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7.2.4 Obsessive-compulsive skin disorders
ICD-11
6B20.Z
Synonyms
Obsessive–compulsive neurotic skin disorders.
Epidemiology
Estimated prevalence in adults: 2.3%. Age of onset: 19.5 years.
Persistent disorder for years (mean of 8.9 years).
Excoriation disorder: 1-5% of the population. Female preponderance.
Onset at adolescence (most common), or adulthood (30 -45 years of age).
Body-focused repetitive behavior disorder. Prevalence onychophagia (nail biting): 25-60%.
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The estimated prevalence of obsessive-compulsive disorders among adults in USA is 2.3% with a mean age of onset: 19.5 years (males before and females after the age of 10). The disorder often persists for years (mean of 8.9 years). Some culturally specific variants exist.
Excoriation disorder affects 1% to 5% of the population with a female preponderance. The onset is frequently at childhood, adolescence (most common), or adulthood (30-45 years of age).
Body-focused repetitive behaviour disorders: onychophagia has a prevalence of 25-60% with a peak during puberty.
Definition
Group of dermatoses secondary to a chronic psychiatric disorder characterized by obsessions and compulsions.
Excoriation disorder (neurotic excoriations): Repetitive picking of skin resulting in noticeable tissue damage.
Body-focused repetitive behaviors: onychophagia, dermatophagia, onychotillomania (nail picking), trichotillomania, cheek/lip biting, nose/ear picking, and knuckle cracking.
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Group of dermatoses secondary to a chronic psychiatric disorder characterized by obsessions and compulsions.
Obsessions: Uncontrollable distressful thoughts.
Compulsions: Recurrent behaviours or thoughts performed in an attempt to decrease the anxiety of the obsessions.
Excoriation disorder (neurotic excoriations) or pathological skin picking: repetitive picking of skin resulting in noticeable tissue damage.
Body-focused repetitive behaviours include: onychophagia (nail biting), dermatophagia, onychotillomania (nail picking), trichotillomania, cheek/lip biting, nose/ear picking, and knuckle cracking.
Aetiology & Pathogenesis
Obsessive-compulsive and related disorders is a category of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5).
Body-focused repetitive behaviors are included under ‘‘unspecified OCRD’’ in DSM-5.
Some OC related-skin and hair disorders, such as trichotillomania (see chapter 7.2.1)
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Obsessive-compulsive and related disorders is a category of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5).
This category also includes:
Body dysmorphic disorder (BDD), and conditions such as trichotillomania, excoriation disorder (skin-picking), hoarding disorder, substance/medication-induced obsessive-compulsive and related disorder and other body-focused repetitive behaviors (e.g., cheek chewing, cuticle pulling, among others).
Body-focused repetitive behaviors are included under ‘‘unspecified OCRD’’ in DSM-5.
Some OC related-skin and hair disorders, such as trichotillomania (see Chapter 7.2.1/2).
Signs & Symptoms
Excoriation disorders:
-Grouped erosions at easily accessible sites. Picking over areas of acne, scars, scabs, or insect bites.
-Acne excoriee: Acne lesions are scratched and picked.
Body-focused repetitive behavior disorder. Variable clinical features such as:
Nail biting: paronychia and gingival injuries.
Rubbing of the proximal nail fold: nail matrix damage.
Chronic biting of the skin: localized thickened plaques (lichenification).
Cheek biting: transverse whitish ridges in the oral mucosa (morsicatio buccorum).
Repeated attempts to decrease or stop skin picking
Associated psychopathology (depression, anxiety, or stress).
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Excoriation disorders:
Grouped erosions at easily accessible sites.
Picking over areas of acne, scars, scabs, or insect bites.
Skin lesions and scars show angulated borders.
Acne excoriée: acne lesions are scratched and picked.
Body-focused repetitive behavior disorder: variable clinical features such as:
Severe nail biting (may cause paronychia and gingival injuries); rubbing of the proximal nail fold and cuticle may result in nail matrix damage.
Chronic biting of the skin can cause localized thickened plaques (lichenification).
In cheek biting, transverse whitish ridges in the oral mucosa are noted (morsicatio buccorum).
Repeated attempts to decrease or stop skin picking. Associated psychopathology (depression, anxiety, or stress).
Psychiatric co-morbidities include body dysmorphic disorder, substance use, and borderline personality disorder.
Localisation
Acne excoriee: frequent facial involvement.
Body-focused repetitive behavior disorder: nails, fingers, oral mucosa, lips. Accessible skin areas.
Classification
Secondary infection, bleeding, and inflammation.
Laboratory & other workups
No abnormalities.
Dermatopathology
Cutaneous ulceration without or minor associated inflammatory infiltrates.
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Cutaneous ulceration without or minor associated inflammatory infiltrates. Sometimes a skin biopsy may be useful in order to rule out an underlying excoriated itchy dermatosis.
Course
Chronic. Waxing and waning evolution.
Complications
Secondary infection, bleeding, and inflammation.
Diagnosis
DSM-5 diagnostic criteria.
Differential Diagnosis
Psychogenic pruritus. Primary psychiatric disorders with secondary excoriations (e.g. delusional infestation or tactile hallucinations).
Skin picking secondary to the physiological effects of a substance (e.g. cocaine) or a medical condition (e.g. scabies).
The differential diagnosis of cheek biting includes oral candidiasis, lichen planus and white sponge nevus.
In nail biting: nail dystrophy, nail matrix damage and mycotic infections.
Prevention & Therapy
Cognitive-behavioral therapy (CBT) and habit reversal training.
Anti-depressive and anti-psychotic agents are helpful by treating underlying anxiety.
N-acetylcysteine 1200 to 3000 mg/ day may reduce skin picking.
In patients with acne excoriee: Additional appropriate acne treatment.
Special
Approximately 90% of individuals with OCD have other psychiatric co-morbidities. The most common co-morbid disorder in OCD is anxiety disorders, depression, impulse control and substance use disorders. The co-morbidity of OCD and depression significantly increases the risk of suicide.
Review Articles
References
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