BRIEF COMMUNICATION
Narrow-band ultraviolet B as a potential alternative treatment for resistant psychogenic excoriation: an open-label study ¨ zden1, Fatma Aydın1, Nilg¨un S¸ent¨urk1, Y¨uksel Bek2, Tayyar Cant¨urk1 & Ahmet Yasar M¨uge G¨uler O ¸ Turanlı1 Departments of 1Dermatology, and 2Biostatistics, Ondokuz May{s University Medical Faculty, Kurupelit/Samsun, Turkey
Summary Key words: Narrow-band ultraviolet B; ultraviolet; psychogenic excoriation; neurotic excoriation; treatment; skin picking
Correspondence: M¨uge G¨uler O¨zden, M.D., Department of Dermatology, Ondokuz May{s University Medical Faculty, Kurupelit/Samsun Turkey. e-mail:
[email protected]
Narrow-band ultraviolet therapy has been used successfully for the treatment of inflammatory skin disorders and generalized pruritus. We have prospectively evaluated seven consecutive patients with resistant psychogenic excoriation (PE) treated with narrowband ultraviolet B (NB-UVB). Approximately 70% of all patients showed improvement in their condition. NB-UVB therapy was well tolerated, with no serious side effects. We may conclude that, when treating a patient with PE, NB-UVB in combination with other approaches may provide extra benefit in resistant cases.
Accepted for publication: 31 March 2010
Conflicts of interest: None declared.
P
sychogenic excoriation (PE) is a well-recognized syndrome characterized by excessive scratching or picking of normal skin (1). Treatment of PE can be very challenging, and there are very few available studies examining this condition. Patients with PE frequently have psychiatric diagnoses, such as obsessivecompulsive disorder, body dysmorphic disorder, substance abuse and eating disorders, trichotillomania, kleptomania, and compulsive buying (1). Despite the use of a variety of topical and intralesional corticosteroids, the condition is usually resistant to treatment. While psychotherapy and/or combination therapy with pharmacologic agents is sufficient in many cases, it may fall short for some resistant cases. In such cases, adjuvant therapy with these drugs may provide extra benefit. Because there are reports supporting the efficacy of broadband (BB) ultraviolet B (UVB) phototherapy in the treatment of pruritus, a prospective open pilot study to evaluate the efficacy and safety of UVB in patients with resistant PE was conducted.
Patients and methods Eleven patients (three males and eight females), with a mean age of 36.38 8.02 years (range, 30–45 years), who were diagnosed with PE were enrolled in the study. Relevant testing, such as scraping for fungus and biopsy, was performed when required. The study was approved by the local Ethical Committee. All patients underwent psychiatric evaluations. All of the patients were 4 18 years of age and had responded unsatisfactorily to antihistamines 162
and topical corticosteroids plus an antipsychotic drug. Exclusion criteria included a psychotic disorder or any internal disease that could cause itching. Baseline laboratory studies included a chest roentgenogram, total and differential blood count, serum biochemistries, thyroid-stimulating hormone, erythrocyte sedimentation rate, total protein, albumin, protein electrophoresis, hepatitis serology, and urine analysis. Pruritus was evaluated by the patient on a visual analog scale (VAS), with scores ranging from 0 (no pruritus) to 10 (worst imaginable pruritus). The response rate to treatment was evaluated by two blinded dermatologists on a four-point scale, as follows: 0, no improvement or worsening; 1, 0–24% improvement; 2, 25–49% improvement; 3, 4 50% improvement; 4, 75–99% improvement; and 5, 100% improvement. Narrow-band UVB (NB-UVB) phototherapy was carried out in an air-conditioned Dr K. H¨onle cabin (D-8033 Martinsried; Ringo Dermalight, Munich, Germany) equipped with 45 Philips TL100 W/01 fluorescent lamps (Phillips, Eeinhoven, the Netherlands). For each patient, the first irradiation dose was 140 mJ/cm2 for skin type I, 200 mJ/cm2 for skin type II, 300 mJ/cm2 for skin type III, and 350 mJ/cm2 for skin type IV. Dose increments were 20% in the absence of an erythematous reaction to the previous exposure and 10% in the case of a slight erythematous reaction. Treatment was continued until the patient became symptom-free or for a maximum of 12 weeks. In addition, patients were asked to keep additional ambient sunlight exposure to a minimum. Phototherapy was
r 2010 John Wiley & Sons A/S Photodermatology, Photoimmunology & Photomedicine 26, 162–164
The efficacy of narrow-band ultraviolet B for resistant psychogenic excoriation
administered three times a week. Patients were assessed by a physician at 1-week intervals by direct questioning about their symptoms based on the VAS. During the study period, no additional systemic or topical treatments were allowed, with the exception of emollients and the drugs prescribed by their psychiatrists (antidepressants and antipsychotics). Patients who achieved 4 50% improvement with respect to the baseline pruritus score were defined as responders. The secondary endpoint was the duration of remission in patients who responded to the phototherapy. Patients were also evaluated for adverse events associated with phototherapy at each visit. Patients who completed the treatment were examined 3 months after completion of phototherapy. Among the responders, patients whose scores reached 75% of the baseline values at any time during the post-treatment follow-up period were considered to have relapsed. Statistical analysis was performed on an intention-to-treat basis using the Wilcoxon signed-rank test to compare clinical and pruritus scores before and after treatment. A P o 0.05 was considered statistically significant.
xerosis were observed. A follow-up duration of 7 4.12 months was noted in the seven patients (median, 7; minimum, 3; and maximum, 12 months). Of these seven patients, four (57.1%) were in remission 3 months after completing treatment (Table 1). However, skin-picking behaviors and pruritus recurred in the remaining three (42.8%) patients at that time. One patient with a 100% clearance reported a moderately relapsing condition 7 months after treatment.
Discussion This is the first prospective study evaluating the effectiveness of NB-UVB treatment in patients with PE. PE is estimated to occur in 2% of patients attending dermatology clinics, and it is frequently associated with psychiatric disorders of the compulsivityimpulsivity spectrum (1). Singareddy et al. (2) reported that patients with pathologic excoriations tend to be anxious and complain of severe sleep disturbances. In some cases, patients may develop severe work and social disability (2). Despite these 10.00
Five of seven patients were females, with ages ranging from 30 to 42 years. Symptoms had been present from 10 months to 6 years. Four of the 11 subjects who claimed that the heat in the cabinet during the irradiation exacerbated their pruritus were excluded from the study after enrollment in the treatment protocol for 1–2 weeks. In the seven subjects who completed the study, a clinical improvement 4 75% was achieved in four patients. The clinical characteristics of the patients and phototherapy parameters are summarized in Table 1. The clinical improvement scores (CIS) decreased by at least 50% in five (71.4%) subjects. Decreases in the mean scores on the VAS were significant for the presence of skin sensations (from 8.29 1.89 to 2.71 2.43, P = 0.018). Of the seven patients, two did not improve by 4 50%; the VASs of these patients changed minimally (from a score of 7 to 4 and 8 to 7) after 12 weeks. Of the five patients who responded to treatment, the mean number of treatments needed to achieve an improvement of 4 50% of the CIS was 4 2.55 (Fig. 1). NBUVB was generally well tolerated. No side effects other than occasional episodes of a moderate erythematous response and
Means of CIS and VAS Scores
Results
8.00
CIS VAS
6.00
4.00
2.00
0.00 0 1 2
3
4
5
6
7
8
9 10 11 12 16 24 Week
Time Fig. 1. Alterations in the visual analog scale (VAS) and clinical improvement scores (CIS) in study patients. Patients’ scores at each assessment recorded before phototherapy (week 0) and during follow-up.
Table 1. Results from NB-UVB therapy of PE
Basal VAS End of treatment VAS VAS at 3 months Percentage of clinical improvement after treatment Percentage of clinical improvement at 3 months Maximum UVB dose (mJ/cm2) Treatment duration (weeks) Side effect Relapse
Patient 1
Patient 2
Patient 3
Patient 4
Patient 5
Patient 6
Patient 7
10 0 0 100% 100% 740 12 Xerosis 7 months later
5 0 0 100% 100% 590 9 – No
10 2 2 4 75% 4 75% 1100 12 Xerosis No
10 3 4 4 75% 50–75% 740 12 Xerosis 3 months later
8 2 3 50–75% 50–75% 740 12 – No
7 4 7 %25–50 0% 1050 9 – Instant
8 7 8 0–25% 0% 1100 12 Xerosis Instant
NB-UVB, narrow-band ultraviolet B; VAS, visual analog scale; PE, psychogenic excoriation.
r 2010 John Wiley & Sons A/S Photodermatology, Photoimmunology & Photomedicine 26, 162–164
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¨ zden et al. O
important findings, PE has received little attention in the scientific literature. A few case reports, open trials, and smallblind studies have shown the efficacy of selective serotonin reuptake inhibitors, doxepin, clomipramine, naltrexone, pimozide, and olanzapine in patients with PE (1, 3). As psychiatrists are reluctant to prescribe antipsychotics to treat PE and as patients almost always reject psychiatric referral, dermatologists must diagnose and treat patients with PE. However, conventional dermatologic treatment has been shown to be unlikely to alleviate the skin-picking behavior. The main difficulty for dermatologists in treating patients is to take medications and compliance with the treatment protocol. To date, no clinical study has investigated the efficacy of NB-UVB in PE. NB-UVB induces apoptosis of dermal mast cells. Increased release of substance P induces mast cell degranulation and histamine secretion. It also reduces the release of neuropeptides, such as substance P, by decreasing epidermal nerve fibers (4). Both BB and NB-UVB radiation have long been used in the treatment of generalized pruritus (5). Patients who completed
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our study showed a significant improvement. The findings of this open-label, preliminary study suggest that NB-UVB treatment is effective in reducing excoriations.
References 1. Arnold LM, Auchenbach MB, McElroy SL. Psychogenic excoriation: clinical features proposed diagnostic criteria, epidemiology and approaches to treatment. CNS Drugs 2001; 15: 351–359. 2. Singareddy R, Moin A, Spurlock L, Davis OM, Uhde TW. Skin picking and sleep disturbances: relationship to anxiety and need for research. Depress Anxiety 2003; 18: 228–232. 3. Phillips KA, Taub SL. Skin picking as a symptom of body dysmorphic disorder. Psychopharmacol Bull 1995; 31: 279–288. 4. Szepietowski JC, Morita A, Tsuji T. Ultraviolet B induces mast cell apoptosis: a hypothetical mechanism of ultraviolet B treatment for uraemic pruritus. Med Hypotheses 2002; 58: 167–170. 5. Sec¸kin D, Demircay Z, Akin O. Generalized pruritus treated with narrowband UVB. Int J Dermatol 2007; 46: 367–370.
r 2010 John Wiley & Sons A/S Photodermatology, Photoimmunology & Photomedicine 26, 162–164
