What else can be done for a 36-year-old diabetic patient with neurotic excoriations, whose uncontrolled diabetes is hindering their recovery, despite improvement with Mupirocin (mupirocin) Ointment 2%?

Management of Neurotic Excoriations in Uncontrolled Diabetes

Optimize glycemic control immediately—this is the single most critical intervention that will directly impact wound healing and prevent further complications in this patient. 1, 2

Immediate Glycemic Control Strategy

Target HbA1c of 6-7% through aggressive treatment intensification. 2, 3 The current uncontrolled diabetes is directly impairing wound healing and increasing infection risk at the excoriation sites. 1

Treatment Intensification Algorithm

• If currently on oral monotherapy: Add a second agent (DPP-4 inhibitor, SGLT2 inhibitor, or GLP-1 receptor agonist) immediately rather than waiting for the next visit. 1
• If on dual therapy without adequate control: Proceed to triple therapy or initiate basal insulin. 1
• If HbA1c remains ≥9%: Consider starting multiple daily insulin injections (basal + prandial) as this population shows poor compliance with annual screenings and likely represents advanced disease. 1, 4

The evidence is clear that lifestyle intervention alone is insufficient when HbA1c ≥7.0%, and pharmacologic escalation must occur promptly. 1

Address the Underlying Psychiatric Component

Refer to a mental health provider experienced in cognitive behavioral therapy for formal evaluation and treatment. 1 This is not optional—neurotic excoriations represent a physical manifestation of an emotional problem that will not resolve with topical therapy alone. 5

Specific Psychiatric Considerations

• Screen for depression using an age-appropriate validated tool (e.g., PHQ-9), as depression prevalence is 19.5% in diabetic patients and directly interferes with self-management behaviors. 1
• Assess for anxiety disorders, particularly obsessive-compulsive features, as these patients often exhibit excessive repetitive behaviors and may have underlying perfectionism or hypersensitivity. 1, 6
• Evaluate for diabetes distress specifically—this differs from depression and may require tailored diabetes education rather than antidepressants. 1

The psychiatric literature on neurotic excoriations reveals that 90% of patients are women (matching this case), with onset typically in the 20s-40s, and these patients often lack insight into needing psychiatric treatment despite significant underlying pathology. 6

Pharmacologic Management of Compulsive Picking

Initiate an SSRI (sertraline 50-200 mg daily or fluoxetine 20-60 mg daily) as first-line treatment for the compulsive component. 1 While the guidelines focus on anxiety and depression in diabetes, the evidence supports SSRIs for repetitive behaviors and obsessive-compulsive features. 1

• Alternative option: Consider low-dose tricyclic antidepressant (amitriptyline 25-75 mg at bedtime) if concurrent neuropathic symptoms are present, though monitor carefully for anticholinergic effects that could worsen glycemic control. 2
• Avoid benzodiazepines despite anxiety symptoms, as they do not address the underlying compulsive behavior and may impair diabetes self-management. 1

Optimize Wound Healing Environment

Continue mupirocin for bacterial colonization, but extend duration to 10-14 days given the diabetes-impaired healing. 1 The 7-day course was appropriate initially, but uncontrolled diabetes requires longer antimicrobial coverage.

Additional Wound Care Measures

• Apply occlusive dressings or hydrocolloid bandages to physically prevent picking access to lesions during high-stress periods. 5
• Screen for diabetic neuropathy using 10-g monofilament testing, as up to 50% of diabetic peripheral neuropathy is asymptomatic but increases ulceration risk. 2, 3
• Assess nutritional status, particularly protein intake and micronutrients (zinc, vitamin C), as these directly impact wound healing in diabetics. 1

Behavioral Interventions

Implement habit reversal training through the mental health referral—this evidence-based technique teaches patients to recognize triggers and substitute alternative behaviors when the urge to pick occurs. 1

• Identify specific stress triggers through detailed history: work stress, family dynamics, or diabetes-related distress itself may be precipitating the picking behavior. 1, 6
• Provide diabetes self-management education (DSME) that is culturally appropriate and addresses the patient's specific barriers to glycemic control. 1

Common Pitfalls to Avoid

• Do not assume the skin lesions will resolve with glycemic control alone—the psychiatric component requires concurrent treatment or the behavior will persist. 5, 6
• Do not delay treatment intensification waiting for "lifestyle modifications to work"—the evidence shows this approach fails when HbA1c is significantly elevated. 1
• Do not overlook depression screening just because the patient presents with a dermatologic complaint—depression in diabetics is often missed and directly impairs self-care. 1
• Do not prescribe anxiolytics without addressing the compulsive component—this treats symptoms without addressing the underlying pathology. 1

Follow-Up Strategy

Schedule diabetes-focused "Right Care" visits every 2 weeks until HbA1c drops below 8%, then monthly until target is reached. 4 These structured visits should include:

• Point-of-care HbA1c or fructosamine testing to monitor glycemic trends. 4
• Medication adherence assessment and barrier identification. 1, 7
• Skin examination to document healing progress and identify new lesions. 5
• Brief mental health screening to assess treatment response. 1

Coordinate care with the mental health provider through shared treatment plans, as fragmented care is a major barrier to success in complex diabetic patients. 1