About a case of excoriative disorder: Brief review of the literature.

Claudia Gutarra R., Magnolia Pizarro B., Edith Figueroa R., Lizardo Cruzado D.

ABSTRACT


The instinctive tendency to manipulate the skin and its small imperfections is a normal constituent of body-focused repetitive behaviors. When this behavior increases without control and causes somatic and psychic damage to the individual, we are dealing with a case of Excoriative Disorder (ED), a pathology that has been included in the International Classification of Diseases (ICD-11), and that, in the Classification American Mental Disorders, is part of the disorders related to the obsessive-compulsive disorder. In adults, the lifetime prevalence of ED ranges between 3 and 5% and presents frequent comorbidities with affective disorders, substance use disorders and pathological personality traits. Although it is not apparently a severe pathology, ED causes significant disability and requires systematic screening due to its frequent side-stepping by both the affected patient and health professionals.

Keywords: Excoriation disorder, obsessive-compulsive spectrum, comorbidity.

INTRODUCTION


Excoriation disorder (ED), also called dermatillomania, is a psychiatric disorder recently incorporated into the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), in 2013. It was recognized in the International Classification of Diseases (ICD-10). only among dermatological diseases with code L98.1: Neurotic excoriation(1). In the ICD-11 (2019) it appears already individualized in mental and behavioral disorders, and together with trichotillomania, it constitutes one of the disorders due to repetitive behavior focused on the body. Excoriation disorder consists of the iterative and excessive behavior of pinching, scratching and manipulation of the skin and its small imperfections, which causes different presentations of dermatological lesions and can lead to considerable tissue damage, occupying an important time in the life of the individual, impacting its functionality, and persists despite attempts to control that behavior (1,2). Other clinical characteristics of this disorder are the emotional discomfort that it causes, whether due to shame, guilt or discomfort or due to the aesthetic consequences that excoriative behavior can entail(3).

It was Erasmus Wilson, an English dermatologist, who in 1875 described several clinical cases that he called “neurotic excoriations,” pointing to the link between characteristics of the nervous system of some individuals and the injuries that they inflicted to themselves. Brocq, in 1889, described a form of “young women’s acne”, highlighting the excoriations carried out on such lesions and the clear predominance in young and female adults. These are the first antecedents of the problem in modern Western medicine (4).

Excoriating disorder and trichotillomania (along with other phenomena not classified as disorders per se, such as onychophagia), are part of the so-called “repetitive behaviors focused on the body”, which differ quantitatively and qualitatively from normal dressing behaviors (grooming), atavistic and protective of ectoparasites in the animal kingdom and which are registered since the phylogenetic level of birds (5). In turn, ED together with hoarding disorder, body dysmorphic disorder, obsessive-compulsive disorder, trichotillomania and excoriative disorder, make up the so-called obsessive-compulsive spectrum, arranged as a separate category in the DSM-5 and ICD-11 (6).

Epidemiological data regarding ED are scarce given its recent diagnostic configuration, but its existence has been demonstrated in all geographical latitudes (7). In the United States of America (US), up to one in three adults meets criteria for some grooming disorder and comorbidity among them is common (7). A lifetime prevalence of ED in the US is cited as ranging between 1.4% and 5.4% of adults, although excoriative behaviors in general can reach a prevalence of more than 60% throughout life (2 ,7). Likewise, comorbidity of ED with major depression, anxiety disorders, psychoactive substance abuse, some personality disorders, obsessive-compulsive disorder and others on the same spectrum is very common (4). Studies in Latin American countries are scarce. A Chilean study showed a prevalence of ED of 0.91% in adults (8).

We are faced with a pathology that, although it is not extremely serious – howewer, there have been reported cases that are life-threatening - is frequent, but as it is ignored by professionals and hidden by those who suffer from it, it prevents it from receiving adequate and timely treatment (9). For this reason, regarding a particularly symptomatic case, we have prepared a brief review of the literature.

CLINICAL CASE


A 25-year-old male, married, father of one son, with high-school degree, motorcycle taxi driver, born and resident in Lima. Since he was a little boy he considered himself a “perfectionist” and “nervous.” He was a victim of child abuse by his father, who was a violent man.

When he was 16 years old, he developed facial acne lesions. On one occasion, a furuncle broke out on his forehead, so he proceeded to pinch it repeatedly until it drained. The next day he did the same with the scab that had formed. He felt uncomfortable with the appearance of the injury, not because it drew attention but because he didn’t like the shape of his lesion. He applied silver nitrate to the skin lesion and rubbed with alcohol and cotton, because he wanted to obtain an “oval, symmetrical” shape. He felt very dysphoric at not achieving his goal and put on a cap to cover the injury. Furthermore, he felt emotionally sad and had a tendency to isolate himself: his relatives inspected his room and found alcoholic beverages bottles and cotton swabs stained with blood. He came to ask for help because he couldn’t stop getting injured. He felt that he no longer wanted to live because “no one was going to love him, due to rejection of his sore “. In response, his mother ridiculed his situation. A few days later he ingested rodenticide with suicidal intent, he repented and asked his family again for help. He was treated at a hospital, gastric lavage was performed and he was referred to an outpatient psychiatric clinic, for which he did not make an appointment.

At the age of 17 years old, he was concerned when he noticed another “pimple” that appeared on his chest, near his left shoulder, although it was not visible because it was covered by his clothes. However, the patient repeatedly pressed on it and tried to squeeze it out even though he did not have pus, using his nails, tweezers, rubbing with paper or cotton, in order for the lesion to be “symmetrical.” He tried not to think about the injury but he couldn’t. After two months he received medical attention because a chronic injury, 2 centimeters in lenght, had occurred. Cleaning and subsequent suturing were performed, but when a protruding scar formed, the patient manipulated and opened it again, this required new surgical treatments until the scar reached 6 centimeters in length.

At the age of 19 years old, their relatives observed that he continually injured his fingers, ripped off “the little skin” around his nails, and became desperate if there were lesions that did not seem symmetrical: so he pinched other undamaged areas of skin to “make them of identic shape” or if there were “little skins hanging.” To hide his injuries she would put band-aids on her fingers, but in his room she would remove them to continue manipulating the area. Simultaneously, the patient began to explore his back for acne lesions using two mirrors and long tweezers. The difficulties inherent in this did not deter him. He even demanded that his partner help him by holding the mirrors. At that time, after handling his injuries, he thought his hands had been contaminated and he washed them for 15 to 20 minutes several times a day, using a bar of soap a day. He also worried if someone touched him physically because he felt “contaminated” and he took a shower more than once a day, and for more than an hour. However, the patient stated that what bothered him most were his concerns about his skin lesions and constantly reviewing them to verify their symmetry or “disappearing” them, not the opinion that others had.

5 years ago (when he was 20 years old) the patient was bothered by a tiny nodule that appeared on his left shoulder. He started to pick it but as he later noticed smaller nodules nearby (apparently it was keratosis pilaris), he decided to use a steel sponge to “remove all the pimples.” At first he tried not to damage his skin, but it was inevitable that the epidermis became denuded in patchy areas along 10 to 15 centimeters on the external area of the shoulder and left arm: he tried to cover this injury with his sleeve but the secretions got wet and they stuck to the clothes. He was taken to a psychiatric consultation but did not follow the instructions, claiming that the drugs “made him groggy,” so the family secretly gave him the medications. He became irritated when they called attention to him or tried to stop his excoriating behavior. He stopped working as a motorcycle taxi driver some days and, confined to his room, he continued to excoriate his injuries.

In these last two years, the patient has continued with his excoriating behaviors: he cannot go out to work unless he has achieved that the scar he is manipulating has the “ovoid” or “rounded” shape that he considers to be appropriate, regardless of whether the scar is covered by clothing or is visible. He frequently appears dysphoric and irritable: sometimes, as his lesions ooze and adhere to his clothing, he is left without clean clothes and must remain half-naked and secluded in his room. He has sometimes wanted to wear other relatives’ clothes and this causes quarrels in the family. Likewise, he has gone so far as to go over his skin, especially his hands and arms, with a razor in order to “remove” imperfections or irregularities, causing cuts that, in turn, motivated new excoriating behaviors, to remove the scabs or scar debris. There were spontaneous fluctuations: at times the intensity of the excoriative behaviors decreased although they never completely disappeared.

One month ago, he extracted the nails from two of his fingers using tweezers and nail clippers because he disliked their appearance (they were gnawed away by his own onychophagia and had onychomycosis), so he was taken to a psychiatric emergency.

Seven days ago, the patient became irritable and aggressive with his family and presented inappropriate behavior such as remaining naked all day in his room: he justified this because his clothes were stained with blood, so he was taken back to a psychiatric emergency, where he was admitted for medical observation and treatment.

Our patient recognizes his behavior as “something bad, that he should not do, but that he cannot control”. However, he comments that he is not sorry and wants to be understood (“this is my way”), indicating that if he does not manipulate his skin, he should feel “very distressed and anxious.” He recognizes that the impulse to manipulate his skin happens continuously throughout the day and thus he can spend more than 8 hours a day on it, although he minimizes the impact on his social and work life (he lacks interaction with friends; his ex-partner and his family supports him financially because his income as a motorcycle taxi driver is not enough). Among the triggers that unchain his behavior, he mentions the tension caused by his bad relationship with her mother: “when I asked her for help, she scoffed saying that my guts won’t come out from my wounds.” Until now, he presents compulsive cleaning behaviors consisting of washing his hands after handling his lesions (not before), which takes him 10 minutes at a time, up to 8 to 10 times a day. He does not present psychotic symptoms nor does he meet the criteria for major depression.

During the physical examination of the patient, multiple scar lesions were observed on the skin of the chest, upper half of the back, shoulders, arms, toes and hands (periungual areas). The lesions had dimensions ranging from 1 millimeter to 2 centimeters in length (Photos 1 and 2). A 6-centimeter keloid surgical scar stands out in the left pectoral area (Photo 3), and in the lateral area of the shoulder and left arm a large area of irregular contours and hyperchromic tone is observed (approximately 10 x 20 cm) (Photo 4), produced by continuous rubbing with “steel sponge”. Multiple areas of denuded skin are also seen in the periungual areas, as well as in several interdigital spaces of the feet. The patient registered 38/50 points on the Skin Picking Impact Scale (SPIS).

DISCUSSION


We are faced with a case of severe excoriative disorder, comorbid with obsessive-compulsive disorder. At some point our patient also presented major depression. Comorbidity of ED occurs in 57 to 100% of cases, especially with depressive and anxiety disorders (6), but also with body dysmorphic disorder and obsessive-compulsive disorder. (2) There is also important comorbidity with substance use disorders (10).

The purpose of configuring the group of disorders related to OCD was the similarity of findings in terms of neurobiology, epidemiology, neuroimaging, familial aggregation and responses to therapy (11). In the ICD-10, compulsions were defined as forms of stereotyped behavior that are continually repeated, compulsions are neither pleasurable per se nor useful in themselves. Likewise, compulsion is an active phenomenon since it implies a struggle between the tendency to motor action and the resistance to it. Although there are phenomenological discrepancies between impulsivity linked to small impulses and compulsions, the obsessive-compulsive spectrum in some cases can incorporate impulsive and compulsive phenomena, that is, compulsivity and impulsivity would not be opposing phenomena but rather with multiple points of intersection (12). In that sense, they should not be seen as opposed extremes of an axis but as orthogonal vectors.

A trimodal peak about the age of onset of the condition has been described: before 10 years of age, a second peak between adolescence and young adulthood, and finally between 30 and 45 years of age (1). The female sex has a prevalence greater than 70-80% (2), probably due to their higher self-report rate, as well as by the hypothetical participation of estrogenic hormones in the pathophysiology of the condition (1). ED is associated with a lower quality of life compared to other disorders of repetitive behaviors focused on the body (2), it has an important psychosocial impact and can lead to serious complications: there are reports of sepsis (13), brain and spinal cord involvement (14, 15), and various soft tissue injuries and deformities that have required hospitalization and surgery (16,17) apart from the permanent aesthetic alterations and consequent emotional repercussions, which are often underestimated (1).

Clinically, ED presents notable heterogeneity. Forms of ED associated with “triggers” that induce excoriative behavior, are distinguished: for example, excoriations triggered by negative feelings such as boredom, sadness or anxiety; but there may also be physical sensations or visual stimuli that trigger the excoriative behavior. Psychosocial stress has been reported as a trigger in up to 90% of cases (1). In this sense, the “emotional regulation” model conceives acts of excoriation as an escape valve for aversive emotions. Individuals with ED would have deficits in their emotional regulation (18). After excoriation, gratification and even pleasure can be experienced, although feelings of guilt and shame and concern about hiding the injuries are also mixed (18). Other explanatory psychological models are the “addictive model” (a percentage of patients find it pleasurable and, therefore, excoriative behavior becomes a positive reinforcer) and the “stimulus regulation model”, although the emotional regulation model has greater empirical support.

The most affected areas are those accessible to manipulation by the patient: face, skull, chest, arms, legs, hands and fingers, scrotum (4) and the periods of time used can be up to several hours (7). Likewise, the transition is described from the beginning, when the excoriating behavior is automatic or unconscious, while the individual is involved in other activities, and after a period of time, it becomes conscious, intentional and compulsive (19). Apparently, excoriating behaviors are more frequent at night (18). Excoriative lesions are usually found in different stages of evolution, due to manipulation of scar lesions and the formation of new and bigger lesions. Although at first only skin affected by previously pre-existing lesions is excoriated, uninjured skin is usually affected at last (20). Although most of patients only use their nails and fingers to excoriate themselves, many of them also use tweezers, scissors, needles, and in some cases, abrasive sponges or sandpaper inclusive (20).

A common antecedent in those who suffer from ED is the experience of child abuse of various kinds and its impact as psychological trauma (21,22). Regarding personality traits associated with ED, high neuroticism (harm avoidance and reward dependence), high introversion, low self-conciousness and emotional regulation difficulties are noted (23). Obsessive personality traits such as rigidity and emotional repression have also been frequently reported (1).

There are various evaluation instruments designed for the assessment and investigation of ED: the first instrument, introduced in 2001, was the Skin Picking Scale, with only 6 items (24). The Skin Picking Impact Scale, with 28 sections, was also designed in 2001 to measure the psychosocial consequences of the problem; both are self-administered. The latter has been translated and validated into the spanish language, in the complete and also in the abbreviated version (25). On the other hand, at a later date, the Milwaukee Inventory for the Dimensions of Adult Skin Picking (MIDAS) was created, which allows compulsive behaviors to be distinguished from impulsive ones, as two underlying factors within ED (26).

Findings that support a greater tendency towards motor impusivity have been incorporated into the neurobiology of ED (27): anomalies in the white matter of the anterior cingulate, also hypoactivation of the dorsal striatum and ventral medial prefrontal cortex have been found; and in general, defects in frontostriatal pathways that exert descending inhibitory control. The right insula, which processes movement stop signals, as well as areas of the inferior parietal and lateral occipital cortex, which link exploratory tactile behaviors and motor responses, show consistent thinning. Regarding genetics, the heritability of the disorder is around 40% (4) and the family of genes for the postsynaptic density of glutamatergic neurons, mainly SAPAP3, has been implicated as those most linked to body focused behaviors (4).

ED therapy is based on both pharmacological and psychotherapeutic approaches (1,2). Although the evidence is discreet and limited, there is data on the usefulness of fluoxetine, citalopram and clomipramine, which are enhancers of serotonergic transmission. Lamotrigine has also been tested (based on the glutamatergic dysfunction underlying ED) but without obvious usefulness. Inositol and naltrexone have also not demonstrated greater clinical utility (28). The perspective of using N-acetylcysteine is interesting, due to its glutamatergic and dopaminergic modulation effect and as an antioxidant, with some studies in favor of its effectiveness (29). Cognitive behavioral therapy, specifically habit reversal therapy (consisting of psychoeducation, cognitive restructuring, conscious recognition of the urge to excoriate and triggering stimuli with modification of behavioral responses) has achieved clinical remission in up to 50% of cases (30). The effectiveness of psychotherapy programs in virtual (online) format based on a cognitive behavioral approach has been demonstrated (31). Likewise, alternative therapies such as yoga and aerobic exercise have been studied that could be adjuvants with pharmacotherapy and psychotherapy (32).

Dermal lesions must be appropriately assumed by the dermatologist professional, as soon as it is pertinent. It is necessary in the proper differential diagnosis to consider various dermatoses such as psoriasis, pruritus due to systemic disease, scabies, as well as other primary psychiatric disorders, therefore, the appropriate approach must be interdisciplinary, and not restricted to psychopathological assessment. Even unusual pathologies such as Lesch-Nyhan or Prader-Willi syndrome should be considered (33).

In conclusion, our case is an example of the severity that ED can reach and the difficulties inherent in its treatment. Comorbidity with OCD is extremely common to the point that the boundaries between one and the other can become blurred. Recent findings suggest that ED is a relatively common disorder in the population and with very high rates of comorbidity (34) and significant deterioration in quality of life (35). It is necessary to systematically search for cases of ED that may underlie and cause suffering in its carriers.

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