The Medicine Cabinet-Ask the Harvard Experts
By Howard LeWine, M.D.
Q: I’ve been suffering from a skin rash for many years. Patches of my skin constantly itch. And the skin has become thick and leathery. I’ve tried everything, but nothing helps. Recently, I saw a new doctor and he diagnosed this problem as neurodermatitis. He suggested an anti-depressant. How can that help?
A: Yes, an anti-depressant can be very effective. In the last few years, doctors have started using the term skin picking disorder (SPD) instead of neurodermatitis. It’s also been called lichen simplex chronicus, psychogenic excoriation, or neurotic excoriation.
SPD is a chronic skin condition caused by repetitive picking, scratching, or rubbing of the skin that results in tissue damage. Often, patients have an almost persistent sense of intense itching and a compulsion to manipulate skin, usually by scratching.
Scratching the itch irritates nerve endings in the skin, resulting in more itching and more scratching. An “itch-scratch-itch cycle” sets in, and it’s tough to break.
Skin picking disorder is frequently seen on the arms or legs, but it can occur on any area that can be reached. Once the skin is irritated and thickened, itching is intense. Scratching feels good and is hard to resist. It’s usually worse at bedtime, when there are few distractions.
To treat SPD, it’s necessary to break the itch-scratch-itch cycle. Here are some tips:
1. Use a mild, unscented soap for bathing.
2. Avoid any perfumed products.
3. Try soothing lotions and cool compresses to relieve itching.
If itching persists, your doctor may want to evaluate you for underlying factors or conditions that may be contributing to the itching. Sometimes a skin biopsy is needed to confirm the condition. Also, allergy testing may be recommended.
Topical steroid creams and ointments prescribed by your physician can reduce itching and redness, but these alone will not be sufficient if scratching continues.
An anti-depressant can be extremely helpful. Most often, doctors prescribe a selective serotonin reuptake inhibitor. Examples include sertraline, fluoxetine and citalopram. Usually the best strategy is to start with a low dose and gradually increase if needed.
Skin picking disorder is not a simple skin condition. It may be caused by or related to a mental health problem, such as depression, obsessive-compulsive disorder, generalized anxiety or body dysmorphic disorder. Treating both the skin with topical agents and the mental health issues with talk therapy and oral medications should help break the itch-scratch-itch cycle.
Howard LeWine, M.D., is an assistant professor of medicine at Harvard Medical School. For additional consumer health information, please visit www.health.harvard.edu.