Is a short course of systemic corticosteroids advisable for an infected dermatillomania lesion?

Systemic Corticosteroids Are Not Recommended for Infected Dermatillomania Lesions

A short course of systemic corticosteroids is contraindicated when infection is present or suspected in dermatillomania lesions; instead, appropriate antibiotics based on culture and sensitivities should be used, along with treatment of the underlying psychiatric condition. 1

Rationale Against Systemic Steroids in Infected Lesions

Infection as an Absolute Contraindication

• When infection is suspected—indicated by failure to respond to oral antibiotics, presence of painful skin lesions, pustules on extremities and trunk, yellow crusts, or discharge—bacterial culture must be obtained and antibiotics administered for at least 14 days based on sensitivities, not systemic corticosteroids. 1

• Systemic corticosteroids are immunosuppressive and will worsen active bacterial infections, potentially leading to sepsis or systemic spread. 1

• The evidence for systemic steroids in dermatologic conditions explicitly states they should only be used for inflammatory processes, not infected ones. 1

When Systemic Steroids Are Appropriate (Not Your Case)

• Short courses of systemic corticosteroids (prednisone 0.5-1 mg/kg for 7 days with weaning over 4-6 weeks) are reserved for severe inflammatory skin reactions (grade 3 rash) without infection. 1

• Even in appropriate inflammatory conditions, systemic steroids carry significant risks including opportunistic infections, adrenal insufficiency, glucose intolerance, osteoporosis, and rebound flaring—risks that are magnified when infection is already present. 2

Correct Management Algorithm for Infected Dermatillomania

Step 1: Confirm Infection and Obtain Culture

• Look for clinical signs: purulent exudate, pustules, yellow crusting, discharge, warmth, erythema extending beyond the picked area, and pain disproportionate to the lesion. 1

• Obtain bacterial culture with antibiotic sensitivities before starting empiric therapy. 1

Step 2: Initiate Appropriate Antibiotic Therapy

• Start empiric coverage for Staphylococcus aureus and streptococci (the most common pathogens in secondarily infected skin lesions) while awaiting culture results. 1

• Continue antibiotics for at least 14 days based on culture sensitivities. 1

• Consider MRSA coverage if risk factors are present or if there is failure to respond to initial therapy. 1

Step 3: Local Wound Care

• Treat the wound with topical wound care, antiseptic measures, and appropriate dressings. 3

• Abscesses may require incision and drainage to prevent progression to sepsis. 1

Step 4: Address the Underlying Psychiatric Condition

• Dermatillomania is classified under obsessive-compulsive and related disorders and requires psychiatric treatment as the definitive management. 3

• Selective serotonin reuptake inhibitors (SSRIs) are the most effective pharmacological treatment for the psychiatric component. 3

• Cognitive behavioral therapy, habit reversal exercises, and support groups are essential non-pharmacological interventions. 3

Critical Pitfalls to Avoid

The Steroid Trap

• Never use systemic corticosteroids when infection is present or suspected—this is the single most dangerous error, as steroids will suppress the immune response and allow infection to progress unchecked. 1, 2

• Even topical corticosteroids should be used cautiously in the presence of infection, as they can mask signs of worsening infection and delay appropriate treatment. 4

Misidentifying Inflammation vs. Infection

• Crusting alone can be present in either active inflammation or infection, making clinical distinction challenging. 1

• When in doubt, obtain culture and treat as infected rather than risk immunosuppression with steroids. 1

Ignoring the Root Cause

• Treating only the skin lesion without addressing the compulsive picking behavior will result in recurrence and potentially more severe tissue damage. 3

• Dermatillomania often coexists with OCD, anxiety disorders, autism, alcohol abuse, and borderline personality disorder—comprehensive psychiatric evaluation is mandatory. 3

Short-Term Steroid Use: When It Might Be Considered (After Infection Resolves)

• If significant residual inflammation persists after the infection has completely cleared (documented by clinical resolution and negative cultures if obtained), a very short course of oral prednisone (approximately 2 weeks at a single morning dose) could be considered for the inflammatory component only. 5

• However, this is rarely necessary in dermatillomania, as the primary pathology is mechanical trauma from picking, not an inflammatory dermatosis. 3

• Tapering is not required for courses of 2 weeks or less, though some experts advise caution regarding HPA axis integrity for up to one year after even short suppressive courses. 5