Case and Research Letters
Rhinotillexomania
Rinotilexomanía
a Departamento de Dermatología, Hospital Universitari Joan XXIII, Tarragona, Spain
b Departamento de Dermatología, Hospital del Mar, Parc de Salut Mar, Barcelona, Spain
c Departamento de Dermatología, Hospital de Viladecans, Viladecans, Barcelona, Spain
d Departamento de Anatomía Patológica, Hospital Universitari de Bellvitge, L’Hospitalet del Llobregat, Barcelona, Spain
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Martín-Callizo, M. Sacristà, Y. Fortuño, R.M. Penín, M.J. Tribó" "autores" => array:5 [ 0 => array:4 [ "nombre" => "C." "apellidos" => "Martín-Callizo" "email" => array:1 [ 0 => "claramartincallizo@gmail.com" ] "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">*</span>" "identificador" => "cor0005" ] ] ] 1 => array:3 [ "nombre" => "M." "apellidos" => "Sacristà" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] ] 2 => array:3 [ "nombre" => "Y." "apellidos" => "Fortuño" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">c</span>" "identificador" => "aff0015" ] ] ] 3 => array:3 [ "nombre" => "R.M." 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"apellidos" => "Tribó" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] ] ] "afiliaciones" => array:4 [ 0 => array:3 [ "entidad" => "Departamento de Dermatología, Hospital Universitari Joan XXIII, Tarragona, Spain" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Departamento de Dermatología, Hospital del Mar, Parc de Salut Mar, Barcelona, Spain" "etiqueta" => "b" "identificador" => "aff0010" ] 2 => array:3 [ "entidad" => "Departamento de Dermatología, Hospital de Viladecans, Viladecans, Barcelona, Spain" "etiqueta" => "c" "identificador" => "aff0015" ] 3 => array:3 [ "entidad" => "Departamento de Anatomía Patológica, Hospital Universitari de Bellvitge, L’Hospitalet del Llobregat, Barcelona, Spain" "etiqueta" => "d" "identificador" => "aff0020" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Rinotilexomanía" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 648 "Ancho" => 900 "Tamanyo" => 96170 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Computed tomography scan showing perforation of the nasal septum but no other alterations.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Rhinotillexomania is a psychiatric compulsive nose-picking disorder. It is more common in children and young adults, and while it rarely has serious consequences, it can result in serious self-inflicted lesions, such as perforation of the nasal septum and destruction of other facial bone structures.</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Case Description</span><p id="par0010" class="elsevierStylePara elsevierViewall">A 26-year-old female worker from the health care sector with no history of substance abuse or any other relevant history was evaluated by the dermatology department for nasal septal perforation of 3 years’ duration accompanied by cacosmia, subjective nasal fullness, epistaxis, and frontal-orbital headache associated with instability. She had been seen in the emergency department on multiple occasions, but the physical examination and other tests had always been unremarkable.</p><p id="par0015" class="elsevierStylePara elsevierViewall">Evaluation by the ear, nose, and throat (ENT) department found no anomalies in any of the following tests: blood tests including serology for syphilis, angiotensin-converting enzyme, antinuclear antibodies, anti-DNA, antineutrophil cytoplasmic antibodies (ANCAs) with a cytoplasmic distribution, and ANCAs with a perinuclear distribution; urine toxicology; and bacterial cultures (all negative). Rhinoscopy showed septal perforation with invasive borders. Computed tomography showed septal perforation but no signs of disease in the sinuses or other bone structures (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>). Six punch biopsies were performed and histologic examination showed an ulcerated mucosa with fibrosis and inflammation of the chorion; there was no evidence of vasculitis, thrombosis, granulomas, or atypia (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>). The patient was prescribed topical and oral antibiotics for 18 months during follow-up at the ENT department but showed little improvement. A septal button was subsequently fitted but was removed 15 days later due to patient intolerance.</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0020" class="elsevierStylePara elsevierViewall">At this point, the patient was referred to the dermatology department as in addition to the unresolved septal perforation, she had linear erosions in the right facial and retroauricular region (<a class="elsevierStyleCrossRef" href="#fig0015">Fig. 3</a>). Histopathologic examination of the lesion behind the ear showed epidermal erosion but no associated alterations.</p><elsevierMultimedia ident="fig0015"></elsevierMultimedia><p id="par0025" class="elsevierStylePara elsevierViewall">Considering the findings and the exhaustive differential diagnosis, we established a diagnosis of exclusion of rhinotillexomania with dermatitis artefacta. The patient was started on oral aripiprazole 2.5<span class="elsevierStyleHsp" style=""></span>mg/d and then 5<span class="elsevierStyleHsp" style=""></span>mg/d. Four months later, the symptoms and facial lesions had disappeared, leaving just the irreparable nasal perforation. At the time of writing, the patient remains asymptomatic.</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Discussion</span><p id="par0030" class="elsevierStylePara elsevierViewall">Rhinotillexomania, or compulsive nose picking, was first described in 1995, when it was classified as an impulse control disorder and conceptualized as dermatitis artefacta.<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">1</span></a> In the current Diagnostic and Statistical Manual of Mental Disorders (fifth edition), rhinotillexomania is classified under a new category called <span class="elsevierStyleItalic">obsessive-compulsive disorder and related disorders</span>, which includes body dysmorphic disorder, trichotillomania, and excoriation disorder (skin picking).<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">2</span></a></p><p id="par0035" class="elsevierStylePara elsevierViewall">On rare occasions, rhinotillexomania can lead to complications, such as bacterial infections, serious nose bleeds, septal perforation, and destruction of other facial structures, including the ethmoidal sinuses<a class="elsevierStyleCrossRefs" href="#bib0060"><span class="elsevierStyleSup">3,4</span></a> and orbit wall.<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">5</span></a> Repeated nose picking has also been associated with other obsessive-compulsive behaviors, such as onychotillomania, onychophagia, and neurotic excoriations, among others.<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">6</span></a></p><p id="par0040" class="elsevierStylePara elsevierViewall">The etiology of obsessive-compulsive disorder lies in a complex system in which anomalous brain circuitry and chemical alterations have an important role. Links to alterations in the serotonin, glutamate, and dopamine pathways are also being studied.<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">6</span></a></p><p id="par0045" class="elsevierStylePara elsevierViewall">Rhinotillexomania is a diagnosis of exclusion that should be established only after ruling out other causes of septal perforation. The most common cause is cocaine use, but other causes include granulomatous disease (Wegener disease, sarcoidosis), infectious disease (Leishmania, leprosy, tuberculosis, syphilis), and malignancy.<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">7</span></a> The certainty of the diagnosis is enhanced by a history of psychiatric disease and improvement with treatment.</p><p id="par0050" class="elsevierStylePara elsevierViewall">Antipsychotic drugs are the first-line treatment for dermatitis artefacta. Aripiprazole is classified as an atypical third-generation antipsychotic and it acts as a partial dopamine D<span class="elsevierStyleInf">2</span> receptor agonist. It is as safe if not safer than its predecessors and has antidepressant and anti-anxiolytic properties when used at low doses.<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">8</span></a></p><p id="par0055" class="elsevierStylePara elsevierViewall">Patients with rhinotillexomania are frequently evaluated by numerous specialists and often seek a second opinion before a diagnosis is established. In addition, most of them undergo multiple examinations and tests before the absence of organic disease is confirmed. In an analysis of the financial impact of dermatitis artefacta in Ireland, Anwar et al.<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">9</span></a> calculated a cost of at least €64<span class="elsevierStyleHsp" style=""></span>500 per patient.</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Conflicts of Interest</span><p id="par0060" class="elsevierStylePara elsevierViewall">The authors declare that they have no conflicts of interest.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:4 [ 0 => array:2 [ "identificador" => "sec0005" "titulo" => "Case Description" ] 1 => array:2 [ "identificador" => "sec0010" "titulo" => "Discussion" ] 2 => array:2 [ "identificador" => "sec0015" "titulo" => "Conflicts of Interest" ] 3 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Martín-Callizo C, Sacristà M, Fortuño Y, Penín RM, Tribó MJ. Rinotilexomanía. Actas Dermosifiliogr. 2018;109:370–371.</p>" ] ] "multimedia" => array:3 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 648 "Ancho" => 900 "Tamanyo" => 96170 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Computed tomography scan showing perforation of the nasal septum but no other alterations.</p>" ] ] 1 => array:7 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 519 "Ancho" => 1500 "Tamanyo" => 377172 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Biopsy of nasal septum (hematoxylin-eosin staining, original magnification ×10).</p>" ] ] 2 => array:7 [ "identificador" => "fig0015" "etiqueta" => "Figure 3" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr3.jpeg" "Alto" => 694 "Ancho" => 900 "Tamanyo" => 93574 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Perforation of nasal septum and excoriations in the right orbital and retroauricular areas.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0015" "bibliografiaReferencia" => array:9 [ 0 => array:3 [ "identificador" => "bib0050" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Rhinotillexomania: Psychiatric disorder or habit?" 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| Year/Month | Html | Total | |
|---|---|---|---|
| 2024 November | 57 | 12 | 69 |
| 2024 October | 650 | 39 | 689 |
| 2024 September | 905 | 39 | 944 |
| 2024 August | 948 | 90 | 1038 |
| 2024 July | 1061 | 32 | 1093 |
| 2024 June | 978 | 48 | 1026 |
| 2024 May | 786 | 58 | 844 |
| 2024 April | 699 | 27 | 726 |
| 2024 March | 1035 | 29 | 1064 |
| 2024 February | 1726 | 35 | 1761 |
| 2024 January | 664 | 36 | 700 |
| 2023 December | 387 | 21 | 408 |
| 2023 November | 437 | 37 | 474 |
| 2023 October | 389 | 35 | 424 |
| 2023 September | 303 | 35 | 338 |
| 2023 August | 302 | 31 | 333 |
| 2023 July | 227 | 46 | 273 |
| 2023 June | 280 | 30 | 310 |
| 2023 May | 327 | 45 | 372 |
| 2023 April | 363 | 38 | 401 |
| 2023 March | 370 | 37 | 407 |
| 2023 February | 281 | 32 | 313 |
| 2023 January | 162 | 46 | 208 |
| 2022 December | 150 | 53 | 203 |
| 2022 November | 107 | 29 | 136 |
| 2022 October | 119 | 31 | 150 |
| 2022 September | 65 | 46 | 111 |
| 2022 August | 73 | 38 | 111 |
| 2022 July | 77 | 44 | 121 |
| 2022 June | 86 | 31 | 117 |
| 2022 May | 167 | 43 | 210 |
| 2022 April | 264 | 40 | 304 |
| 2022 March | 262 | 46 | 308 |
| 2022 February | 205 | 38 | 243 |
| 2022 January | 218 | 51 | 269 |
| 2021 December | 153 | 44 | 197 |
| 2021 November | 133 | 63 | 196 |
| 2021 October | 154 | 62 | 216 |
| 2021 September | 107 | 43 | 150 |
| 2021 August | 174 | 38 | 212 |
| 2021 July | 202 | 31 | 233 |
| 2021 June | 191 | 23 | 214 |
| 2021 May | 193 | 48 | 241 |
| 2021 April | 579 | 78 | 657 |
| 2021 March | 311 | 39 | 350 |
| 2021 February | 145 | 41 | 186 |
| 2021 January | 106 | 16 | 122 |
| 2020 December | 108 | 34 | 142 |
| 2020 November | 97 | 26 | 123 |
| 2020 October | 106 | 21 | 127 |
| 2020 September | 76 | 28 | 104 |
| 2020 August | 65 | 23 | 88 |
| 2020 July | 55 | 21 | 76 |
| 2020 June | 49 | 41 | 90 |
| 2020 May | 26 | 18 | 44 |
| 2020 April | 33 | 21 | 54 |
| 2020 March | 30 | 28 | 58 |
| 2020 February | 1 | 2 | 3 |
| 2020 January | 4 | 0 | 4 |
| 2019 December | 8 | 0 | 8 |
| 2019 November | 4 | 0 | 4 |
| 2019 September | 10 | 0 | 10 |
| 2019 August | 4 | 0 | 4 |
| 2019 July | 4 | 0 | 4 |
| 2019 June | 4 | 0 | 4 |
| 2019 May | 7 | 0 | 7 |
| 2019 April | 2 | 0 | 2 |
| 2019 March | 3 | 0 | 3 |
| 2019 February | 3 | 0 | 3 |
| 2018 December | 4 | 0 | 4 |
| 2018 November | 2 | 0 | 2 |
| 2018 October | 1 | 0 | 1 |
| 2018 September | 3 | 0 | 3 |
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