Generally, neurotic excoriation is a self-inflicted skin lesion that results from repetitive scratching, and due to the fact that it occurs without a known physical skin problem, it is regarded as a physical manifestation of emotional problem. The lesion would be characterized by linear, clean erosions, scars and scabs that can be hyperpigmented or hypopigmented. Usually similar in size and shape, neurotic excoriation lesions are grouped on easily exposed and accessible areas of the body, such as the upper back, face and extensor surfaces.
This condition is basically produced by repetitive scratching without an underlying physical pathology, where most of the time, the patient has a comorbid mental illness, usually mood disorder or anxiety. Unlike other self-inflicted dermatoses, neurotic excoriation acknowledges a self-inflicted nature of the lesion, where the quantity of the lesions varies, ranging from a few to several hundreds. Though the prevalence and incidence of this condition is thought to be underreported and common, it has been observed in a small percentage in dermatology clinic patients5 and those with pruritus, primarily affecting women.
Basically, this approach should be empathic and supportive, but should be open to other methods should other issues emerge. A cognitive-behavioral approach would focus on aiding the patient to understand his condition through education and alternative responses to pruritic sensations. The most difficult time for a patient would be at night when he feels itching in the near-sleep state. Now, a close working relationship with a therapist would alert the physician to increases in stress levels in the patient, presenting as new somatic concerns. The possibility of other psychiatric diagnoses that would emerge during therapy might also indicate a need of alterations in the treatment method, which include medications.
Study shows that the serotonergic effect of selective serotonin reuptake inhibitors (SSRIs) has consistently produced the strongest antipruritic response in patients suffering neurotic excoriation. It also observed that the relief of pruritus was not related to changes in the mood of the patient, occurring sooner than expected for antidepressant effects. Combined with reports of a similar effect using the serotonin type 3 receptor antagonist ondansetron, this finding suggests that serotonin sites may be key in treating pruritus.
Obsessive compulsive disorder (OCD) is also speculated to be an underlying component in some cases, but patient would minimize or deny the condition, as often times, a lower dosage of an SSRI is needed to lift depression symptoms compared to improving OCD symptoms, which implies an increased dosage to produce a partial response.
The cycle of itching and scratching induces mast cell degranulation and cytokines that should respond to antihistamines, but reports that support trials of these drugs and tricyclic antidepressants indicated that these agents have more side effects and less consistent efficacy.
Alternative and Complementary Medicine
Aside from counseling and pharmacologic treatments, there are traditional methods to treating neurotic excoriation, including acupuncture, hypnosis for direct intervention in the itch-scratch cycle and supportive and family therapy, which is effective in reducing underlying stressors.
In general, neurotic excoriation is a skin manifestation of an emotional problem that requires a biopsychosocial spiritual approach. The physician should be well-equipped to help patients who are suffering from this difficult condition.