Erythromelalgia

Hypnotic suggestion successfully alleviated the behavioral picking aspect of acne excoriee des juenes filles in a pregnant woman who had been picking al the acne lesions on her face for 15 years. Acne excoriee is a subset of psychogenic or neurotic excoriation. Conventional topical antibiotic treatment was used to treat the acne. Compared with other treatments for uncomplicated acne excoriee, hypnosis is relatively brief and cost-effective and is non-toxic in pregnancy.

Keywords: Acne excoriee, habit, hypnosis, Obsessive Compulsive Disorder (OCD), suggestion

Introduction

Hypnosis has also been used successfully for multiple skin conditions such as alopecia areata, atopic dermatitis, congenital ichthyosiform erythroderma, dyshidrotic dermatitis, erythromelalgia, furuncles, glossodynia, herpes simplex, hyperhidrosis, ichthyosis vulgaris, lichen planus, neurodermatitis, nummular dermatitis, post-herpetic neuralgia, pruritus, psoriasis, rosacea, trichotillomania, urticaria, verruca vulgaris, and vitiligo (Shenefelt 2000). This article reviews the causes and treatment of acne excoriee and presents a case example in which hypnotic suggestions were used for the effective treatment of a patient with acne excoriee.

Acne Excoriee

Acne excoriee des juenes filles is a special subset of psychogenic or neurotic excoriation, typically beginning in adolescent women, which is superimposed on mild to moderate acne vulgaris. Clinically it is seen as acne lesions on the face that have been worsened by habitually scratching or picking at them. It was initially described in the French literature by Brocq (1898). Acne excoriee was first mentioned in the English medical literature by Adamson (1915). he grouped acne excoriee together with acne urticata and neurodermatitis under the concept of "neurotic excoriations". Wrong (1954) noted a prevalence of excoriated acne among 12,000 consecutive private patients of 0.63 percent, with 0.6 percent female and 0.03 percent male. Age distribution for females was 27 percent at 11 to 20 years old, 47 percent at 21 to 30 years old, and 26 percent at 31 to 40 years old. Average duration of the condition was 6.5 years with a range of 3 months to 21 years. The lesions were located on the face only in 70 percent, on the face and back in 20 percent, and on the face and other parts of the body in 10 percent. Typical acne was present in addition to the excoriations in 33 percent while only increased oiliness and no clear-cut acne lesions were present in 67 percent. The latter probably had mild acne initially but continued picking after resolution of the acne. The picking produces excoriations which crust and may heal with hyperpigmentation, hypopigmcntation, or scarring.

Acne Excoriee: Stress-Relieving Habit, Psychosomatic Symptom, or Indicator of Serious Psychiatric Problems?

Habit with Psychogenic Overlay

In general many of the treatment approaches to situations in which dermatologie conditions are worsened by skin picking and irritation are those used for habit control. The acne excoriee is hypothesized to be a self-soothing habit that may serve other psychological tasks as well. Azrin and Nunn (1973) described a treatment of neurodermatitis that they called habit reversal. The four techniques involved were:

1.) awareness training,

2.) practice of a competing response,

3.) motivation for habit control, and

4.) generalization training.

Kenyon (1966) discussed psychosomatic aspects of acne, including brief mention of acne excoriee. According to Plewig and Kligman (1975), these young women may have disturbed psychosexual adjustments, low self-esteem, and emotional lability. They believed that these patients confirmed their flawed self-image by excoriating their faces and consequently reducing their attractiveness. The habit of excoriating the acne may go on for decades. Vogel (1974) studied two female patients in their mid-twenties who had acne excoriee and histories of acne since puberty. Both had stressful childhoods. One had been forbidden to criticize her mother and the other had lost her father in war and was raised in unhappy circumstances as a stepchild. What had started as the commonplace teenage behavior of squeezing and picking at acne papules and comedones (blackheads) developed into a form of stress relief with greatly increased frequency and duration of picking at and manipulating the acne papules and comedones. The stress relief through picking became a ritual or habit, a conditioned reflex in response to stress. Suppressed aggression toward others became self-directed aggression and self-punishment. Aggression was expressed psychosomatically as picking at acne lesions on the skin rather than through direct verbalization.

Kent and Drummond (1989) used habit reversal behavior modification to treat a case of acne excoriee in a 32-year-old woman with a 20 year history of picking at her facial skin that began when she developed acne at age 12 years. She spent about 2 hours a day examining her skin in a mirror and picking at it, primarily early morning and evening. She was asked to record the frequency and duration of each episode of picking. Then she was instructed that whenever she felt the urge to pick her skin, she was to hold her arms straight by her sides and clench her fists until the urge had passed. After a month of practicing these techniques at home, she noted a dramatic reduction in picking to less than 10 minutes a week. This improvement was maintained at 2 and 4 month follow-ups.

Hypnosis has not been used often in the treatment of acne excoriee. Hollander (1959) described using posthypnotic suggestion to achieve control of acne excoriee in two cases. The patient was instructed under hypnosis to remember the word "scar" whenever she wanted to pick her face and to refrain from picking by saying "scar" instead. The excoriations resolved, but not the underlying acne.

Psychiatric Issues

A different kind of treatment approach was used by Sneddon and Sneddon (1983), one of whom was a dermatologist and the other a psychiatrist. They described eight female patients with acne excoriee ranging in age from 21 to 43 years, with onset of the picking starting at puberty for most, but ranging from childhood to age 33 years. All but one of their patients had underlying active acne. The dermatologist tended to focus on treating the acne and suggesting that the patient stop picking. Simple suggestion was insufficient to stop the habit. With this population the psychiatrist focused on what was inducing and perpetuating the habit. Their histories disclosed neurotic traits and various kinds of phobias since childhood. For most, the self-mutilation by picking seemed to provide a defense or excuse for not dealing with some issue in their life.

Bach and Bach (1993) discussed psychiatric issues in acne excoriee. They studied 12 patients with acne excoriee. Two patients exhibited dysthymia and two patients had a personality disorder, but eight of the 12 did not fulfill DSM-HI-R criteria for any disorder. There was no evidence of any underlying obsessive-compulsive disorder or body image disorder. Fried (1994) presented psychogenic causes of pruritus and self-excoriation. he classified acne excoriee under neurotic excoriations. According to Fried, neurotic excoriations are often accompanied by underlying anxiety or depression. Frequently these individuals are perfectionistic, obsessive-compulsive, and have a strong uncontrollable impulse to rid themselves of a perceived imperfection by scratching at it. Many of these individuals are in need of psychological intervention but refuse psychiatric referral. In those cases he advocated for psychopharmacologic intervention by dermatologists using antidepressants, anxiolytics, and antipsychotics.

Arnold, McElroy, Mutasim, Dwight, Lamerson, and Morris (1998) described characteristics of 34 adults with psychogenic excoriation. Most of their subjects were women with a mean onset at age 38 years and a chronic course averaging five years. They excluded individuals younger than 18 years and did not specifically note any patients with acne excoriee. all 34 of their patients had at least one DSM-IV comorbid psychiatric disorder. Forty one percent had undifferentiated somatoform disorder, 32 percent body dysmorphic disorder, 21 percent impulse control disorder, and 6 percent obsessive-compulsive disorder.

Arnold, Auchenbach, and McElroy (2001) included acne excoriee as a subset of psychogenic excoriation. They proposed diagnostic criteria for psychogenic excoriation and described three subtypes:

1.) impulsive,

2.) compulsive, and

3.) mixed.

Psychiatric comorbidity was common and included mood and anxiety disorders, obsessive-compulsive disorder, body dysmorphic disorder, and various impulse control disorders. They discussed treatment options including pharmacotherapy with selective serotonin reuptake inhibitors (SSRIs), doxepin, clomipramine, naltrexone, pimozine, and olanzapine. Behavioral treatment and psychotherapy were also discussed.

Gupta and Gupta (2001) reported a case of a 28 year old woman with acne excoriee for 16 years who had a significant decrease in her excoriations after 4 weeks of therapy with olanzapine 2.5 mg at bedtime. She continued on the olanzapine 2.5 mg daily for 6 months while undergoing psychotherapy to deal with psychosocial Stressors arising from childhood abuse and her feelings of anger and helplessness toward the perpetrator. These memories had previously flared her picking behavior. After stopping the olanzapine her excoriations had not recurred on followup extending to 4 months.

Fried (2002) reported that the picking component of acne excoriee in a young adult woman responded to cognitive-behavioral therapy coupled with biofeedback, minocycline, and sertraline. A multimodal approach such as this is often beneficial in resistant cases.

Case Report

A 32-year-old pregnant Caucasian female presented with mild to moderate papular (raised lesions) acne with multiple excoriations. She said that she had been picking at her acne for 15 years. Treatment with 2 percent erythromycin ointment was instituted and she was instructed to stop scratching at her acne. Other acne treatments were omitted due to her pregnancy. The papular component of her acne improved gradually over several weeks, but she continued to pick at her acne. After some discussion she consented to medical hypnosis for her excoriating habit. A Hypnotic Induction Profile was performed and she scored 9 on the newer scale of 16 (Spiegel, Greenleaf, & Spiegel, 2000), or 7 on the older scale of 10 (Spiegel & Spiegel, 1978). That placed her in the moderately hypnotizable group. The eye roll induction was performed and she was instructed to descend to a safe place as I counted to 10, and to enjoy the sights, sounds, fragrances, feelings, and other sensations.

She was then given the suggestion that she is beautiful and that her beauty contains slight imperfections, just as nature is beautiful with slight imperfections, and that the imperfections add to her natural beauty. She was told that "perfection is the enemy of good" and that perfection is less beautiful than natural beauty is. She was also given the suggestion that she would visualize a scar and think of the word "scar" every time she reached toward her face to pick at her skin. The trance was terminated using a 10 count after giving her additional posthypnotic suggestions for a feeling of calm and tranquility and for daily self-hypnosis for reinforcement.

When the patient was seen in clinic 6 days later, her facial excoriations had already healed. She reported that she had stopped picking at her face the day of the initial hypnosis and had used self-hypnosis for reinforcement. She still had mild papular acne on the face. The eye roll induction was repeated and she was directed to her safe place. She was then instructed to imagine herself sitting in a movie theater, seeing herself in a movie on the screen picking at the acne, then seeing herself several weeks later with scars where she had picked. Again she was told that she has a naturally pretty face and that it is OK to be good, not perfect. The statement "perfection is the enemy of good" was repeated. She was reminded to visualize a scar and think of the word "scar" if she started to reach up to scratch her face.

The patient was seen again in follow-up in 2 weeks. She had continued to refrain from picking and her acne was still mild. Because her insurance would not cover medical hypnotherapy, she stopped follow-ups but continued for several months to do the self-hypnosis. During a telephone contact with the patient 16 months after her last visit, she stated that she had refrained totally from picking at her face for 8 months. After giving birth, she had gotten out of the habit of self-hypnosis. She had then gradually resumed some picking during stressful times but not nearly to the previous extent. She felt that if the picking became a significant problem for her again that she could bring it under control with self-hypnosis.

Discussion

Part of the art of being a dermatologist is being able to choose appropriate therapeutic modalities for specific patients, and patient selection for particular treatments is one of the most important aspects of successful medical hypnosis in dermatology. In the case described there was no evidence of serious psychopathology or of other possible manifestations of Obsessive Compulsive Disorder (Frederick, 2002) or other co-morbid conditions such as depression. In keeping with Ginandes' (2002) integrative model of hypnotically facilitated therapy, a decision was made to begin with the simplest, most clear-cut attempt to address the behavior with hypnotic suggestion directed at the patient's acceptance of her natural imperfections into which was incorporated some of Hollander's (1959) script. This treatment was effective (Amundson, Alladin, & Gill, 2003) in liberating her from her symptoms.

It is important to note that when patients with acne excoriee show any signs of significant psychopathology that suggest that there is more than a stress-relieving habit present, or are refractory to suggestive hypnotic treatment, it is necessary for them to be referred to an appropriate mental health practitioner for diagnosis and further treatment. Among the possibilities for such patients are obsessive compulsive spectrum difficulties (Frederick, 2002) that exceed the scope of dermatologie expertise. Similarly, hypnosis by a dermatologist would be contraindicated in the presence of mania, severe depression, psychosis, or were there evidence of other kinds of self-mutilations such as cutting or burning.

However, this case report, as well as that of Hollander's (1959), suggest that hypnosis can be an effective (Amundson, Alladin, & Gill, 2003) and appropriate primary treatment for the excoriation aspect of acne excoriee when used with highly and moderately hypnotizable individuals who have little or no other apparent psychopathology (Shenefelt, 2000). It must be accompanied by standard acne treatments employed for the acneiform aspects.

Hypnotic intervention was successful in the reported case with fairly brief visits and minimal utilization of resources. It is non-toxic and relatively safe, with few side effects. In the above case, hypnosis was an ideal intervention since the patient was pregnant. For individuals who fall within the low hypnotizable range, cognitivebehavioral therapy with or without biofeedback may be appropriate (Shenefelt, 2003) as may insight oriented psychodynamic psychotherapy (Sneddon & Sneddon, 1983). With resistant cases that are characterized by the patient's refusal to accept a mental health referral (Fried, 1994), the addition of SSRIs or low dose olanzapine may prove helpful. Close observation of these individuals is recommended.

As for the issue of efficacy of hypnotic suggestion in acne excoriee, it would be ideal to have a randomized controlled trial with measures of hypnotizability in each patient and comparisons of the options of hypnotherapy, cognitive-behavioral therapy, biofeedback, psychodynamic psychotherapy, and SSRI or olanzapine therapy. However, the literature indicates that acne excoriee is seen with relative infrequency, and it would be a challenge to find an adequate cohort of patients willing to enroll in such a trial.

References

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Amundson, J.K., Alladin, A., & Gill, E. (2003). Efficacy vs. effectiveness research in psychotherapy: Implications for clinical hypnosis. American Journal of Clinical Hypnosis, 46(1), 11-29.

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Wrong, N.M. (1954). Excoriated acne of young females. Archives of Dermatology and Syphilology, 70, 576-582.

Philip D. Shenefelt

University of South Florida College of Medicine

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Philip D. Shenefelt, M.D.

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E-mail : pshenefe @hsc.usf.edu

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