Despite his insistence that he was not scratching his abdomen, the lack of primary lesions and the appearance of horizontally oriented excoriations over the abdomen in multiple stages of healing were consistent with neurotic excoriations.
Neurotic excoriation is frequently associated with psychiatric disease, especially obsessive-compulsive disorder and depression.1 Stimulant-use, either by prescription or illicit, can lead to increased self-grooming behaviors, motor tics, and scratching. High doses of stimulants can trigger paranoia and tactile hallucinations.
In this case, the preponderance of skin lesions occurring on the left side of the patient’s abdomen fit with a right-handed individual, which the patient was. On his anterior lower legs, there were linear excoriations oriented vertically. Close observation of the patient during history taking revealed unconscious skin-picking behavior, and dead skin and debris could be noted under his fingernails. Two punch biopsies of active lesions were consistent with excoriations and excluded inflammatory causes of itching. (Careful evaluation for scabies, eczema, urticaria, and contact dermatitis was also performed.)
In this case, the patient’s psychiatrist reduced his dosage of lisdexamfetamine to a starting dose of 30 mg daily, which led to decreased skin scratching behavior. While the patient continued to have limited insight into the nature of his skin changes, progress was measured by a reduction in the number of active lesions.
Text courtesy of Jonathan Karnes, MD, medical director, MDFMR Dermatology Services, Augusta, ME. Photos courtesy of Jonathan Karnes, MD (copyright retained).