ABSTRACT: Scratching, rubbing, and impairment of epidermal integrity can produce pathological changes in the skin. Patients who have neurotic excoriations respond to treatment with selective serotonin reuptake inhibitors, which alleviate pruritus independent of their antidepressant effects. Perforating folliculitis is usually associated with renal disease, but it can occur with diabetes or as an isolated finding. UV-B phototherapy can relieve associated pruritus. Chondrodermatitis nodularis chronica helicis (CNH) results from pressure to the ear. Although the diagnosis can usually be made clinically, a biopsy can help rule out basal cell carcinoma and keratoacanthoma, which can mimic CNH. The key to the treatment of intertrigo is to eliminate the friction, heat, and maceration that predispose patients to this disease.
Key words: neurotic excoriation, perforating folliculitis, chondrodermatitis nodularis chronica helicis, hyperkeratosis, intertrigo
The skin is not a passive agent. When manipulated, it reacts to maintain its function and when it cannot do so, a variety of pathological states result.
In this 2-part series, I describe the secondary changes that scratching, rubbing, and impairment of epidermal integrity can produce. The focus is on those conditions that are more commonly found in older adults.
Here I discuss neurotic excoriations, perforating folliculitis, chondrodermatitis nodularis chronica helicis (CNH), hyperkeratosis, and intertrigo. In the first Part (Skin Disorders in Older Adults: Dermatoses Related to Scratching, Rubbing, and Impaired Epidermal Integrity, Part 1), I addressed postinflammatory pigmentary alteration, amyloidosis, lichen simplex chronicus, and prurigo nodularis.
Figure 1 – These erosions and crusts are neurotic excoriations.
Repetitive scratching or picking creates neurotic excoriations. This condition can be initiated by a minor skin lesion, such as an insect bite, folliculitis, or acne, but it can also be independent of any pathology. Because there is no significant underlying skin disease, neurotic excoriations are considered a dermatological manifestation of a psychiatric disorder. The scratching or picking is usually episodic and irregular; however, it can be constant.
Figure 2 – Geometric erosions remained after this elderly patient had scratched away the bullae of pemphigus vulgaris. These lesions resemble neurotic excoriations.
Neurotic excoriations feature clean, linear or geometric erosions, crusts, and scars that can be hypopigmented or hyperpigmented (Figure 1). The erosions and scars 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 symmetrical. In elderly debilitated patients, neurotic excoriations must be distinguished from primary blistering diseases, such as pemphigus vulgaris (Figure 2) and dermatitis herpetiformis, which can manifest with geometric erosions after a patient has scratched away the bullae.
In the treatment of neurotic excoriations, studies have shown that selective serotonin reuptake inhibitors consistently have the greatest antipruritic effect.1-3 The relief of pruritus is unrelated to changes in the patient's mood and occurs more rapidly than would be expected for antidepressant effects. Because of its sedating and antipsychotic effects, doxepin (10 to 25 mg PO at bedtime) is also useful in treating neurotic excoriations.
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