Development and Discussion
The association between psychiatric and dermatological disorders has
been well characterized in the current literature, with estimates of up
to 40% of patients with dermatology with concomitant psychiatric
problems, often related to their skin condition [3].
The most common underlying psychopathological conditions are depression
and anxiety, borderline personality disorder, body dysmorphic disorder,
substance use disorder, eating disorders, trichotillomania, and
kleptomania. Self-destructive behavior, difficulty expressing anger, and
obsessive-compulsive disorder are also identified. In this sense, loss,
recent grief, and obsessive-compulsive personality are factors that can
be related to the diagnosis [7]. Emotional traumas suffered during
child development, abandonment, family breakdown, restricted emotional
ties, adulthood with difficulties in performing tasks that require
emotional maturity, and the ability to control impulses. Family
histories were notable for depressive disorders and psychoactive
substance use disorders. Most patients experience increasing tension
before excoriation and relief after [7].
Committed to the task of integrating the work of dermatologists and
psychologists, Psychodermatology has proposed to research and treat
dermatoses that present factors that are more susceptible to
psychological determinants [8,9]. Torres emphasizes the importance
of understanding the psychiatric conditions present in dermatoses, thus,
the case discussion in an interdisciplinary team can prove to be an
effective strategy due to the complexity of the symptoms that the
patient may present [10,11]. Within psychogenic dermatoses are
neurotic excoriations. They are characterized by compulsive
self-produced lesions with the nails that the patient justifies by the
uncontrollable sensation of itching, burning, or the need to remove
something from the skin, such as small follicular papules, keratosis or
other elements [12].
There is a vicious circle between itching, scarring, and skin damage,
which again leads to an uncomfortable feeling and scratching. The
chronicity of skin lesions result in the thickening of the epidermis
with accentuation of the grooves and color, a reaction called
lichenification [13]. Fingernails can be usual agents and abrasions
can take typical forms. The lesions may be primary or be associated with
a pre-existing lesion of another nature, which may occur on the face, or
on any part of the body, and the pruritus may be present, but it is
rarely perceived as a primary lesion. Excoriations are usually less than
an inch in diameter and are covered with hematic crusts and erythematous
borders. Its resolution can leave a clear scar with hyperpigmented
edges. Lesions are noted in all stages, usually more frequent and
concentrated in the forearms, face, neck, and shoulders. In general,
patients are under stress and depressed, and the compulsive aspect
refers to unconscious feelings of guilt and the need for self-punishment
[13].
In this context, a clinical study evaluated the psychiatric
characteristics of neurotic excoriation and investigated the effect of
traumatic events in childhood on the disease [14]. Thirty-eight
patients with neurotic excoriations who had not received psychiatric
treatment in the past year and 40 healthy individuals with similar
sociodemographic characteristics were included in the study. For
clinical evaluation, the DSM-IV Structured Clinical Interview for Axis I
Disorders, Beck’s Depression Inventory, Beck’s Anxiety Inventory, and
the Short Form Childhood Trauma Questionnaire were applied to all
individuals. It was observed that 78.9% of patients with neurotic
excoriations were diagnosed with at least one Axis I psychiatric
disorder, whose most frequent diagnoses were severe depressive disorders
and anxiety disorders. The levels of anxiety and depression were
significantly higher in the patient group than in healthy individuals.
In relation to the Childhood Trauma Questionnaire, the emotional
neglect, emotional abuse, and physical abuse subscales, and the weighted
average total scores were significantly higher in the patient group (p
<0.05). Therefore, there is a close relationship between
neurotic excoriations and traumatic events in childhood, as well as the
psychiatric problems that accompany them. We assume that early
interventions by dermatologists and psychiatrists and, in particular, a
detailed investigation of traumatic events in childhood, establishing a
therapeutic collaboration, are highly important and that the use of
psychotherapeutic interventions can result in better treatment results
in many patients [14].
In this sense, the doctor-patient relationship is extremely important
for better acceptance of the diagnosis and for greater adherence to
treatment [15-17]. Currently, the therapeutic conduct of neurotic
excoriation consists of an indication of antidepressants and
antipsychotics. Among the non-medication therapeutic possibilities, the
literature refers to behavioral psychotherapy, focal, or brief [18].
The goal of psychotherapy is to bring repressed feelings to the surface
through the use of verbalized content. Treatments considered effective
in case reports include a behavioral technique called ”habit reversal”;
which consists of self-monitoring, recording of episodes of scratches,
and procedures that produce alternative responses to scratching
[19].
Thus, pharmacological therapies that include selective serotonin
reuptake inhibitors (SSRIs), serotonin-noradrenaline reuptake
inhibitors, antipsychotics, and glutaminergic modulating agents. SSRIs
and N-acetylcysteine proved to be effective. In addition, atomoxetine
is a selective noradrenaline reuptake inhibitor used in the treatment of
attention-deficit / hyperactivity disorder (ADHD). A case report
presented a 9-year-old girl with a comorbid diagnosis of ADHD and ED
successfully treated with atomoxetine. There was a positive result in
the performance of this drug, but more studies are needed on the
effectiveness of atomoxetine in the treatment of ED in the presence and
absence of ADHD [20]. Thus, there is a search for a clinical
solution, through dermatological consultations, which, when
unsuccessful, increase anxiety, making patients more frustrated,
worsening existing psychological symptoms [20].
In addition, a systematic review study analyzed the evidence on skin
disorder, as defined by the Arnold criteria or the Diagnostic and
Statistical Manual of Mental Disorders - fifth edition (DSM-5), and
examined whether the skin palpation disorder justifies the inclusion in
DSM-5 as a distinct disorder [21]. Thus, a total of 20 studies were
considered eligible in 1554. Most of the articles were case-control
studies with small clinical samples. Only one of Blashfield’s five
criteria was met. There were commonly accepted diagnostic criteria and
evaluation scales present in the literature. Only a small proportion of
published studies on skin disorder used validated criteria. Therefore,
the current literature fulfills only one of the five Blashfield criteria
for the inclusion of skin palpation disorder as a specific entity in
psychiatric diagnostic manuals. More empirical studies on skin palpation
disorder are needed to substantiate skin palpation disorder as a
disorder distinct from related disorders in the obsessive-compulsive
category and related disorders [21].