Psychocutaneous Medicine

Pathologic Grooming Behavior: Facial Dermatillomania

Scott S. Harris, MD; Donald Kushon, MD; Ernest Benedetto, MD

Dermatillomania is a pathologic grooming dis- illness and the outcome in this patient. We also order characterized by repetitive, ritualistic, review pertinent literature. impulsive skin picking without an underlying der- matologic condition. It can lead to skin damage Case Report and distress and can affect patient function. A 57-year-old married white woman presented with This disorder has not received much atten- a 30-year history of picking out facial hair and skin tion in the literature, with few studies reporting abnormalities with tweezers. Picking took place clan- treatment efficacy. Patients with dermatillomania destinely for 3 to 5 hours every night, primarily when typically present to primary care physicians and alone while watching television programs. There was frequently are referred to dermatologists; only no underlying dermatologic condition, yet she felt rarely do patients receive additional psychiatric that her hair and skin irregularities made her “look consultation that may improveCUTIS treatment efficacy like a man” or a “bearded lady in the circus.” She and decrease morbidity. We provide a case report reported that the picking action had a calming or of long-standing facial dermatillomania and our soothing effect, while her objective for picking was multimodal treatment approach. to have perfectly smooth skin. Subsequent infec- Cutis. 2011;87:14-18. tions and constant mutilation resulted in the use of heavy cover-up cosmetics during the last 20 years. The patient shunned any activity that would affect Doermatillomania is a pathologicNot grooming dis- the integrityCopy of the makeup, fearing others would order characterized by repetitive, ritualistic, discover her picking disorder. She avoided anything D impulsive skin picking without an underlying that would dampen her face including swimming, dermatologic condition. It can lead to skin damage exercise, or any increased activity that might cause and distress and can affect patient function. perspiration, which led to an increasingly sedentary Although this disorder is prevalent, it has nebulous lifestyle. In addition, she avoided physical contact diagnostic criteria as well as scarce and conflicting that might cause the makeup to rub off her face. This data on treatment. Patients with dermatillomania avoidant behavior resulted in continual strain on her typically present to primary care physicians and fre- relationships, culminating in a total lack of physical quently are referred to dermatologists; only rarely do contact and sexual intimacy with her husband for the patients receive additional psychiatric consultation last 2 years. that may improve treatment efficacy and decrease Relevant medical history included 40 years of morbidity. We report a case of an innovative mul- nail-biting, which began at 7 years of age and timodal method of intervention for long-standing resulted in periodic bleeding. This behavior stopped at 47 years of age (10 years prior to presentation) when she developed an overbite, which disabled her nail-biting. The patient had a 1½-year episode of hairpulling, though it did not result in thinning or From Drexel University College of Medicine, balding, which spontaneously resolved. Addition- Philadelphia, Pennsylvania. The authors report no conflict of interest. ally, she had a 30-year history of daily binge eating Correspondence: Scott S. Harris, MD, 36 Clark St, Unit 4E, and presented with a body mass index of 37.3 Brooklyn, NY 11201 ([email protected]). (normal, 18.5–24.9). She also had a history of breast

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cancer treated with chemotherapy and radiation. not otherwise specified) was made. The differential Family history was noncontributory. diagnosis included (preoc- Attempts at alternative hair removal (ie, waxing, cupation with a specific part of the body due to a electrolysis) had proved futile, as the hair and bumps perception that it is flawed or grotesque) and depres- were not reduced enough to substantially alter her sion not otherwise specified. She also exhibited fea- hair-picking behavior. In the 3 years prior to pre- tures of dysthymic disorder (prolonged nonepisodic sentation, she began treatment with an outside der- depressed mood) and binge as well as matologist. He described widespread inflammatory a history of and onychotillomania. indurated papules and many excoriations covering Because there was not an adequate decrease the cheek and chin areas (Figure 1). To reduce the of skin picking despite prolonged treatment, we thickness, growth speed, and amount of hair, laser changed her medication from sertraline hydrochlo- hair removal was administered along with spirono- ride to 20 mg of duloxetine twice daily. Cognitive- lactone, eflornithine hydrochloride cream, and topi- behavioral interventions, including keeping a log cal steroids. He also prescribed prophylactic oral and of skin picking and associated emotions with the topical antibiotics to prevent recurrent infection. intention of increasing the patient’s awareness of Initially these interventions notably decreased her picking behavior and associated mood state, facial hair, irregularities, and picking; however, the were recommended. She was asked to increase patient continued to dig into her skin and pick any the pleasurable activities in her life such as guitar imperfections to make her skin perfectly smooth. playing and body massage and to limit triggers According to the patient, at this point the derma- associated with picking such as television watching. tologist suggested that “there could possibly be an The patient also was asked to give her tweezers away, underlying reason for [her] picking that needed to be but she refused. As a way of releasing , she was addressed.” She also reported, “I must admit that out encouraged to increase physical activity with exer- of the dozens of doctors I see, he was the only one cise, such as pool walking. Habit substitution was to see a deeper problem.” Prior to the psychiatric attempted by asking her to use a fidget ring, a finger referral, the patient had never seen a psychiatrist/ ring with 2 bands that allow the outer ring to spin. psychologist. However, 5 yearsCUTIS prior, her oncologist The patient was told to use the ring whenever she had prescribed 50 mg daily of sertraline hydrochlo- felt the need to pick. ride (1 year following breast cancer treatment) for Over the following 6 months, sex counseling anxiety, dysphoria, and decreased energy. In other was introduced as well as medication optimization, attempts, she was unable to tolerate venlafax- titrating up her maintenance dosage of duloxetine ine hydrochloride, paroxetine hydrochloride, or an to 60 mg daily. The patient began regular exer- increased dosage of sertraline hydrochloride. cise, a daily log in her diary, and regular use of DuringDo the first visit after Nota comprehensive psy- her fidgetCopy ring. Over time, she experienced a pro- chiatric interview, the diagnosis of dermatillomania gressive increase in sexual fulfillment, improvement (included in the category of impulse control disorder of mood, resolution of facial pain, and an 11-lb

A B

Figure 1. Widespread inflammatory indurated papules and excoriations covering the cheek and chin areas caused by skin picking (A and B).

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weight loss. At 6 months the patient reported com- is a pathologic self-grooming behavior in which plete remission of skin picking and lessened/rare nail length is controlled by teeth rather than nail binge eating (1 time every 3 weeks); she was satisfied scissors/clippers.3 with the results (Figure 2). Using the skin picking Dermatillomania, also known as pathologic skin scale presented by Keuthen et al,1 which evaluates picking, compulsive skin picking, or neurotic exco- 6 items on a 5-point scale (05none; 45extreme) riation, has received the least attention in the medi- with a maximum score of 24, the severity of skin cal literature. This classification can be applied to picking had been reduced from a score of 22 before situations of repetitive, ritualistic, or impulsive skin treatment to 4 at 6 months posttreatment (Table). picking in the absence of an underlying dermato- logic condition. The picking leads to tissue damage Comment and causes substantial distress or impairment in daily Impulse Control Disorders—Dermatillomania (skin functioning.5 Skin picking typically is chronic (the picking), trichotillomania (hairpulling), and ony- average duration is 5221 years) and is 8 times more chophagy (nail-biting) are forms of grooming behav- prevalent in females. Most patients spend a total of iors specified under impulse control disorders not 3 hours or less per day excoriating the skin.6 otherwise specified. These disorders are character- Despite a high prevalence, substantial impair- ized by an individual’s failure or extreme difficulty ment, and morbidity, patients may go untreated for to control impulses despite negative consequences. years due to low patient presentation to healthcare Prevalence of this disorder is hard to quantify because professionals from embarrassment, guilt, or denial, of the lack of standard classifications as well as poor and underdiagnosis and recognition from limited differentiation of severity in epidemiologic stud- literature and education regarding diagnosis and ies. The estimated prevalence in the population of possible treatment options. Together, these qualities pathologic dermatillomania is 2% to 5%, with the have led to undertreatment and a limited number condition presenting more frequently in females. and power of studies. These disorders typically begin in childhood/early The most common psychiatric comorbidities adolescence and are more common in families with include anxiety disorders, mood disorders, alcohol a history of obsessive-compulsiveCUTIS disorder.2,3 Of these abuse/dependence, and body dysmorphic disorder. impulse control disorders, only trichotillomania has a The most common personality disorders Diagnostic and Statistical Manual of Mental Disorders associated with dermatillomania are obsessive- (FourthDo Edition) classification. Not4 Onychophagy compulsive Copy and borderline Patient Evaluation Using Skin Picking Scalea

Before Treatment 6-mo Posttreatment

Frequency of urges 4 1

Intensity of urges 4 2

Time spent picking 4 0

Interference with daily function 3 0

Distress 4 1

Behavior avoidance 3 0

Total 22 4

aItems measured on a 5-point scale (05none; 45extreme).1

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personality disorder.6 Pathologic grooming behaviors have been associated with the obsessive-compulsive spectrum, as they have been shown to have simi- lar underlying triggers, neurotransmitter circuits, motivations, clinical courses, comorbidities, and family history. Neuroimaging has shown that these disor- ders, as with other impulse control disorders, are caused by positive reinforcement in the reward system in the nucleus accumbens and serotoner- gic circuits. An associated impaired inhibition of motor responses also has been demonstrated. Par- ticular genes implicated include 5-hydroxytryptamine receptor genes; homeobox B8, Hoxb8; and SLIT and NTRK2like family, 7 member 1, SLITRK1. Figure 2. At 6 months posttreatment with cognitive- There also is a strong correlation and possible behavioral interventions and duloxetine, the patient similar etiology with body dysmorphic disorder, as experienced complete remission of skin picking and suggested in our case with our patient’s preoccupa- associated symptoms. tion and feelings of being “a bearded lady.” Approxi- mately 44.9% of patients with body dysmorphic disorder report lifetime dermatillomania.8 reversal. It included 19 females, predominately col- Treatment—First-line treatment of trichotillo- lege students, and showed a greater reduction, but and onychophagy is habit reversal,3 which not complete remission, in skin picking when com- may entail awareness, relaxation training, competing pared to no intervention.10 In children, randomized rewarded response training (movements incompat- controlled studies are lacking; however, some case ible with habitual behaviors),CUTIS and training to control reports exist, including a 9-year-old boy who showed habitual behaviors in different everyday situations.5 the greatest efficacy when replacement behavior Other interventions with some varying degrees of was combined with amphetamine and dextroam- success include relaxation techniques, decrease in phetamine tablets for comorbid attention-deficit/ associated activities and environments, reinforce- hyperactivity disorder.11 ment (particularly in children), punishment, and self- Studies on pharmacologic treatment of derma- monitoring. Pharmacologic interventions have more tillomania include a small double-blind, placebo- successDo with trichotillomania thanNot with onychophagy controlled Copy trial by Hendrickx et al12 in 1991 that and primarily include clomipramine hydrochloride failed to establish the efficacy of fluvoxamine maleate. and selective serotonin reuptake inhibitors.3 In 1997, Simeon et al13 reported that fluoxetine Dermatillomania treatment is not as well- hydrochloride was superior to placebo in a trial with established. A few studies have been published on the 17 participants. In 2001, Bloch et al14 published treatment of skin picking, and there has been poor a small open-label fluoxetine hydrochloride trial. comparison in response among severity, underlying Following this trial, responders were randomized to skin conditions, comorbid psychiatric conditions, double-blind treatment with fluoxetine hydrochloride emotional versus compulsive motivation, and treat- or placebo control. Improvement was sustained ment outcomes. in the experimental group, but the placebo group Dermatologic treatments used alone usually are returned to pretrial baselines.14 Similarly, open-label not efficacious for body dysmorphic disorder,9 and the trials of both sertraline hydrochloride and fluvox- standard of care for the other obsessive-compulsive amine maleate resulted in reductions in skin-picking disorders and pathologic grooming behaviors are behavior as reported by Kalivas et al15 in 1996 psychiatric. Therefore, it is reasonable to extrapo- and Arnold et al16 in 1999. In a study by Keuthen late based on theoretical underpinnings and logic et al17 published in 2007, escitalopram was used in an that psychiatric treatment should be considered for open-label study that revealed a 44.8% (13/29) full patients with dermatillomania who do not respond response. Case reports of doxepin, clomipramine, quickly to dermatologic treatment to address the naltrexone, pimozide, and the addition of olanzapine underlying psychiatric condition. to selective serotonin reuptake inhibitors demon- Regarding behavioral interventions, there strate varying degrees of response.6,18 When dosing is 1 randomized controlled trial evaluating habit antidepressants, it is general practice to begin at a

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low dosage and titrate up based on tolerability and 4. American Psychiatric Association. Diagnostic and efficacy, with at least 4 weeks between dosage changes Statistical Manual of Mental Disorders. 4th ed. to properly assess response to a preexisting dose. Washington, DC: American Psychiatric Skin Picking Scale—To standardize diagnosis and Association; 1994. treatment response, it may be useful to employ 5. Deckersbach T, Wilhelm S, Keuthen NJ, et al. Cognitive- the skin picking scale.1 It may provide encourage- behavior therapy for self-injurious skin picking. a case ment to the patient with a more objective scale of series. Behav Modif. 2002;26:361-377. progress and a gauge of treatment success. Six items 6. Arnold LM, Auchenbach MB, McElroy SL. Psychogenic are rated on a 5-point scale (05none; 45extreme). excoriation. clinical features, proposed diagnostic criteria, The 6 items include frequency of urges, intensity epidemiology and approaches to treatment. CNS Drugs. of urges, time spent picking/time taken away from 2001;15:351-359. other activities, skin picking interference with daily 7. Stein DJ, Chamberlain SR, Fineberg N. An A-B-C function, level of anxiety when picking is prevented, model of habit disorders: hair-pulling, skin-picking, and avoidance of other activities due to results of and other stereotypic conditions. CNS Spectr. 2006;11: skin picking.1 824-827. 8. Grant JE, Menard W, Phillips KA. Pathological skin pick- Conclusion ing in individuals with body dysmorphic disorder. Gen Our case demonstrated the application of duloxetine, Hosp . 2006;28:487-493. a selective serotonin-norepinephrine reuptake 9. Phillips KA, Grant J, Siniscalchi J, et al. Surgical inhibitor, to achieve remission in a patient with and nonpsychiatric medical treatment of patients with long-standing, severe, refractory dermatillomania. In body dysmorphic disorder. Psychosomatics. 2001;42: addition, we applied behavior replacement with a 504-510. fidget ring, increased pleasurable activity, increased 10. Teng EJ, Woods DW, Twohig MP. Habit reversal as a treat- exercise, and use of a diary, in addition to concurrent ment for chronic skin picking: a pilot investigation. Behav dermatologic treatment, to minimize dysmorphia. Modif. 2006;30:411-422. Although our case demonstrates an efficacious 11. Lane KL, Thompson A, Reske CL, et al. Reducing skin approach to the treatmentCUTIS of dermatillomania, picking via competing activities. J Appl Behav Anal. larger-scale studies are needed to validate the reli- 2006;39:459-462. ability of duloxetine as well as the combination of 12. Hendrickx B, Van Moffaert M, Spiers R, et al. The treat- behavioral and pharmacologic treatments. Long- ment of psychocutaneous disorders: a new approach. Curr term results also must be assessed, coupled with Ther Res Clin Exp. 1991;49:111-119. guidelines for duration of treatment. Continued 13. Simeon D, Stein DJ, Gross S, et al. A double-blind trial follow-up and a trial discontinuation are needed to of fluoxetine in pathologic skin picking. J Clin Psychiatry. assessDo the appropriate treatment Not length. 1997;58:341-347.Copy Further studies should be undertaken to deter- 14. Bloch MR, Elliott M, Thompson H, et al. Fluoxetine mine possible screening questions and common red- in pathologic skin-picking: open-label and double-blind flag features, which will help identify patients at risk results. Psychosomatics. 2001;42:314-319. for impulse control disorders who may be hesitant to 15. Kalivas J, Kalivas L, Gilman D, et al. Sertraline in the seek treatment. treatment of neurotic excoriations and related disorders. Arch Dermatol. 1996;132:589-590. REFERENCES 16. Arnold LM, Mutasim DF, Dwight MM, et al. An 1. Keuthen NJ, Wilhelm S, Deckersbach T, et al. The Skin open clinical trial of fluvoxamine treatment of psy- Picking Scale: scale construction and psychometric analy- chogenic excoriation. J Clin Psychopharmacol. 1999; ses. J Psychosom Res. 2001;50:337-341. 19:15-18. 2. Hayes SL, Storch EA, Berlanga L. Skin picking behaviors: 17. Keuthen NJ, Jameson M, Loh R, et al. Open-label esci- an examination of the prevalence and severity in a com- talopram treatment for pathological skin picking. Int Clin munity sample. J Anxiety Disord. 2009;23:314-319. Psychopharmacol. 2007;22:268-274. 3. Bohne A, Keuthen N, Wilhelm S. Pathologic hairpull- 18. Christensen RC. Olanzapine augmentation of fluox- ing, skin picking, and . Ann Clin Psychiatry. etine in the treatment of pathological skin picking. Can J 2005;17:227-232. Psychiatry. 2004;49:788-789.

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