Psychogenic excoriation

Management Strategy

Although psychogenic excoriation is primarily a psychiatric disorder, patients usually present first to a dermatologist rather than seeking assistance from a psychiatric professional. In general, concurrent psychotherapy and psychopharmacological treatment is recommended.

If depression or anxiety is the underlying psychopathology, antidepressants and anxiolytics are considered first-line treatment. Selective serotonin reuptake inhibitors (SSRIs) have been shown to be effective in patients with psychogenic excoriation. The author JK has also found success using the tricyclic antidepressant doxepin. Although there are no clinical trials demonstrating its efficacy in this condition, doxepin is often useful due to its combined antidepressant and antihistaminic/antipruritic activity, which may be critical in disrupting the itch–scratch cycle. Doxepin is typically started at 10 mg nightly, with a gradual increase in dose of 10 mg every 2–4 weeks. A dose of 100 mg every evening is the usual effective antidepressant dose and may be particularly effective if the underlying psychopathology is major depression. For anxiety, lower doses typically suffice. If the patient requires higher dosages, a maximum of 300 mg daily may be used per US Food and Drug Administration (FDA) guidelines following careful titration, provided there are no side effects. Because doxepin can prolong the QT interval, a screening electrocardiogram (ECG) is recommended for patients over age 55 or any patient with a past history of cardiac dysrhythmia. Sedation, syncope, seizures, weight gain, and orthostatic hypotension are other potential side effects. Of note, SSRIs have better safety profiles than doxepin, as they are less associated with sedation and cardiac conduction abnormalities. However, SSRIs do not provide the same antipruritic/antihistaminergic as doxepin, and some, such as fluoxetine, may increase anxiety in patients at initiation of therapy.

A recent randomized, placebo-controlled, double-blinded trial of the glutamatergic agent N -acetylcysteine (NAC) dosed at 1200–3000 mg/day found significant improvement in skin picking when compared with placebo. Other tricyclic antidepressants, such as clomipramine and amitriptyline, and various benzodiazepines are third-line therapies that should only be considered if the patient does not respond to more conventional treatments or cannot tolerate the side effects.

For treatment of underlying psychosis, antipsychotics can be effective. For example, pimozide and risperidone may have a role in rare cases in which patients present with psychogenic excoriations due to false ideations. These include trichophobia, a delusion in which patients believe that they must dig out something from the skin that surrounds hair roots in order for their hair to grow normally.

When borderline personality is the underlying psychopathology, psychotherapy is recommended. Psychotherapy and cognitive behavioral techniques, including habit-reversal therapy, aversion therapy, and acceptance and commitment therapy, have been reported to be effective for this disorder.

Other treatment options may further enhance systemic pharmacologic treatments and psychotherapy. Treating associated infection and pruritus with antibiotics and antihistamines (oral or topical), respectively, may provide additional benefit. Narrowband ultraviolet (NB-UVB) phototherapy may also be helpful for pruritus.