By Gary M. White, MD
Various disorders including trichotillomania, neurotic excoriations, and dermatitis artefacta, are factitial or self-inflicted. The term neurotic excoriations is applied to the patient who picks and scratches the skin usually in response to anxiety or stress and in the absence of a primary dermatologic disorder.
The patient scratches the skin leading to excoriations, scabs, and then scars. The extensor arms are most commonly affected, followed by the extensor legs and occasionally the face. The back is almost always spared which helps in distinguishing this from such diseases as PLEVA, and staphylococcal folliculitis. Many presentations may occur, e.g., factitial cheilitis. Women are much more likely to scratch their acne then men (see acne exocorie).
The patient may note a watery fluid emanating from the lesions (which represents serous fluid). Delusions of parasitosis should be excluded.
Treatment tends to be easier when the patient has good insight as compared to when the patient denies categorically that s/he is scratching. If there is reasonable insight, then strategies can be focused on behavioral approaches to stop scratching. For example, cover the lesion, cut fingernails, know triggers and avoid them, substitute something for scratching, and cover lesions at night (is covering gone in AM?). One of my patients who had extensive lesions on the abdomen did well after wearing a girdle.
If there is little insight, then trying various bland creams and oral or topical antibiotics if infected is helpful. Frequent followup visits, encouragement to be "gentle" with the skin, and covering 24/7 to "help it heal" can be beneficial.
A topical steroid-impregnated tape (e.g., Cordran) as well as UVB can be very helpful to reduce itch and decrease scratching. See also lichen simplex chronicus and prurigo nodularis for treatment ideas.
Some women scratch their faces tremendously. Whether there is acne there or not is sometimes hard to tell. See also acne exocorie.
Sometimes the scratching and rubbing induces linear purpuric lesions, here shown in a child.
Many old, white scars from scratching.
This patient finally admitted injecting paint thinner into his skin. JAAD August 2014 Volume 71, Issue 2, Pages 376–381
Factitial ulcer after herpes zoster in an elderly woman with Alzheimer's dementia. JAAD October 2010 Volume 63, Issue 4, Pages 724–725
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