Acne Excoriee, or excoriated acne, is a result of acne lesions being compulsively picked at and scratched, resulting in red marks and scars. In this article, we will cover what exactly acne excoriee is, what causes it, as well as reflections from an acne dermatologist on how skin affects one’s psychology and why it is so important that we impart correct beliefs in one’s childhood/teenage years. Including an excerpt from Acne Care Bible: Dermatologist’s Tips For Acne Treatment & Prevention by Dr. Teo Wan Lin, dermatologist at TWL Specialist Skin & Laser Centre.
What is Acne Excoriee?
It is a condition that predominantly affects young teenage girls who may have the condition persist to adulthood. It is characterized by areas of raw broken skin present over the face together with acne lesions. The characteristic is that these have a circular, what we termed as an “excoriated” appearance which is consistent with picking and peeling of the skin.
As we know, acne itself is associated with significant psychosocial disturbances. The period of one’s teenage years is already fraught with emotional ups and downs associated with both physiological changes as well as the complex interplay of social factors that occur in a teenager’s life. The teenage years are also the beginning of when one starts to develop sexual awareness. This is a critical factor influencing one’s self-esteem as the teenager often becomes self-conscious about his/her perceived attractiveness.
Acne undoubtedly can leave one’s self-esteem scarred primarily because of cosmetic disfigurement. Acne bumps are visible on one’s face, are often painful and can lead to discomfort. It is my observation that individuals with acne tend to develop a self-perpetuating cycle of feeling upset about the pimples, expressing the frustration through destructive habits such as squeezing pimples and picking them which then leads to secondary bacterial infections. This then becomes an ongoing acne problem that never seems to fully go away. I shall share in the following segment how I treat my patients with this condition.
How to identify acne excoriee?
Whether you are a parent of a teenager or a teenager yourself, this age group of young adults is critical in the diagnosis of acne excoriee. In fact, in French, this is known as “acne excoriee des jeunes filles”, literally translating to “acne excoriee of young girls”. I have never diagnosed a male patient with this condition so it does seem to pre-select the female gender. I have also seen adult female patients with this condition but the key thing to note is that all their acne excoriee problems started when they were teenagers. The clinical appearance of acne excoriee is characteristic to the trained eye.
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Appearance of skin lesions
These are some signs dermatologists look out for when diagnosing acne excoriee. Excoriated papules appear as areas of broken skin which are often circular. These are the result of digging, picking and peeling the areas where the blemishes are. The second feature will be that of hyperpigmentation. When these picked areas heal, they often lead to dark marks. These marks are first red then brown before turning into a dark brown or even grayish in individuals of color. The third feature would be the presence of other types of acne. Acne excoriee is never a standalone condition. It always occurs together with a true underlying condition such as comedonal or cystic acne.
Psychological impact of acne excoriee
All dermatologists recognize the importance of the mind and its influence on the skin and vice-versa. Acne excoriee is a classic example of how skin conditions can greatly affect one’s psychology.
When I interview patients with acne excoriee, their responses are similar. The patient often feels extremely ashamed, they feel “dirty” because their skin has these spots that never seem to go away. It is a very difficult emotional experience for these individuals who are constantly suffering from a sense of shame due to not having “clean skin”. As a result of this negative psychology, many of the patients end up trying to “clean” their skin by digging and picking. However, a lot of them are “unconscious” that their behaviour leads to scarring and pigmentation which they experience and often justify it as necessary because they keep getting new zits they need to “pop”.
The self-perpetuating cycle of acne excoriee
Next, I shall move on to the actual cognitive-physiological process of when the individual with acne excoriee starts to pick their skin. The individual first observes a pimple on the surface of the skin which may or may not appear to have a visible tract to the surface. If they view it as a superficial pimple where there is a whitehead or a blackhead that could potentially be squeezed out, they start extracting the cyst and squeezing pimples. What’s usually going on in their thought processes at this stage is usually this: if I squeeze the contents of the pimple out it will flatten and disappear.
This is not an entirely irrational thought, for it is typically backed by previous experiences whereby the acne bump did resolve upon its contents being extruded. This likely formed a positive reinforcement cognitive loop whereby the mind and intuition associates the act with a positive outcome. There is almost a “gratification” that occurs if and when any pus or material is expressed, causing the individual to blindly disregard the scarring that occurs as a result of squeezing pimples. On the other hand, should the pimple be a “blind” pimple, and nothing comes out after repeatedly squeezing pimples, the individual then develops deep frustration and a sense of shame, leading to depressive feelings.
However, there is a definite psychological bias here which also forms the basis of many obsessive compulsive disorders (OCD). The act which is a “compulsion” is meant to relieve the individual’s “obsession” with their pimple. What it fails to establish is the objective awareness that squeezing pimples has more often than not causes worsened acne cysts and scars. In my experience, where there is an attempt by a physician (i.e. myself) to highlight this, the patient will then deny that there is any link between their actions and the resultant condition, and then justify their behaviour with “but then the pimple will never go away if I don’t squeeze it.”
However, in acne excoriee, there is usually no link to any true psychiatric condition, nor is there any other evidence of OCD features found in the individual suffering from acne excoriee. Occasionally, where there are concomitant symptoms of depression or anxiety, appropriate referrals for psychiatric co management are made.
Acne excoriee can also occur when individuals use instruments to extract their acne as well. The appearance of all these lesions is classical and using an instrument to extract acne is by no means recommended by dermatologists nor does it lead to a favorable outcome. It is also not recommended to go for a facial treatment whereby a therapist extracts it for you.
The reason being whatever instrument that is being used to extrude the debris and pus contained within the acne bump is usually going to introduce more infection with superficial skin bacteria. It will then worsen inflammation which is the primary cause of acne itself. If the pimple appears to be blind and deep-seated within the skin, the individual will panic further because they feel the immense need to squeeze it out before the pimple stays permanent.
“If I don’t squeeze it out, it will leave a mark and it will never go away.” The perpetual repeating of such a thought process causes a habit to form. As you know, our minds and our movements are connected by way of neurons in the brain as well as certain chemicals that are associated with our emotions. Patients with acne excoriee feel a sense of relief from their emotional discomfort when squeezing pimples and picking their skin.
The pathophysiology of acne and how acne excoriee develops is a true complication that needs to be addressed separately
Acne itself is predominantly genetic. The genetics of an individual leads to inflammation. Combined with hormonally influenced oil production which occurs when one enters into puberty, the presence of bacteria on the surface of one’s skin forms the perfect environment for acne bumps to develop. Acne excoriee is best viewed as an abnormal response by the individual to the development of physiological acne. Many teenagers go through puberty years with minimal damage to skin, experiencing acne bumps here and there, but it is never severe enough to cause acne excoriee.
Acne excoriee occurs in individuals with physiological acne as well. Most of these patients do not have severe cystic acne, rather they have mild to moderate acne but they have a heightened sense of how their appearance may affect the perception of others around them. This escalates into anxiety and a need to remove facial blemishes from one’s skin via various methods. Part of this could be due to peer/media influence as well, or an underlying body dysmorphic condition.
When one sees extraction such as needle decompression being advertised, some may assume that physical extraction is needed to treat their acne and start to afflict these traumatic methods by themselves. However, it is very important to note that all these therapies are done in a medical setting, with sterile instruments and with careful patient selection. However, there are a lot of therapists who do advocate extraction contrary to what dermatologists advise, thus we do not blame the individual for believing that this is a viable method of acne treatment. Once the habit is formed, the individual develops a sense of satisfaction, even catharsis from squeezing pimples or excoriating their acne bumps.Tags: ~All Topics, Acne, Dermatology, Skin Health