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Neurotic Excoriations


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ThinkkerDM

So to be clear - 

9m chronic condition and you would like to send to the ER?

 

Already on an antihistamine so titration unlikely help

 

 

In answer to OP

Ddx - gotta have scabies in the Ddx - I have treated a few of these people (just to rule and it) and tada they get better....

 

I would try a good moisturizing cream

review meds they are on carefully to ensure not a med side effect

make sure and double sure they are not doing cocaine

could try OTC steroid ointment

 

 

Psych consult

Derm consult

 

 

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I would send to the ED for the fact it is a skin condition.  Heh.   Ohh- you thought I meant emergency department; I meant excoriation department.  Humor is not my best at any time, and especially not this early.  

But back to reality: based on the fact it is a "neurotic excoriation", I am figuring the work up has excluded most everything else.  Starting on the legs is a bit weird.  So, the antihistamine currently is- most likely 2nd generation.  I use hydroxyzine a lot for anxiety.  It may help.

Make sure the SSRI is at the most effective dose; you could try buspirone.  

UDS may be negative on a first run, and make sure it includes meth and byproducts.  Steroid creams are nice but if moderate intensity or above, remind them about time limits.  

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10 hours ago, thinkertdm said:

I would send to the ED for the fact it is a skin condition.  Heh.   Ohh- you thought I meant emergency department; I meant excoriation department.  Humor is not my best at any time, and especially not this early.  

  

Ahhh now I get it!!!  I guess I am a little slow on the uptake.....

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Derm will do a few things: 1.) Culture to R/O secondary infection 2.) Maybe take a small bx to prove nothing else is going on 3.) Prescribe high potency steroid ointment to be applied under occlusion BID for a couple weeks; encourage pt to keep nails trimmed short and keep the skin covered as much as possible 4.) Recommend ongoing evaluation/care w/psych

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Don't forget autoimmune issues - check thyroid antibodies, especially in women.

Think food allergy or work environment - used to treat a ton of cops with fungal dermatitis from heavy, hot kevlar vests that never got washed or dried properly.

I get a fabulous and impressively uncomfortable rash on my legs from knapweed that grows in our acreage and hits my legs if in shorts.

Dermatology mantra - if it's wet - dry it - if it's dry - wet it.

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On 9/8/2019 at 3:22 PM, ohiovolffemtp said:

@SteakPA: what was the dosing of the NAC?  Were you recommending the OTC dietary supplement?  How long before the patient began to notice a difference if it was going to work for them?

Thanks!

Yes, OTC NAC qday. I don't personally have experience with recommending it (I'm a new grad going into CT surg so far far from this specialty of medicine). I saw a patient back after recommending it during my rotation and they said even within a few days it was helpful.

Of course, as others have mentioned in detail, ruling out other causes is important but this is a relatively inexpensive way to potentially give some relief if you truly feel the excoriations are caused by picking due to anxiety.

Edited by steakPA
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