An elderly nursing-home patient with early Alzheimer’s disease picks the front of her scalp (to the point of bleeding and infection) and pulls out her hair. There is no apparent skin pathology in the area. I have asked the nursing home staff to trim her nails and have tried potent topical corticosteroids and doxepin (Zonalon) cream, but the problem continues. What other options exist?
—Melissa Raue, PA, Pound Ridge, N.Y.
The management for this woman has three components: (1) Exclude local or systemic disease as the underlying cause of her cutaneous lesions; (2) treat the secondary complications, such as infection, with appropriate topical and/or systemic antibiotics; (3) prevent the effects of her chronic picking. In addition to nail trimming, using a barrier (such as an occlusive dressing or a swimming/shower cap) to cover the area being injured may initially help promote healing and possibly result in the resolution of her picking.
—Philip R. Cohen, MD (105-11)