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Neurotic Excoriations

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How to successfully treat  Neurotic Excoriations!!!  9 month history originally on both lower legs now upper back and chest.  Any thoughts?  On anti deppressent  "to calm the nerves" from making skin itchy and an anti histamine.  Not seen a derm yet.  Thanks

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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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Clip nails

Socks on hands

Check UDS for meth - they get heebie jeebies and scratch all over

Check for scabies - family or bed partner with same

Hibiclens in shower to prevent secondary infection

Hydroxyzine for itching and anxiety

Clomipramine for OCD tendencies

Psych for root cause investigation and therapy

Rinse, repeat

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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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25 minutes ago, ventana said:

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

It was a little play on the “send every one to the Ed”

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Evaluate for superinfection.  One way to tell that it is really neurotic excoriation is to make sure the lesions are only in places easily accessible to the patient's hands.

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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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@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!

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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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