Neurotic Excoriations/Factitial Dermatitis

Patients with neurotic excoriations, compulsively pick at their skin and often, no precipitating cause can be determined.
Factitial dermatitis is a self-induced condition caused by habitual scratching or picking, in which lesions tend to show a wide range of bizarre patterns uncharacteristic of any specific disease (Fig. 24.3).

Clinical Manifestations ⬆ ⬇

Erosions, linear crusts, or ulcerations that suggest manipulation by the patient.
Postinflammatory hyperpigmentation and whitish hypopigmented postinflammatory lesions indicate chronicity (see Fig. 24.2).
Many lesions tend to be located on the upper back or ankles—areas that are easily reachable by the patient (see Figs. 24.1 and 24.2).
Factitial lesions often present as deep ulcerations with geometric shapes (Fig. 24.4).
The presence of factitial dermatitis may imply that the patient has severe emotional problems such as obsessive-compulsive disorder, or delusions of parasitosis (see below) that underlie the repetitive self-destructive behavior.

Diagnosis ⬆

The diagnosis is either given by the patient, who readily admits that the lesions are self-created, or the lesions themselves may be indicative of the disorder.
Bizarre-appearing lesions and an affect of la belle indifférence on the part of the patient suggest factitial dermatitis as the cause.

Management

High-potency topical corticosteroids, topical corticosteroids under occlusion, and intralesional corticosteroids are sometimes useful, but these treatments will be ineffective if the underlying psychological cause is not addressed.
Bedtime antihistamines are sometimes helpful.
Psychotherapy and/or psychopharmacologic drugs should be used, if indicated.

Helpful Hint

When the diagnosis is in doubt, the lesions may be covered with a thick dressing, and the patient is then instructed not to remove it. Consequently, when the patient cannot access the lesions, they tend to heal rapidly.