A 55-year-old woman presents with severe itching on her arms and legs. The itching disrupts her sleep, and she sometimes scratches her arms and legs until exhaustion (Figures 155-1 and 155-2).1 She had used moisturizers, emollients, and topical corticosteroids, but they only alleviated the itching temporarily. The itching began 10 months earlier after finalizing the divorce from her husband of 20 years. The patient's right leg had been amputated above the knee after a car accident, and she now wore a prosthetic leg. The patient readily admitted to a great deal of psychological distress. She described feeling depressed since her divorce, and the loss of her leg further aggravated her situation. She has had difficulty securing a job and had high anxiety about being able to pay for rent and bills. The physician diagnosed an "excoriation disorder," and the patient understood that she was doing this to her own skin. The patient improved with nail cutting, topical clobetasol, and acknowledging the self-inflicted nature of her excoriations. One year later, the patient was working in the hospital laboratory with a tremendous improvement in her skin condition (Figure 155-3).
Excoriation disorder (neurodermatitis) seen on 3 of 4 extremities. The fourth extremity is a prosthetic leg. (Reproduced with permission from Usatine RP, Saldana-Arregui MA. Excoriations and ulcers on the arms and legs. J Fam Pract. 2004;53(9):713-716. Frontline Medical Communications. Inc.)
Excoriation disorder with close-up of arm. (Reproduced with permission from Usatine RP, Saldana-Arregui MA. Excoriations and ulcers on the arms and legs. J Fam Pract. 2004;53(9):713-716. Frontline Medical Communications. Inc.)
Same patient with excoriation disorder 1 year later after successful therapy. Hypopigmented scarring remains. (Reproduced with permission from Richard P. Usatine, MD.)
Psychocutaneous disorders (sometimes referred to as "self-inflicted dermatoses" or "psychogenic dermatoses") include excoriation disorder, lichen simplex chronicus, and prurigo nodularis. In these conditions, repeated scratching, skin-picking, rubbing, or other self-inflicted damage to the skin occurs for psychiatric reasons, without evidence of a primary medical or dermatologic disorder. Psychocutaneous disorders can present a challenge to the clinician, as multiple underlying medical etiologies must be ruled out to arrive at their diagnosis and the pathophysiology of these diseases is not well understood. In addition, these disorders may be difficult to treat successfully. There is no clear standard of care for treatment, although a vast array of treatments targeting different etiologies has been tried clinically, and many have some amount of research to support them. As with other psychosomatic conditions, nonpharmacologic interventions, including the physician–patient relationship itself, are important to treatment.