Psychosomatics 43:251-252, June 2002
© 2002 The Academy of Psychosomatic Medicine
Psychogenic Excoriation and Cancer
Olu Osaba, M.D., Detroit, Michigan, and
Greg Mahr, M.D.
Key Words: Risperidone • Sialorrhea
TO THE EDITOR: Psychogenic excoriation has been described as a syndrome of repetitive picking and scratching of skin in the absence of any underlying dermatologic disease.1 Although not formally included in the DSM-IV, psychogenic excoriation has been categorized as an impulse control disorder.2 Impulse control disorders are known to produce dermatologic pathology.3 The authors describe an unusual case of psychogenic excoriation that may have led to a squamous cell carcinoma of the external ear.
Ms. C is a 52-year-old Caucasian married but separated female who was referred to the consultation liaison service by the otolaryngology service for a 6-month history of recurrent external ear infections.
Ms. C was in her normal state of health until 6 months prior to presentation. At that time, she noticed an increased sensitivity of the skin surrounding her left ear. This was subsequently followed by a large amount of pain and swelling in the same ear. She was diagnosed with an external ear infection and prescribed several courses of antibiotics. Her symptoms appeared to resolve but later recurred with discontinuation of the antibiotics. At the time of admission, she had a bleeding and ulcerated ear canal.
Ms. C stated that as far back as she could remember, she had always had a habit of inserting sharp objects, such as pins and needles, in her left inner ear and stroking the skin of the ear with the object. She stated that this started as an intense concern that the skin around her ear was dirty and had to be cleaned. Initially, she cleaned the ear with blunt objects but as time went on used sharp objects, such as a pin and needle. She derived significant pleasure from this activity. She picked her ear only in the privacy of her home and did not do it at work. She said she especially enjoyed cleaning the ear whenever she was watching a movie at home. She stated that she continued to stroke the ear while it was infected and swollen even though she was instructed not to do this. Ms. C separated from her husband about 6 months prior to her initial presentation. She noted that she picked her ear more since the onset of her separation and impending divorce. The stroking helped to relieve anxiety and tension. Ms. C also stated that her mother, younger sister, and daughter all compulsively picked at their ears. Her daughter also pulled at her hair. Neither Ms. C nor anyone in her family had sought psychiatric treatment for this issue. She had, however, sought counseling for her marital problems.
On interview, Ms. C was calm and cooperative. She continually manipulated her ear with her finger wrapped in tissue. Although she appeared anxious, the rest of the interview was unremarkable.
Ms. C was diagnosed with impulse control disorder NOS. She was started on Paxil 20 mg at bedtime with a plan to increase by 10 mg every 2–3 days as tolerated to reach a maximum of 60 mg/per day.
An intraoperative biopsy of her ear canal revealed an invasive squamous cell carcinoma of the ear canal. Her prognosis was determined to be poor. Ms. C was subsequently referred to the oncology service and underwent extensive palliative radiotherapy and chemotherapy and was ultimately referred for hospice care.
Discussion
The impulse control disorders are characterized by irresistible impulses to commit acts that may be harmful to self or others and are preceded by increased tension and anxiety followed by contentment, pleasure, or gratification once the acts are performed. The individual may or may not feel regret, self-reproach, or guilt following the act.
In psychogenic excoriation, the individual compulsively picks at the skin. Psychogenic excoriation is thought to have an incidence of 2% in patients seen in dermatologic clinics.4 Women are affected more often that men with a mean age of onset between 30 and 40 years of age.4
Some authors have suggested that impulse control disorders are related to mood disorders and obsessive-compulsive disorders.4 They have also suggested that these three groups of disorders are one continuous spectrum of disorders and have collectively labeled them as obsessive-compulsive spectrum disorders.5 These disorders are thought to have similar pathophysiologic origins, clinical course, and treatment.
Ms. C's years of compulsive "picking" may have led to her fatal squamous cell carcinoma. Squamous cell carcinoma is rare in the ear canal. Chronic irritation with the destruction and rebuilding of cells that occurs during healing can trigger this tumor.6
REFERENCES
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Weintrub E, Robinson C, Newmeyer M: Catastrophic medical complication in psychogenic excoriation. South Med J 2000; 93;1099;1101
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Stein DJ, Hutt CS, Spitz JL, et al: Compulsive picking and obsessive-compulsive disorders. Psychosomatics 1993; 34:177-180[Free Full Text]
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Woodruff PWR, Higgins EM, du Vivier AWP, Wessely S: Psychiatric illness in-patients referred to a dermatology-psychiatry clinic. Gen Hosp Psychiatry 1997; 19;29-35
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McElroy SL, Hudson JI, Pope HG, Keck PE, Aizley HG: The DSM-III-R impulse control not elsewhere classified: Clinical characteristics and relationship to other psychiatric disorders. Am J Psychiatry 1992; 149:318-327[Abstract/Free Full Text]
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Hollander E: Obsessive compulsive spectrum disorders: An overview. Psychiatr Ann 1993; 23:355-358
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Eroglu A, Camlibel S: Risk factors for locoregional recurrence of scar carcinoma. Br J Surg 1997; 84:1744-1746[CrossRef][Medline]
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