SKINIPEDIA - Skin Diseases: Neurotic Skin Excoriations
Neurotic Skin Excoriations by: Noah S Scheinfeld, MD, JD, FAAD, Assistant Clinical Professor, Department of Dermatology, Columbia University; Consulting Staff, Department of Dermatology, St Luke's Roosevelt Hospital Center, Beth Israel Medical Center, New York Eye and Ear Infirmary; Private Practice
Neurotic Skin Excoriations: Medical Care
Medication
Neurotic excoriations are treated with a variety of psychotropic medications. The doses can be lower than those used in treating depression, and the medications can act more quickly.
Using hypnosis to facilitate resolution of psychogenic excoriations in acne excoriée has been reported.
Olanzapine may be an effective adjunctive therapy in the management of acne excoriée. Paroxetine was reportedly effective in a case of psychogenic pruritus and neurotic excoriations.
Antipsychotic agents
Decrease the urge to scratch and relieve anxiety.
Doxepin (Sinequan)
Inhibits histamine and acetylcholine activity and has proven useful in the treatment of various forms of depression associated with chronic and neuropathic pain.
10-25 mg PO qhs
Pediatric
Not commonly used
<12 years: Not recommended
>12 years: 10 mg qhs
Decreases antihypertensive effects of clonidine but increases effects of sympathomimetics and benzodiazepines; effects of desipramine increase with phenytoin, carbamazepine, and barbiturates
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Caution in cardiovascular disease, conduction disturbances, seizure disorders, urinary retention, and hyperthyroidism; caution in patients receiving thyroid replacement
Antianxiety agents
Used to reduce the level of anxiety in patients who experience pruritus.
Buspirone (BuSpar)
A 5-HT1 agonist with serotonergic neurotransmission and some dopaminergic effects in CNS. Has anxiolytic effect but may take up to 2-3 wk for full efficacy.
Adult
15 mg PO qd/tid
Pediatric
Not established
Documented hypersensitivity
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Caution in hepatic or renal impairment
Antidepressant agents
May be used to improve mood and to restore normal sleep patterns in patients who experience pruritus.
Fluoxetine (Prozac)
Selectively inhibits presynaptic serotonin reuptake with minimal or no effect in the reuptake of norepinephrine or dopamine.
Adult
20 mg PO qd
Pediatric
<18 years: Not established; initial doses of 20 mg/d in children 6-14 y have been used
>18 years: Administer as in adults
Increases toxicity of diazepam and trazodone by decreasing clearance; also increases toxicity of MAOIs and highly protein bound drugs; serotonin syndrome (ie, myoclonus, rigidity, confusion, nausea, hyperthermia, autonomic instability, coma, eventual death) occurs with simultaneous use of other serotonergic agents (eg, anorectic agents, tramadol, buspirone, trazodone, clomipramine, nefazodone, tryptophan); discontinue other serotonergic agents at least 2 wk prior to SSRIs
Documented hypersensitivity; concurrently taking MAOIs or have taken them in the last 2 wk
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Caution in hepatic impairment and history of seizures; discontinue MAOIs at least 14 d before initiating therapy
Topical cortisone agents
Have anti-inflammatory properties and cause profound and varied metabolic effects. Corticosteroids modify the body's immune response to diverse stimuli.
Triamcinolone topical (Aristocort)
Treats inflammatory dermatosis that is responsive to steroids. Decreases inflammation by suppressing the migration of polymorphonuclear leukocytes and reversing capillary permeability.
Adult
Apply thin film bid/tid until favorable response obtained
Pediatric
Apply as in adults with caution
Documented hypersensitivity; fungal, viral, and bacterial skin infections
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Do not use in decreased skin circulation; prolonged use, applying over large areas, and using potent steroids and occlusive dressings may result in systemic absorption; systemic absorption may cause Cushing syndrome, reversible HPA-axis suppression, hyperglycemia, and glycosuria
Antiepileptic agents
Decrease impulsiveness.
Topiramate (Topamax)
Sulfamate-substituted monosaccharide with broad spectrum of antiepileptic activity that may have state-dependent sodium channel blocking action. Potentiates inhibitory activity of GABA. May block glutamate activity.
Not necessary to monitor plasma concentrations to optimize therapy. On occasion, addition of topiramate to phenytoin may require phenytoin dose adjustment to achieve optimal clinical outcome.
50 mg/d and titrate by 50 mg/d at 1-wk intervals to target a dose of 200 mg bid; not to exceed 1600 mg/d
Pediatric
Not established
Neurotic Skin Excoriations, Medications, Part V
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