COMMUNICATIONS AND BRIEF REPORTS Treatment of Facial Scarring and Ulceration Resulting from Acne Excorie´e with 585-nm Pulsed Dye Laser Irradiation and Cognitive Psychotherapy L EYDA E. B OWES , MD, AND T INA S. A LSTER , MD Washington Institute of Dermatologic Laser Surgery, Washington, DC Self-inflicted skin ulcers and scars are often observed in patients with compulsive skin picking. The term ‘‘neurotic excoriation’’ has been used to describe this condition and may or may not coexist with other true skin pathologies, such as acne. The condition poses a diagnostic and treatment challenge because patients often also have an undiagnosed underlying psychologic disorder. CASE REPORTS. Two patients with numerous linear and stellate facial ulcers and hypertrophic and erythematous scars were diagnosed with acne excorie´e in the setting of an obsessivecompulsive disorder linked to emotional stress and anxiety. The scars were treated with a 585-nm flashlamp-pumped pulsed dye laser using a 7-mm spot size, 1.5-msec pulse duration, and BACKGROUND. fluence range of 4.5 to 6.0 J/cm2. The patients received concomitant cognitive psychodynamic therapy to halt the cycle of impulse-driven skin picking and ulcer/scar formation. Marked clinical improvement of the scars and successful treatment of the acne excorie´e were achieved with this combination approach. Relapses occurred when psychodynamic intervention was interrupted. CONCLUSION. The 585-nm flashlamp-pumped pulsed dye laser improves the appearance of hypertrophic erythematous facial scars and ulcers in patients with severe acne excorie´e. Proper diagnosis of underlying impulse-control disorders and ongoing psychodynamic therapy is necessary to maintain improvement. LEYDA E. BOWES, MD, AND TINA S. ALSTER, MD HAVE INDICATED NO SIGNIFICANT INTEREST WITH COMMERCIAL SUPPORTERS. THE PSYCHOCUTANEOUS disorders span a vast range of entities from primary skin conditions known to have psychologic sequelae (e.g., psoriasis, pemphigus, alopecia, acne vulgaris) to psychologic or psychiatric conditions resulting in severe skin morbidity.1 The latter group of psychiatric conditions with skin manifestations are difficult to diagnose and are often misdiagnosed. Commonly, these ‘‘psychodermatoses’’ are grouped into one broad category generally known as ‘‘neurotic excoriations.’’2 This designation conflicts with the proper identification of true psychologic disorders from which the patient may suffer and limits the extent and proper selection of required treatment modalities. Neurotic excoriation (also referred to as psychogenic excoriation, compulsive skin picking, dermatotillomania, and acne excorie´e) is characterized by excessive picking and scratching of normal skin or skin with minimal surface texture irregularities.3 This condition affects up to 2% of patients in dermatology clinics and leads to marked functional disability, further emotional distress, and medical complications (infections, limb loss, severe bleeding).2 Address correspondence and reprint requests to: Tina S. Alster, MD, Washington Institute of Dermatologic Laser Surgery, 2311 M Street, NW, Suite 200, Washington, DC, or e-mail: [email protected]. Acne excorie´e has received special attention by pediatricians and mental health professionals because of the underlying presence of obsessive-compulsive personality and body dysmorphic disorders affecting most patients with severe excoriations.4–10 Treatment of this entity has repeatedly proven to be challenging.2 Patients often develop disfiguring ulcers and scars as a result of uncontrollable skin picking. This further aggravates the situation, because much of the skin mutilation stems from the patient’s falsely perceived imperfection or ugliness. We report our experience with two patients who developed disfiguring facial ulcers and scars resulting from uncontrollable skin picking of mild or ‘‘presumed’’ acne lesions. The patients were successfully treated with a combination approach that consisted of acne-specific pharmacotherapy, 585-nm pulsed dye laser scar revision, and psychotherapeutic intervention to address and modify the obsessive-compulsive behavior. Case 1 A 38-year-old woman presented for treatment of facial acne vulgaris. The patient stated that she had suffered from cystic acne for 10 years and had undergone excision of atrophic acne scars 4 years prior. The r 2004 by the American Society for Dermatologic Surgery, Inc. Published by Blackwell Publishing, Inc. ISSN: 1076-0512/04/$15.00/0 Dermatol Surg 2004;30:934–938 Dermatol Surg 30:6:June 2004 BOWES AND ALSTER: FACIAL SCARRING AND ULCERATION RESULTING FROM ACNE EXCORIE´E patient expressed her concern about the worsening of her acne over the preceding year. She was using overthe-counter herbal and natural remedies to treat her acne; however, she noted that these substances would often irritate her skin. She admitted to occasional picking of her skin. The patient related a medical history significant for migraine headaches, asthma, high blood pressure, and irritable bowel syndrome for which she was receiving medical treatment. Evaluation and Treatment The patient appeared underweight for her age, sex, and height. Examination of her facial skin revealed scattered excoriated and crusted papules and sharply bordered, stellate ulcers on the cheeks. Linear and angular fibrotic hypertrophic and atrophic scars were also present on the cheeks and brow (Figure 1). A diagnosis of acne excorie´e was made and treatment was initiated with oral doxycycline (100 mg daily) and twice daily application of 1% clindamycin solution pledgets to the face and mupirocin ointment to the ulcers. An additional 1-week course of ciprofloxacin (500 mg twice daily) was prescribed to eradicate bacteria cultured from within the ulcers. The importance of cessation of the skin-picking behavior was stressed to the patient. Within 1 month, the acne lesions improved on the prescribed regimen and the facial ulcers decreased in size and depth. Two weeks later; however, the patient presented with larger and new facial ulcers and erythematous scars from excoriated acne lesions. A therapeutic redirection was undertaken and focus was placed on treatment of the new disfiguring erythematous scars with a 585-nm pulsed dye laser, as well as 935 addressing the psychologic factors underlying the patient’s impulsive skin picking. Treatment with the 585-nm Flashlamp-Pumped Pulsed Dye Laser A 585-nm flashlamp-pumped pulsed dye laser (Sclerolaser, Candela Laser Corp., Wayland, MA) was used to treat the erythematous and hypertrophic scars, as well as the excoriated ulcers at fluences ranging 4.5 to 6.0 J/ cm2 (7-mm spot size, 1.5-ms pulse duration). A total of three treatments were performed at 6-week time intervals. The patient tolerated the treatments well and no complications were encountered. Psychodynamic Therapy The patient reported significant family tension in her life that was relieved by picking her facial skin, particularly any acne lesions present. The behavior would persist for several days to weeks until total elimination of the acne lesion had been perceived. The situation was exacerbated in the presence of mirrors, in which the lesions and/or their remains were regularly scrutinized. Large deep ulcers, such as those present on her initial exam, were thus effected. In view of the situation, basic psychodynamic intervention and counseling was initiated during her primary dermatologic consultation. The patient was also referred to a psychotherapist who implemented behavior modification techniques (e.g., avoidance of unnecessary situations of conflict, removal of mirrors from the house) and cognitive psychotherapy to alleviate her ailment. The patient was made aware of the genesis of her skin picking habit and was suggested new coping mechanisms to resolve her conflicts and more appropriately channel her feelings of frustration or anxiety. Results Figure 1. Linear and angular fibrotic hypertrophic and atrophic scars before treatment Patient evaluation after initiation of psychotherapy and pulsed dye laser scar treatment revealed complete healing of all ulcers and improved skin color and texture with increased pliability of facial scars (Figure 2). The patient was pleased with the results, motivating her to pursue continued therapy. Several months later, however, the patient again presented with a new deep facial ulcer on her cheek without evidence of acne (Figure 3). Old scars from previous ulcers had remained pliable and smooth. Treatment at this time was aimed at wound care with dilute acetic acid compresses to the ulcer base, followed by application of mupiricin ointment and occlusion with thin Duoderm dressing. The latter was performed to promote formation of healthy granulation tissue and 936 BOWES AND ALSTER: FACIAL SCARRING AND ULCERATION RESULTING FROM ACNE EXCORIE´E Figure 2. Improvement seen after 585-nm pulsed dye laser treatment. Figure 3. New excoriations and sharp bordered ulcers seen in absence of acne. Dermatol Surg 30:6:June 2004 Figure 4. Angular scars and ulcers before treatment Figure 5. Clinical improvement after 585-nm pulsed dye laser treatment. Evaluation and Treatment to prevent further manipulation of the ulcer by the patient. The patient was strongly encouraged to continue her psychotherapy sessions, having apparently missed several appointments in the preceding weeks. Multiple hypertrophic linear and stellate scars were present on the cheeks and chin (Figure 4). No acneiform lesions were evident, but several excoriations were observed in facial areas in which the patient reported ‘‘early’’ acne lesions. The patient was counseled to avoid further manipulation of the areas with an agreement to initiate laser scar revision only after she had been ‘‘excoriation free’’ for 1 month. Case 2 A 54-year-old woman reported an 18-month history of acne; she admitted to picking, both with her fingers and using a variety of cosmetic instruments. She had used silicone gel and topical and oral antibiotics without significant improvement. A psychiatric evaluation revealed obsessive-compulsive disorder and depression for which she was placed on Effexor. Pulsed Dye Laser Treatment Treatment was begun 1 month thereafter using a 585nm pulsed dye laser at 4.5 J/cm2 (10-mm spot, 1.5-ms pulse duration). An additional three treatments at 5.0 J/cm2 were delivered at 6-week time intervals with progressive clinical improvement seen (Figure 5). No Dermatol Surg 30:6:June 2004 BOWES AND ALSTER: FACIAL SCARRING AND ULCERATION RESULTING FROM ACNE EXCORIE´E recurrence of the obsessive picking disorder was encountered 6 months after the final laser session, with the patient remaining on antidepressants and outpatient psychotherapy. Discussion Patients with acne excorie´e resulting in disfiguring facial ulcers and scars pose a true treatment challenge to the physician. On physical examination, excoriations, ulcers, and a range of early and late scars are often present, providing a visual timeline of the disorder. There commonly exists at least one comorbid psychiatric diagnosis, such as obsessive-compulsive personality disorder or body dysmorphic disorder,8,9 rendering multimodal (dermatologic and psychiatric) treatment a necessity. Special emphasis should thus be placed on interrupting the repetitive cycle of events that perpetuates this psychodermatosis. The psychologic illness affecting many of these patients can be managed with behavior modification psychotherapy and/or oral pharmacologic agents.3 In two separate series of patients with psychogenic excoriations, the most common body site of skin picking was the face and/or areas with pimples and scabs.8,9 Behavioral techniques such as ‘‘habit reversal’’ (a multicomponent program that consists of selfmonitoring, with recordation of scratching episodes and procedures that outline alternative responses to scratching) and ‘‘eclectic’’ psychotherapy programs with insight-oriented components and behavior modification can be used to eliminate or reduce the skin picking compulsion.3,10 While psychotherapy is sufficient in many cases, providing the patient with the appropriate guidance and tools necessary to identify possible anxiety- or compulsion-triggering factors and the ability to modify them, it may fall short for disorders where chemical imbalance plays a role. In these latter cases, combination therapy with pharmacologic agents is necessary.3 The term psychodermatology is used herein to describe a combined treatment approach whereby the psychologic and dermatologic issues are addressed. From the dermatologic point of view, active acne vulgaris lesions, as well as the excoriations, ulcers, and scars, should be treated simultaneously. Nonirritating topical antibiotics as well as oral antibiotics should be prescribed for any observable acne and/or secondarily infected excoriations or ulcers. Semiocclusive protective dressings are particularly helpful in preventing further trauma and excoriations of the areas from compulsive skin picking. The use of isotretinoin may not be safe in these patients owing to the possibility of continued excoriations and the known detrimental 937 effect of isotretinoin on wound healing. Compliance requirements and the need for close laboratory monitoring also serve as deterrents to isotretinoin use in these patients. Finally, the resultant scars can be safely and effectively treated with a 585-nm pulsed dye laser. A variety of erythematous, atrophic, hypertrophic, and keloid scars have been shown to respond favorably to 585-nm pulse dye laser irradiation.11–26 The improvement of hypertrophic scars following treatment with a pulsed dye laser was first demonstrated in argon laser-induced fibrosis in port-wine stains.11 Subsequent studies of patients with erythematous facial acne scars who received one to two treatments with a pulsed dye laser also revealed significant improvement in skin texture and erythema.15 The positive effect of pulsed dye laser irradiation on hypertrophic surgical scars, either alone12–14 or in combination with intralesional corticosteroids as adjunctive therapy,26 has also been demonstrated. Studies have shown a dependence of scar response on the wavelength, fluence, and number of treatments applied, with the 585-nm wavelength, lower fluences (3–5 J/cm2), and repeat treatments (42) leading to the most favorable response.21,27 Even atrophic scars and rhytides have shown improvement after pulsed dye laser irradiation.20,22,23 Microvasculature-specific pulsed dye laser irradiation has been postulated to potentially lead to release of growth factors (e.g., platelet-derived growth factor) from the blood vessels into the dermal milieu, eliciting a cascade of events that culminate in fibroblast activation and enhanced dermal collagen deposition.25 Such events could also explain, at least in part, the reduction in depth and size of atrophic acne scars noted after pulsed dye laser treatment.23 Therefore, a 585-nm pulsed dye laser may play a superior role in the treatment of facial acne and traumatic scars, because the coexistence of the hypertrophic, erythematous, and atrophic components can each be effectively treated with the same laser. Although other treatments for facial scars that result from trauma and/or acne are available, including dermabrasion, chemical peels, and ablative CO2 or erbium:YAG laser resurfacing, each of these treatments involve a degree of injury to the epidermis and dermis that may not be suitable for patients with acne excorie´e. The uncontrollable skin picking habits of acne excorie´e patients may severely impair the wound healing process and could lead to further scarring and secondary infection. In view of the possible risks inherent to these treatments and the distinct possibility of patient exacerbation of the problem, 585-nm pulsed dye laser irradiation may be a preferable treatment choice for the scars and ulcers seen in these cases. 938 BOWES AND ALSTER: FACIAL SCARRING AND ULCERATION RESULTING FROM ACNE EXCORIE´E In conclusion, when treating a patient with acne excorie´e, it is important to identify any underlying psychologic disorder that could account for the skin picking behavior. Early and ongoing psychotherapeutic intervention will increase the likelihood of more effective management of this complex psychodermatosis. Additionally, synchronous implementation of a skin treatment regimen will provide faster resolution of lesions which will, in turn, improve the patient’s self-image, decrease the risk of further skin manipulation, and render behavior modification more effective. References 1. Folks DG, Warnock JK. Psychocutaneous disorders. Curr Psychiatry Rep 2001;3:219–25. 2. O’Sullivan RL, Phillips KA, Keuthen NJ, Wilhelm S. Near-fatal skin picking from delusional body dysmorphic syndrome responsive to fluvoxamine. Psychosomatics 1999;40:79–81. 3. Arnold LM, Auchenbach MB, McElroy SL. Psychogenic excoriation: clinical features, proposed diagnostic criteria, epidemiology and approaches to treatment. CNS Drugs 2001;15:351–9. 4. Koo JY, Smith LL. Psychologic aspects of acne. Pediatr Dermatol 1991;8:185–8. 5. Koo JY, Smith LL. 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