Scratching the Surface: Excoriation Behavior Revealing an Underlying Pediatric Acute-onset Neuropsychiatric Syndrome Flare

Pediatric acute-onset neuropsychiatric syndrome (PANS) is characterized by the abrupt onset of obsessive–compulsive symptoms or restricted eating, accompanied by additional neuropsychiatric manifestations following infectious or inflammatory triggers. We report a 12-year-old boy who presented with acute behavioral changes following a febrile illness, with spontaneous partial remission and subsequent relapse marked by prominent excoriation behavior. Clinical evaluation revealed elevated anti-streptolysin-O titers, normal neuroimaging and electroencephalogram findings, and symptom patterns fulfilling diagnostic criteria for PANS. The child showed marked clinical improvement following treatment with corticosteroids and antibiotics, with sustained remission at 6-month follow-up. This case highlights excoriation disorder as an uncommon but clinically relevant manifestation of PANS and underscores the importance of recognizing atypical obsessive–compulsive related behaviors in children presenting with sudden-onset neuropsychiatric symptoms.