Case Presentation: The case represents a 74-year-old female who presented to the emergency room with constitution of symptoms including headache, fatigue, Upper extremity/Neck pain and worsening of “skin rash”. For the past 10 years, the patient had suffered from Compulsive Skin picking disorder, necessitating multiple visits to PCP and Dermatologist with recurrent courses of antibiotics and Hydroxyzine for superimposed cellulitis and superficial wound infections. Per Family, the patient is noticeably picking and scabbing her back, her skin demonstrating excoriations and open wounds of various size and depth with chronic scarring. During hospitalization, the patient was noted to be septic from presumably skin/Cellulitis infection and was started on broad spectrum antibiotics Cefepime and Vancomycin. Later, the same day her blood cultures came back positive for MRSA. Unfortunately, less than 24 hours into admission, the patient suffered cardiac arrest from septic shock in the setting of poor cardiopulmonary reserve with low ejection fraction and chronic pulmonary hypertension. The patient was resuscitated per ACLS protocol and intubated requiring multiple vasopressors while in ICU. Over a period of time, the patient developed multiorgan failure, rib fractures and pneumomediastinum secondary to aggressive CPR. Subsequently MRI brain revealed evidence of multiple embolic strokes concerning endocarditis, but Transesophageal Echocardiogram was not pursued, as it would not change the prognosis. The patient was transitioned to comfort care as per family wishes, which later resulted in her demise. In spite of broad-spectrum antibiotics, bacteremia was not contained, with evidence of high bacterial burden as repeat blood cultures remained positive even prior to withdrawal of care.

Discussion: Skin picking disorder (SPD) / Excoriation disorder / Dermatillomania is the condition where a patient compulsively picks or scratches their skin, causing injuries or scarring, visible tissue damage and impairment in social functioning. Patients with SPD may present with features of impulse control disorder. SPD appears as excoriated, polymorphic and varying sized lesions with wide variation in extent and severity. Skin is largest organ of body and its epidermal integrity vital for maintaining osmotic balance, to exclude microorganism serving as first line of defense in fighting infection, consistent scratching can act as breeding ground for these agents to not only impair healing but also exposing inner organs to fatal damage – cellulitis, Bacteremia, Osteomyelitis.

Conclusions: This case illustrates the potential life-threatening manifestations of skin picking disorder – Bacteremia and Septic shock. SPD includes 5 diagnostic criteria- Recurrent skin picking; repeated attempts to stop skin picking; impairment in social, occupational, or other important areas of functioning, not attributable to effects of substance or other medical condition, not better accounted for by another DSM-5 disorder. Given shortage of Behavior Health Providers, early recognition of this disorder and the potential rare life-threatening complication like this, should prompt early trial of pharmacological therapy (including SSRI) by PCP and who may then further consider role of Cognitive Behavior therapy and antipsychotics through psychiatric/ psychodermatological referral. We recommend medical continuity awareness on intervention that impacts the root cause of SPD rather than reactively treating symptoms.