Excoriation disorder (ED) and skin-centered body dysmorphic disorder (BDD) are underrecognized in dermatology clinics and should suggest psychiatric interventions, according to the results of a study published in Dermatologic Therapy.
Although approximately 30% to 40% of patients who see a dermatologist have underlying psychological disorders that affect or cause the presenting skin disorders, the mental health component is often left unaddressed, the researchers noted. It is important that dermatologists are able to appropriately diagnose skin-centered BDD and ED and to educate patients on the necessary psychiatric component of effective treatment as both are associated with increased morbidity and BDD is associated with increased suicide risk. The perpetuation of these disorders is inevitable without appropriate psychiatric intervention, the investigators believe.
ED is a well-known form of chronic pathological skin picking affecting up to 5.4% of the general population and is characterized by the compulsive squeezing, rubbing, pulling, abrading, or tearing of the skin. Patients with ED are typically motivated to habitual or compulsive skin picking by the relief from anxiety that is derived by the removal and disposal of the skin lesion or scab. The majority of those with this disorder are women, most commonly middle aged. Although ED patients often have true underlying skin disorders, their lesions may not appear consistent with the primary morphology, it was pointed out. The distribution of lesions in patients with ED is primarily on accessible areas such as the face, scalp, dorsal hands, forearms, buttocks, and uppermost portion of the back, often in places that can be hidden by clothing. Due to the hidden nature of ED lesions, a full examination is important for ED diagnosis.
Skin-centered BDD is characterized by the excessive preoccupation with a perceived defect in the appearance of the patient’s skin. Skin picking is meant to improve the perceived imperfection, but often worsens the issue and creates a feedback loop. Most individuals with skin-centered BDD are women who have true acne vulgaris. As the study explained, patients with skin-centered BDD often are also diagnosed with mood and anxiety disorders and often experience significant impairment in psychosocial functioning, have reduced quality of life, and have higher suicide rates. Patients with skin-centered BDD may or may not be delusional about their perceived skin defect and may develop ED.
ED can result in mild to disfiguring skin lesions that can worsen any underlying skin disorders and increase underlying anxiety. Medical management of the underlying skin condition may improve ED but will not address the root of the maladaptive behavior. That is why, the investigators said, without addressing the underlying psychiatric disorder, medical management of the presumed skin condition may become excessive and ineffective. Current psychiatric therapies for ED include psychoeducation and cognitive behavioral therapy. Management of BDD is similar to that of ED but may also include selective serotonin reuptake inhibitors (SSRIs).
Patients with both conditions are likely to present to dermatology and are unlikely to openly divulge their symptoms and behavior, the study authors acknowledged. Therefore, dermatologists should screen any patient with an atypical morphological presentation or treatment-resistant skin condition for ED or skin-centered BDD. The researchers encourage dermatologists “to act as health advocates in explaining and validating the reasons for a psychiatric approach.”
McDonald A, Jafferany M, Rohani K. Excoriation disorder vs skin-centered body dysmorphic disorder: A clinical and therapeutic update. [published online July 7, 2020]. Dermatological Therapy. doi:10.1111/dth.13994