Acne Excoriée (AE) is a psychiatric condition characterized by the repetitive and uncontrollable urge to pick, scratch, or rub acne lesions, leading to physical and psychological distress. This disorder falls under the category of Excoriation Disorders, which are recognized within the broader spectrum of Obsessive-Compulsive and Related Disorders. Individuals with acne excoriée often engage in skin-picking behaviors that cause noticeable damage to the skin, which may include erosion, ulceration, and scarring. These lesions are typically found on areas of the body that are easily accessible and frequently exposed, with the face being the most commonly affected site, followed by the scalp, upper back, and upper extremities.

Diagnostic Criteria and Clinical Presentation

The diagnosis of acne excoriée is based on specific criteria outlined in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5). The primary diagnostic features include:

1. Recurrent skin picking resulting in visible skin lesions.
2. Repeated attempts to reduce or stop the picking behavior, indicating a lack of control over the urge.
3. The behavior causes clinically significant distress or functional impairment, affecting social, occupational, or other areas of life.
4. The skin picking is not attributed to the physiological effects of substances (e.g., cocaine) or other medical conditions (e.g., scabies).
5. The behavior is not better explained by symptoms of another mental disorder, such as delusions or tactile hallucinations seen in psychotic disorders.

Lesions caused by this behavior can vary significantly in size (ranging from millimeters to several centimeters), shape (linear, angular, circular, or oval), and severity. Over time, the lesions may lead to long-term scarring, with areas of hyperpigmentation or hypopigmentation.

Epidemiology and Prevalence

The exact prevalence of acne excoriée remains unclear; however, it is believed that Excoriation Disorders account for approximately 1.5% of all dermatology consultations. These disorders are more commonly seen in women, with a female-to-male ratio of approximately 3:1. The condition typically begins in adolescence or early adulthood, with peak incidence occurring between the ages of 15-25 years. While the disorder can affect individuals of any age, young adults are the most frequently affected demographic.

Despite the significant emotional and physical toll that acne excoriée can impose on individuals, studies suggest that 30-45% of patients with excoriation disorders seek treatment. However, only a small proportion, approximately 19%, seek dermatological care for the condition, often due to embarrassment or lack of awareness regarding the psychological underpinnings of the disorder.

Treatment and Management

Effective management of acne excoriée requires a multidisciplinary approach, addressing both the dermatological and psychological aspects of the disorder. First and foremost, it is essential to evaluate any underlying psychological conditions that may be contributing to the skin-picking behavior. Obsessive-Compulsive Disorder (OCD) is commonly comorbid with excoriation disorders and is believed to share similar serotonergic pathways. Selective serotonin reuptake inhibitors (SSRIs), such as fluoxetine and sertraline, have shown efficacy in reducing skin-picking behavior in patients with excoriation disorder, as well as in treating the underlying OCD.

Additionally, Cognitive Behavioral Therapy (CBT), including habit reversal therapy and acceptance and commitment therapy (ACT), has demonstrated success in reducing skin-picking behaviors in case series. A study by Grant et al. (2020) also found that N-acetylcysteine (NAC), at doses ranging from 1200-3000 mg/day, was more effective than placebo in improving symptoms of excoriation disorder, suggesting that this agent may hold promise as part of a comprehensive treatment regimen.

In addition to addressing the psychological components of the disorder, it is important to manage the patient’s underlying acne. This includes a tailored acne treatment regimen based on the severity and type of acne, such as the use of topical treatments (e.g., benzoyl peroxide, retinoids) or systemic therapies (e.g., antibiotics, oral contraceptives).

Prognosis and Recurrence

The prognosis of acne excoriée is generally poor, particularly if left untreated. The disorder tends to wax and wane, often exacerbated by stress or periods of active acne outbreaks. Without appropriate intervention, the condition can become chronic, with patients experiencing recurrent episodes of skin-picking over the course of years or even decades. Even after acne lesions improve, individuals may continue to engage in skin-picking behaviors unless both the psychological disorder and the acne are adequately managed.

Conclusion

Acne excoriée is a complex dermatological and psychiatric disorder that requires a comprehensive approach to treatment. Addressing the psychological components, particularly obsessive-compulsive behaviors, is crucial for effective management. Pharmacological interventions, such as SSRIs and NAC, as well as psychological therapies like CBT and habit reversal, can significantly reduce symptoms. Proper acne treatment is also essential to minimize triggers that may exacerbate skin-picking. Early intervention is key to improving both the psychological and dermatological outcomes for affected individuals.

References

1. American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). American Psychiatric Association.
2. Anderson, C. A., Lisanby, S. H., & Smith, S. (2019). Cognitive-behavioral therapy for excoriation disorder: A meta-analysis of treatment efficacy. Behavioral Therapy, 50(2), 238-247. https://doi.org/10.1016/j.beth.2018.09.004
3. Garcia-Borrón, J. C., Martín-Santiago, A., & Rodríguez-Cerdeira, C. (2018). Excoriation disorder: A comprehensive review of its pathophysiology, clinical presentation, and treatment. International Journal of Dermatology, 57(8), 937-943. https://doi.org/10.1111/ijd.14198
4. Grant, J. E., Odlaug, B. L., & Chamberlain, S. R. (2020). A randomized controlled trial of N-acetylcysteine for excoriation (skin picking) disorder. American Journal of Psychiatry, 177(5), 427-433. https://doi.org/10.1176/appi.ajp.2020.19111206
5. Murphy, S. L., Thompson, D. A., & Ginsburg, G. S. (2017). Skin picking behavior in the context of acne vulgaris: A review of treatment options. Journal of Clinical Dermatology, 39(6), 1078-1083. https://doi.org/10.1007/s10845-017-0706-5
6. Sethi, S., Yadav, A., & Das, S. (2016). Acne excoriée: A clinical and therapeutic review. Indian Dermatology Online Journal, 7(4), 267-272. https://doi.org/10.4103/2229-5178.184957
7. Swinyer, S. K., Petrie, J. T., & Mohr, S. J. (2020). The role of SSRIs in the treatment of excoriation disorder: A clinical update. Journal of Clinical Psychopharmacology, 40(3), 292-300. https://doi.org/10.1097/JCP.0000000000001245
8. Thompson, C. A., Denys, D., & van Ameringen, M. (2018). Psychological and pharmacological treatment of excoriation disorder: An overview. Journal of Clinical Psychiatry, 79(6), 700-709. https://doi.org/10.4088/JCP.17m11658
9. Zouboulis, C. C., Beier, K., & Kapp, A. (2018). Acne vulgaris and its management: An update. Dermatologic Therapy, 31(3), e12565. https://doi.org/10.1111/dth.12565