Download Treatment of Facial Scarring and Ulceration Resulting from Acne

COMMUNICATIONS AND BRIEF REPORTS
Treatment of Facial Scarring and Ulceration Resulting
from Acne Excoriée 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 excoriée 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 excoriée 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 excoriée.
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 excoriée) 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 excoriée 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
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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 excoriée 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
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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
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BOWES AND ALSTER: FACIAL SCARRING AND ULCERATION RESULTING FROM ACNE EXCORIÉE
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
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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 excoriée 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
excoriée. The uncontrollable skin picking habits of
acne excoriée 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.
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BOWES AND ALSTER: FACIAL SCARRING AND ULCERATION RESULTING FROM ACNE EXCORIÉE
In conclusion, when treating a patient with acne
excoriée, 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.
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