David Smith, OMS-IV; West Virginia School of Osteopathic Medicine, Lewisburg WV
Lydia Shedlofsky, DO; Affiliated Dermatology, Scottsdale AZ
Acne Excoriée is an excoriation disorder in which patients have a conscious, repetitive, and uncontrollable desire to pick, scratch, or rub acne lesions. Excoriation disorders are a distinct entity within the group of Obsessive-Compulsive (OCD) and Related Disorders. All diagnostic criteria for excoriation disorders must be met for diagnosis and are as follows:
- Recurrent skin picking, resulting in skin lesions
- Repeated attempts to decrease picking behavior
- Skin picking causes clinically significant distress or impairment in social, occupational, or other areas of functioning
- Skin picking is not attributable to the physiologic effect of a substance (e.g. cocaine) or another medical condition (e.g. scabies)
- Skin picking is not better explained by symptoms of another mental disorder (e.g. delusions or tactile hallucinations in a psychotic disorder)
Lesions vary in size (millimeters to several centimeters), shape (linear/angular to circular/oval) and are grouped along sites of the body that are easily accessible and usually exposed. The most common site affected is the face, followed by the scalp, upper back, and upper extremities. Ultimately, the repeated picking results in erosions, ulcerations, and long-term scarring with hyper or hypopigmentation.
Prevalence of acne excoriée is unknown. However, the prevalence of Excoriation Disorders accounts for approximately 1.5% of all visits in dermatology. They are most common in women with a female-to-male ratio of approximately 3:1. The age of onset spans between 15-45 years with peak incidence in the early twenties.
Individuals with Excoriation Disorder often do not seek treatment for their condition, largely due to feelings of embarrassment or lack of awareness. Studies show that only 30-45% of individuals with this disorder seek treatment and only 19% receive dermatological intervention.
When treating a patient with acne excoriée, it is important to first identify any underlying psychological disorder that could account for skin picking behavior. Since Obsessive–Compulsive Disorders are associated with serotonin mediated neural pathways, SSRIs can be helpful in patients with Excoriation Disorder as well as OCD itself. Cognitive behavioral therapy, habit reversal therapy, and acceptance enhanced behavior, have also been reported to reduce skin picking in case series. A recent study conducted by the University of Chicago found that 1200-3000 mg/day of N-acetylcysteine has led to more improvement than placebo in a recent randomized controlled study of adults with excoriation disorder. In addition to these therapies, appropriate treatment of the patient’s acne should be initiated, depending on acne severity and type.
Except in mild transient cases triggered by an immediate stress, the prognoses for excoriation disorders are poor. The condition tends to wax and wane with the circumstances of the patient’s life. Recurrence of even mild acne may be accompanied by resumption of picking unless the associated psychological disorder is addressed. Patients need intervention but sometimes have difficulty in changing the habit of picking even after acne has improved. Without medical and psychiatric treatment focused on the obsessive-compulsive component of illness, excoriation disorders tend to be a chronic condition. For some individuals, the disorder may come and go for weeks, months, or years at a time.
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