Acne Excoriée
Acne excoriée (also called acné excoriée des jeunes filles) is a psychocutaneous disorder in which a person repeatedly picks, squeezes, scratches or scrapes at real acne lesions or at perceived flaws on the facial skin. Unlike ordinary acne, which arises from a malfunction of the pilosebaceous unit, most of the visible damage in this condition is secondary: the patient creates it themselves, on top of very mild acne or sometimes no acne at all.
The biology and behavior behind acne excoriée reflect a complex interplay between the neuroendocrine system and the skin barrier:
- The psychocutaneous axis: Psychological stress, anxiety or obsessive-compulsive disorder (OCD) trigger the release of corticotropin-releasing hormone (CRH) and neuropeptides, notably substance P, from sensory nerve endings in the skin. These signals provoke local inflammation and slightly increase sebaceous gland activity, producing very mild inflammatory papules.
- Self-inflicted mechanical barrier damage: Constant scratching and squeezing push the tissue beyond what it can withstand. The stratum corneum tears and the outer layer of keratinocytes is destroyed, leaving shallow and deep erosions (excoriations). Without this protective barrier, resident bacteria such as Staphylococcus aureus can invade, causing secondary infection and blood-stained, weeping crusts.
- Scarring and pigment changes: Repeated mechanical injury to the upper dermis unleashes a surge of pro-inflammatory cytokines. This drives melanocytes in the basal layer to produce more melanin, leading to deep post-inflammatory hyperpigmentation (PIH). At the same time, squeezing breaks down collagen around the basement membrane and releases matrix metalloproteinases (MMPs), so healing goes wrong and tethered, fibrotic atrophic scars form.
At Haute-Derma, our first clinical priority in acne excoriée is to protect the skin from self-inflicted mechanical damage, promote moist wound healing and keep marks and scars to a minimum, all without further irritating the skin's sensory nerves.
Our Approach to Managing Acne Excoriée at Haute-Derma
Getting this condition under control takes close coordination between dermatologic repair and behavioral support:
- Mechanical protection and barrier repair come first: Protective dressings stop fingers from touching the lesions directly while keeping the wound optimally moist to shorten healing time.
- No harsh exfoliating actives during the active phase: While the skin has many bleeding erosions and crusts, high-strength benzoyl peroxide, strong salicylic acid and high-strength retinoids are contraindicated, to avoid chemical burns on open skin and to avoid further agitating the skin's nervous system.
- Behavioral support: We identify what sets off the picking (anxiety, depression, work stress) and teach habit reversal training techniques, or coordinate specialist therapy when indicated.
Clinical Assessment and Diagnosis
Establishing a diagnosis of acne excoriée involves:
- A detailed history: We ask when the lesions flare, about mirror habits and how often the patient picks, and we assess any accompanying anxiety or stress.
- Clinical examination: Typical findings are linear excoriations, shallow erosions, hemorrhagic crusts and red-brown macules, concentrated in areas the hands reach easily (forehead, cheeks, chin, shoulders, upper chest), while the mid-back and other hard-to-reach areas are usually completely spared.
- Dermoscopy: We see linear breaks in the epidermis, pinpoint bleeding from ruptured superficial capillaries and patches of red-brown hyperpigmentation around the scratched areas, without corresponding comedones.
Clinical Management and Treatment at Haute-Derma
Treatment aims to speed healing, rebuild the skin's natural protective barrier and address pigment changes left behind:
- Protective and restorative topical care:
- Sterile hydrocolloid patches: Applied over open erosions, they act as a physical barrier that keeps fingers off the lesion and create a moist healing environment that speeds re-epithelialization.
- Barrier-repair complex: Products containing panthenol (vitamin B5), Centella asiatica (with purified madecassoside) and skin-identical ceramides soothe itching and stinging and strengthen the intercellular lipid layer.
- Light and vascular laser therapy:
- Nd:YAG laser (1064 nm): Used at low energy to target damaged small vessels beneath the excoriations, it reduces redness and stimulates healthy collagen production to help prevent atrophic scars, without peeling the skin surface.
- Red LED light (633 nm): Regular sessions calm local inflammation, improve microcirculation and support the natural repair of keratinocytes.
- Neuroendocrine and psychiatric support:
- When the picking is severely compulsive, we arrange a psychiatric consultation to consider serotonin-modulating medication (such as SSRIs) to help control the unconscious urge to pick.
