another mental disorder (eg, delusions or tactile hallucinations [psychotic disorder], attempts to improve a perceived defect or flaw in one’s appearance [body dysmorphic disorder], stereotypies [stereotypic movement disorder], or intention to harm oneself [nonsuicidal self-injury])

Associated features supporting the diagnosis include a range of behaviors or rituals involving the skin that has been picked. Examples include examining, playing with or even swallowing the skin after it has been pulled off. Picking can be accompanied by different emotional states. The act of picking can be triggered by anxiety or boredom and be preceded by a sense of tension. Afterwards individuals might feel a sense of pleasure, relief or gratification. Pain is not routinely reported.[2]

Histologic Findings

Biopsy samples of neurotic excoriations generally reveal epidermal ulceration with a mild superficial mixed infiltrate and crusts formed from fluid and red blood cells (RBCs). In older lesions, superficial dermal scar tissue and changes of lichen simplex chronicus (eg, irregular epidermal hyperplasia with hyperkeratosis, hypergranulosis, and vertical streaking of papillary dermal collagen) may be observed.

Imaging Studies

Functional MRI can define abnormal brain activation in picking disorders.[15]

 

Treatment

Approach Considerations

The patient’s denial of psychic distress and the possible negative feelings aroused in health care personnel make management of excoriation (skin-picking) disorder difficult. It is has been estimated that about 20% of patients with excoriation (skin-picking) disorder look for treatment. This is thought to be due to the belief that the condition is untreatable or considering it a “bad habit” or due to fear of social embarrassment. A dermatologist rather than a psychiatrist or psychologist often first sees those that do seek treatment.[1]

Setting limits for the protection of both the physician and patient; creating an accepting, empathic, and nonjudgmental environment; and closely supervising symptomatic dermatologic care permit the development of a therapeutic relationship in which psychological issues may be gradually introduced, which may occasionally permit referral to a psychiatrist. Issues of etiology should be sidestepped because confrontation is counterproductive.

If the patient refuses referral to a psychiatrist, psychotropic drug therapy prescribed by dermatologists is helpful and appropriate. The upper dose range of selective serotonin reuptake inhibitors (SSRIs) or low-dose atypical antipsychotic agents may be effective.

Using hypnosis to facilitate resolution of psychogenic excoriations in acne excoriée has been reported. 

Pharmacologic Therapy

There is currently no medication approved by the US Food and Drug Administration approved for the treatment of excoriation (skin picking) disorder.[16]  Attempts to treat it with a variety of psychotropic medication classes include antipsychotic agents, antianxiety agents, antidepressant agents, topical cortisone agents, and antiepileptic agents.

In 2005, Krishnan and Koo reported that pathology of the opioid neurotransmitter system and the central nervous system (CNS) is the neurologic basis for neurotic excoriations, which suggested that psychiatric medications that can normalize CNS pathology can abate neurotic excoriations.[17]  In line with this, glutamate, an excitatory CNS neurotransmitter, has been reported as being potentially helpful for treating picking disorders when other conventional therapies fail.[18]  A two-center randomized, double-blind trial with 66 adults with excoriation disorder assessed N-acetylcysteine against placebo for 12 weeks, with 47% of N-acetylcysteine group reporting improvement compared to 19% receiving placebo. N-acetylcysteine, an amino acid that appears to restore extracellular glutamate concentration in the nucleus accumbens, has been shown to significantly reduce skin-picking symptoms, and it is well tolerated.[16]

Studies have shown that the serotonergic effect of SSRIs produces an antipruritic effect.[19, 20] The relief of pruritus is unrelated to changes in the patient’s mood and happens faster than would be expected for antidepressant effects.

Olanzapine may be an effective adjunctive therapy in the management of acne excoriée.[21] Paroxetine was reportedly effective in a case of psychogenic pruritus and neurotic excoriations.[22] Lithium has been used to treat neurotic excoriations, but further study is needed.[23] Dereli et al found that gabapentin is a useful treatment for recalcitrant chronic prurigo nodularis.[24]

Hypnosis

In a study by Shenefelt, hypnotic suggestion successfully alleviated the behavioral picking aspect of acne excoriée des jeunes filles in a pregnant woman who had been picking at the acne lesions on her face for 15 years.[25] Acne excoriée is a subset of psychogenic or neurotic excoriation. Conventional topical antibiotic treatment was used to treat the acne. Compared with other treatments for uncomplicated acne excoriée, hypnosis is relatively brief and cost-effective and is nontoxic in pregnancy.

Consultations

A meta analysis of 9 studies examined the efficacy of various psychiatric treatments available for excoriation disorder including cognitive-behavioral therapy (CBT), acceptance and commitment therapy (ACT), and habit reversal training (HRT). The overall findings suggest that behavioral treatments were associated with large reductions in severity of excoriation disorder from baseline to post treatment.[26]  CBT involves psychoeducation, relapse prevention, and cognitive restructuring. HRT, which is used to treat a variety of repetitive behavior problems, involves competing response training. ACT entails acceptance and mindfulness strategies as well as commitment and behavior change strategies.[1]

A psychiatrist and a psychologist should be consulted. Neurotic excoriations can be associated with psychopathology. Social stressors may be well hidden because of shame or a delusional belief system. Suppression, inappropriate channeling, and repression of aggression can be consequences of unmet emotional needs. Conflicts can result from past or current situations. Resolving these issues alone can be difficult.

Excoriation disorder can be associated with anxiety disorders, low self-confidence, generalized apprehension, meticulousness, depressive mood, and hypersensitivity to perceived self-negativism. Thus, the intervention of a psychiatrist or other trained mental health care professionals can be useful. Patients can benefit from psychotherapy and other forms of counseling.[27]

Long-Term Monitoring

Lesions can be kept to a minimum, the patient can be protected from unnecessary and intrusive studies, and society can be protected from escalating and unnecessary expenditure of medical resources if, rather than discharging the patient, the dermatologist continues to see the patient on an ongoing basis for supervision and support, regardless of whether lesions are present.

Patients with neurotic excoriations can be seen by psychiatrists and benefit from follow-up care to encourage the maintenance of treatment. As outpatients, patients with neurotic excoriations can be treated with low-dose psychotropic medications and cortisone creams.

Prevention

Physical barriers (eg, an Unna sleeve) can be an effective treatment for neurotic excoriations.[28]

 

Medication

Medication Summary

Excoriation (skin-picking) disorder is treated with a variety of psychotropic medications. Attempts to treat it with a variety of psychotropic medication classes include antipsychotic agents, antianxiety agents, antidepressant agents, topical cortisone agents, and antiepileptic agents.

A two-center randomized, double-blind trial with 66 adults with excoriation disorder assessed N-acetylcysteine against placebo for 12 weeks, with 47% of N-acetylcysteine group reporting improvement compared to 19% receiving placebo. N-acetylcysteine, an amino acid that appears to restore extracellular glutamate concentration in the nucleus accumbens, has been shown to significantly reduce skin-picking symptoms, and it is well tolerated.[16]

In 2005, Krishnan and Koo reported that pathology of the opioid neurotransmitter system and the central nervous system (CNS) is the neurologic basis for neurotic excoriations, which suggested that psychiatric medications that can normalize CNS pathology can abate neurotic excoriations.[17]  In line with this, glutamate, an excitatory CNS neurotransmitter, has been reported as being potentially helpful for treating picking disorders when other conventional therapies fail.[18]  Adding venlafaxine to a treatment regimen of aripiprazole abated a case of treatment-resistant excoriation disorder.[29]

Antidepressants, TCAs

Class Summary

Antipsychotic agents decrease the urge to scratch and relieve anxiety.

Doxepin

For its sedating and antipsychotic effects, doxepin (10-25 mg orally at bedtime) is a useful medication in treating neurotic excoriations. Doxepin inhibits histamine and acetylcholine activity and has proved useful in the treatment of various forms of depression associated with chronic and neuropathic pain.

Anxiolytics, Nonbenzodiazepine

Class Summary

Antianxiety agents are used to reduce the level of anxiety in patients who experience pruritus.

Buspirone (BuSpar)

The mechanism of action of buspirone is unknown. It has high affinity for serotonin 5-HT1A and 5-HT2 receptors and moderate affinity for dopamine D2 receptors. It does not affect benzodiazepine-GABA receptors.

Antidepressant, SSRIs

Class Summary

Antidepressants may be used to improve mood and to restore normal sleep patterns in patients who experience pruritus.

Fluoxetine (Prozac)

Fluoxetine selectively inhibits presynaptic serotonin reuptake, with minimal or no effect on reuptake of norepinephrine or dopamine.

Paroxetine (Paxil, Paxil CR, Pexeva)

Paroxetine (Paxil, Paxil CR, Pexeva)

Paroxetine is a potent selective inhibitor of neuronal serotonin reuptake. It has a weak effect on norepinephrine and dopamine neuronal reuptake. For maintenance therapy, make dosage adjustments to maintain the patient on the lowest effective dosage, and reassess the patient periodically to determine the need for continued treatment.

Fluvoxamine (Luvox CR)

Fluvoxamine is a potent selective inhibitor of neuronal serotonin reuptake. It does not significantly bind to alpha-adrenergic, histamine, or cholinergic receptors and, thus, has fewer adverse effects than tricyclic antidepressants (TCAs).

Citalopram (Celexa)

Citalopram enhances serotonin activity by selective reuptake inhibition at the neuronal membrane. Although citalopram is not FDA approved for use in children, various clinical trials have shown efficacy in the treatment of moderate-to-severe major depressive disorder (MDD) in children and adolescents.

Escitalopram (Lexapro)

Escitalopram is the S-enantiomer of citalopram. It may have a faster onset of depression relief (1-2 wk) in comparison with other antidepressants. 

Corticosteroids, Topical

Class Summary

Topical corticosteroids have anti-inflammatory properties and cause profound and varied metabolic effects. They modify the body’s immune response to diverse stimuli.

Triamcinolone topical (Kenalog, Triderm, Trianex, Oralone)

Topical triamcinolone treats inflammatory dermatosis that is responsive to steroids. It decreases inflammation by suppressing the migration of polymorphonuclear leukocytes and reversing capillary permeability.

Hydrocortisone topical (Westcort, U-Cort, Ala-Cort, Caldecort)

Topical hydrocortisone is an adrenocorticosteroid derivative that is suitable for application to skin or external mucous membranes and is used to treat inflammatory dermatoses that are responsive to steroids. It decreases inflammation by suppressing the migration of polymorphonuclear leukocytes (PMNs) and reversing capillary permeability.

Betamethasone topical (Diprolene, Luxiq)

Topical betamethasone is used to treat inflammatory dermatoses responsive to steroids. It decreases inflammation by suppressing migration of PMNs and reversing capillary permeability. It affects production of lymphokines and has an inhibitory effect on Langerhans cells.

Clobetasol (Temovate, Temovate E, Olux, Olux-E)

Clobetasol is a class I superpotent topical steroid. It suppresses mitosis and increases synthesis of proteins that decrease inflammation and cause vasoconstriction.

Anticonvulsants, Other

Class Summary

Antiepileptic agents decrease impulsiveness.

Topiramate (Topamax, Topiragen)

Topiramate is a sulfamate-substituted monosaccharide with a broad spectrum of antiepileptic activity that may have state-dependent sodium channel blocking action. It potentiates the inhibitory activity of gamma-aminobutyric acid (GABA) and may block glutamate activity.

Monitoring of plasma concentrations is not necessary for optimizing therapy. On occasion, addition of topiramate to phenytoin may necessitate adjustment of the phenytoin dosage to achieve optimal clinical outcome.

 

Questions & Answers

Overview

How is excoriation (skin-picking) disorder characterized?

What are the signs and symptoms of excoriation (skin-picking) disorder?

Which psychiatric and medical diagnoses should be included in the differential diagnoses of excoriation (skin-picking) disorder?

Which physical findings suggest excoriation (skin-picking) disorder?

How is excoriation (skin-picking) disorder diagnosed?

Which studies are performed in the workup of excoriation (skin-picking) disorder?

How is excoriation (skin-picking) disorder treated?

Which medications are used in the treatment of excoriation (skin-picking) disorder?

Which nonpharmacologic interventions are used in the treatment of excoriation (skin-picking) disorder?

What is excoriation (skin-picking) disorder?

What causes excoriation (skin-picking) disorder?

What is the prevalence of excoriation (skin-picking) disorder?

What is the prognosis of excoriation (skin-picking) disorder?

Presentation

Which clinical history findings are characteristic in patients with excoriation (skin-picking) disorder?

Which psychiatric disorders are associated with excoriation (skin-picking) disorder?

How is excoriation (skin-picking) disorder differentiated from trigeminal trophic syndrome or acne excoriée?

Which physical condition must be excluded prior to a diagnosis of excoriation (skin-picking) disorder?

Which physical findings are characteristic of excoriation (skin-picking) disorder?

DDX

Which conditions are included in the differential diagnoses of excoriation (skin-picking) disorder?

What are the differential diagnoses for Excoriation Disorder?

Workup

What is the role of Skin Picking Reward Scale (SPRS) in the workup of excoriation (skin-picking) disorder?

What is the role of lab tests in the workup of excoriation (skin-picking) disorder?

How is excoriation (skin-picking) disorder classified in DSM-5?

What are the DSM-5 diagnostic criteria for excoriation (skin-picking) disorder?

Which histologic findings are characteristic of excoriation (skin-picking) disorder?

What is the role of imaging studies in the workup of excoriation (skin-picking) disorder?

Treatment

How should a dermatologist approach the treatment of excoriation (skin-picking) disorder?

What is the role of medications in the treatment of excoriation (skin-picking) disorder?

What is the role of hypnosis in the treatment of excoriation (skin-picking) disorder?

Which specialist consultations are beneficial to patients with excoriation (skin-picking) disorder?

What is included in the long-term monitoring of excoriation (skin-picking) disorder?

How is recurrence of excoriation (skin-picking) disorder prevented?

Medications

What is the role of psychotropic medications in the treatment of excoriation (skin-picking) disorder?

Which medications in the drug class Anticonvulsants, Other are used in the treatment of Excoriation Disorder?

Which medications in the drug class Corticosteroids, Topical are used in the treatment of Excoriation Disorder?

Which medications in the drug class Antidepressant, SSRIs are used in the treatment of Excoriation Disorder?

Which medications in the drug class Anxiolytics, Nonbenzodiazepine are used in the treatment of Excoriation Disorder?

Which medications in the drug class Antidepressants, TCAs are used in the treatment of Excoriation Disorder?