Neurotic Excoriations: A Diagnosis of Exclusion

Georgann Anetakis Poulos, MD; Lana Alghothani, BS; Seth Bendo, MD; Matthew J. Zirwas, MD

All from The Ohio State University Medical Center, Division of Dermatology, Columbus, Ohio

Disclosure: The authors report no relevant conflicts of interest.

Abstract
Patients with psychiatric disease may use the skin as a means of communication during times of increased emotional distress. Furthermore, a high incidence of skin disorders among patients with a primary psychiatric condition, including depression, schizophrenia, and anxiety, has been demonstrated, with neurotic excoriation being one of the most commonly diagnosed. Despite the strong association and incidence of psychogenic excoriation in patients with a primary psychiatric disorder, it is important for primary care physicians and dermatologists alike to realize that these patients may have true dermatological disease. The authors present a 53-year-old woman with past medical history significant for schizophrenia, depression, hepatitis C, and diabetes mellitus type II, who was transferred from an outside hospital secondary to anemia in association with diffuse skin lesions. Although she adamantly denied self-inducing the skin lesions, she was diagnosed with neurotic excoriations by primary care and specialty care physicians on three different occasions. After a thorough workup during this admission, the patient was diagnosed with bullous pemphigoid.  (J Clin Aesthet Dermatol. 2012;5(2):63–64.)

The authors present the case of a 53-year-old woman with past medical history significant for schizophrenia, depression, hepatitis C, and diabetes mellitus type II who was transferred from an outside hospital to The Ohio State University Medical Center secondary to anemia in association with diffuse skin lesions.

Dermatology was consulted by Internal Medicine to assist in diagnosis. Of note, the patient had been admitted on three separate occasions to outside hospitals and diagnosed with neurotic excoriations by primary care and specialty care physicians. The skin eruption and associated severe pruritis began approximately 4 to 6 months prior to presenting to the authors’ medical center. The arms and legs were affected first with subsequent skin lesions appearing on the abdomen, chest, and face, which was affected last. The patient adamantly denied self-inducing the skin lesions.

On physical exam, scattered erosions were visible on the cheeks with hemorrhagic crusting also evident on the nasal alae and lips (Figure 1). In addition, similar lesions were diffusely apparent on the patient’s upper chest (Figure 2), and a few flaccid bullae among numerous superficial erosions were evident on the patient’s arms and legs bilaterally.

On admission, viral cultures, blood cultures, a complete blood count, and erythrocyte sedimentation rate were obtained. The patient was initially started on empiric intravenous (IV) acyclovir. The authors’ initial clinical differential diagnosis included paraneoplastic pemphigus, disseminated herpes simplex virus, and autoimmune blistering disease including pemphigus vulgaris. Dermatology performed a skin biopsy of the patient’s right upper arm for hematoxylin and eosin (H&E) and direct immunofluorescence (DIF) microscopy. Direct fluorescent analysis (DFA) was also obtained for herpes simplex virus (HSV) and varicella zoster virus (VZV).

The skin biopsy demonstrated a subepidermal bulla. A lymphocytic infiltrate with occasional neutrophils and scattered eosinophils was present throughout the dermis. DIF microscopy demonstrated linear immunoglobulin G (IgG) and C3 present along the basement membrane. Given the histological differential diagnosis of epidermolysis bullosa acquisita and bullous pemphigoid (BP), serum was sent to the Mayo Clinic for salt split skin testing. Antibodies against BP180 and BP230 antigens were detected in the serum. In addition, the salt split skin test demonstrated antibodies against the BP antigens bound to the epidermal roof.

The patient was diagnosed with bullous pemphigoid and was initially treated with oral prednisone 60mg daily and was to follow up with dermatology closely as an outpatient for consideration of steroid-sparing agents.

Discussion
Patients with psychiatric disease may use the skin as a means of communication during times of increased emotional distress. Several studies have supported this observation and have demonstrated a high incidence of skin disorders among patients with a primary psychiatric condition, most commonly depression, schizophrenia, anxiety, and manic depressive psychosis.[1–3] Of the numerous associated skin conditions in this patient population, neurotic excoriation remains one of the most commonly diagnosed.[2,4,5] Psychogenic or neurotic excoriation, characterized by excessive picking and scratching of normal-appearing skin, affects approximately two percent of dermatological patients2 and is most frequently seen in middle-aged females.[6]

Given the established association between psychogenic excoriation and psychiatric disease, it is not surprising that patients with psychiatric comorbidities presenting with skin lesions are often times incorrectly diagnosed with neurotic excoriation, even before completion of a basic workup to rule out other causes.
Despite the strong association and incidence of psychogenic excoriation in patients with a primary psychiatric disorder, it is important for primary care physicians and dermatologists alike to realize that these patients may have true dermatological disease. A complete workup is imperative to rule out other dermatological conditions prior to diagnosing a patient with psychogenic excoriation or any other psychocutaneous disorder. Finally, it is of paramount importance for primary care physicians to consult or refer to specialists when a patient presents with unexplained skin lesions so that adequate testing and appropriate treatment is afforded the patient.

Although our patient was ultimately found to have bullous pemphigoid, she was originally misdiagnosed with neurotic excoriation during multiple separate admissions to local medical centers. The patient’s psychiatric comorbidities, including depression and schizophrenia, most likely contributed to a lack of an appropriate workup and therefore, an initial incorrect diagnosis. At a recent admission to an outside hospital, the patient was continued on fluoxetine in hopes of treating both the depression and the skin lesions; however, after failing to respond to treatment and adamantly denying excessively scratching or picking at the lesions, she was ultimately transferred to the tertiary care center for further evaluation.

During the authors’ assessment, a broad differential diagnosis was formed, including bullous pemphigoid, pemphigus vulgaris (PV), paraneoplastic pemphigus, and disseminated herpes. Appropriate testing was done and based on the clinical examination and results of the initial skin biopsy. Salt split skin testing ultimately led to the correct diagnosis. This case demonstrates the importance of searching for true dermatological disease in any patient with abnormal skin manifestations, regardless of the patient’s psychiatric comorbidities. We as dermatologists must be advocates for this very vulnerable patient population in need.

References
1.    Kuruvila M, Gahalaut P, Zacharia A. A study of skin disorders in patients with primary psychiatric conditions. Indian J Dermatol Venereol Leprol. 2004;70:292–295.
2.    Arnold LM, Auchenbach MB, McElroy SL. Psychogenic excoriation: clinical features, proposed diagnostic criteria, epidemiology, and approaches to treatment. CNS Drugs. 2001;15:351–359.
3.    Arnold LM, McElroy SL, Mutasim DF, et al. Characteristics of 34 adults with psychogenic excoriation. J Clin Psychiatry. 1998;59:509–514.
4.    Ehsani AH, Toosi S, Shahshahani MM, Arbabi M, Noormohammadpour P. Psycho-cutaneous disorders: an epidemiologic study. JEADV. 2009;23:945–947.
5.    Gupta M, Gupta A, Habennan H. Neurotic excoriations: a review and some new perspectives. Compr Psychiatry. 1986;27:381–386.
6.    Mutasim DF, Adams BB. The psychiatric profile of patients with psychogenic excoriation. J Am Acad Dermatol. 2009;61:611–613.