What is the treatment for excoriated skin on the buttocks?

Treatment of Excoriated Skin on the Buttocks

For excoriated skin on the buttocks, immediately identify and address the underlying cause (bile acids, infection, parasitic disease, or behavioral disorder), then provide wound care with gentle cleansing, barrier protection using thick emollients or topical cholestyramine if bile-related, and monitor for signs of infection requiring intervention. 1, 2

Initial Assessment and Cause Identification

The first priority is determining the etiology of excoriation, as treatment differs substantially:

• Examine for parasitic causes if the patient has travel history to endemic areas, particularly looking for larva currens (linear urticarial rash moving 5-10 cm/hour on trunk, upper legs, and buttocks from Strongyloides stercoralis) 1
• Assess for bile acid-related irritation in infants or patients with rapid gastrointestinal transit, ostomies, or promotility agents (cisapride), which can cause severe perianal and buttock excoriation 2
• Evaluate for behavioral excoriation disorder in patients with psychiatric comorbidities, repetitive picking behaviors, or self-induced lesions 3, 4
• Rule out infection by examining for expanding erythema >5 cm, purulent discharge, fever >38.5°C, or severe disproportionate pain 5

Wound Care and Barrier Protection

Basic Wound Management

• Irrigate with copious sterile saline or clean tap water to remove debris and reduce bacterial burden 6, 5
• Apply thick, bland emollients (creams or ointments with minimal fragrances or preservatives) to protect surrounding skin and prevent further maceration 1
• Use non-adherent dressings to protect the wound while allowing drainage, changing every 5-7 days if no complications arise 6, 5
• Avoid aggressive cleansing with antiseptics unless clear infection is present 5

Bile Acid-Related Excoriation (Specific Treatment)

• Prepare topical cholestyramine ointment (bile acid sequestrant) and apply to affected areas, which can achieve complete resolution within 3 days by irreversibly binding bile acids in stool 2
• This approach is particularly effective when excoriation develops after starting promotility agents or in patients with shortened gastrointestinal transit time 2

Moisture and Friction Management

• Apply barrier films or creams to protect surrounding skin from excess moisture 1
• Clean affected skin at least once daily using antimicrobial cleanser if overgranulation or exudate is present 1
• Avoid mechanical stress including prolonged sitting on hard surfaces without cushioning 1

Infection Monitoring and Treatment

When to Suspect Infection

• Monitor for fever >38.5°C, heart rate >110 bpm, expanding erythema, purulent discharge with foul odor, or severe pain 5
• Rising C-reactive protein, neutrophilia, or monoculture on skin swabs indicate developing infection 7, 5
• Do NOT treat with antibiotics unless clinical signs of infection are clearly present 6, 5

If Infection Confirmed

• Obtain wound cultures using tissue specimens or curettage from the debrided base rather than swabs 6
• Apply topical antimicrobial agents such as silver sulfadiazine 1% or polyhexanide 0.02%-0.04% cream only when infection is documented 1
• Consider systemic antibiotics only with signs of systemic infection, as indiscriminate prophylactic antibiotics increase resistant organisms and Candida colonization 5

Parasitic Causes (If Travel History Present)

Larva Currens from Strongyloides

• Treat with ivermectin 200 μg/kg PO single dose or albendazole 400 mg PO once daily for 3 days if characteristic itchy, linear rash on buttocks/trunk is present 1

Onchocerciasis (If Endemic Area Exposure)

• Seek specialist input urgently and exclude loiasis before treatment 1
• Treat with doxycycline 200 mg PO once daily for 6 weeks plus ivermectin 200 μg/kg monthly for 3 months if severe pruritus and excoriation with skin changes are present 1

Behavioral Excoriation Disorder Management

If self-induced picking is identified:

• Combine pharmacotherapy with psychotherapy as multidisciplinary approach is essential 3, 8, 4
• Consider mirtazapine augmentation (noradrenergic and specific serotonergic antidepressant with antihistaminergic effects) for severe cases with psychiatric comorbidities, which can provide remarkable improvement 8
• Fluoxetine or escitalopram are first-line pharmacological options 8
• Adjunctive therapies including yoga and aerobic exercise show promise in reducing picking behaviors when combined with primary treatments 3

Follow-Up and Monitoring

• Examine within 24 hours of initial presentation to assess for infection or progression 5
• Continue monitoring for signs of clinical deterioration, extension of excoriation, or delayed healing 5
• If wound conversion occurs (progression to deeper defect) or local sepsis develops, consider surgical debridement 5

Critical Pitfalls to Avoid

• Do not apply topical antibiotics prophylactically without clear infection signs, as this promotes resistance 6, 5
• Do not use aggressive antiseptic cleansing on intact excoriated skin, as this causes further irritation 5
• Do not overlook bile acid etiology in infants or patients with gastrointestinal disorders, as standard barrier creams will fail 2
• Do not miss parasitic causes in travelers from endemic areas, as specific antiparasitic treatment is required 1