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Excoriation (Skin-Picking) Disorder

by Katharine A. Phillips, MD, Dan J. Stein, MD, PhD

Excoriation disorder is characterized by recurrent picking of one's skin resulting in skin lesions.

Patients with excoriation disorder repeatedly pick at or scratch their skin for noncosmetic reasons (ie, not to remove a lesion that they perceive as unattractive or possibly cancerous). Some patients pick at healthy skin; others pick at minor lesions such as calluses, pimples, or scabs.

Some patients pick at their skin somewhat automatically (ie, without full awareness); others are more conscious of the activity. The picking is not triggered by obsessions or concerns about appearance but may be preceded by a feeling of tension or anxiety that is relieved by the picking, which often is also accompanied by a feeling of gratification.

Skin picking often begins during adolescence, although it may begin at various ages. At any given point in time, about 1 to 2% of people have the disorder. About 75% of them are female.

Symptoms and Signs

Skin picking is usually chronic, with waxing and waning of symptoms. Sites of skin picking may change over time. Patterns of skin picking vary from patient to patient. Some have multiple areas of scarring; others focus on only a few lesions. Many patients try to camouflage the skin lesions with clothing or make-up.

Skin picking may be accompanied by a range of behaviors or rituals. Patients may search fastidiously for a particular kind of scab to pull; they may try to ensure that the scab is pulled off in a particular way (using either fingers or an implement) and may bite or swallow the scab once it has been pulled off.

Patients may feel embarrassed by or ashamed of the appearance of the skin-picking sites. Patients may avoid situations in which others may see the skin lesions and typically do not pick in front of others, except for family members. Some patients may pick the skin of other people. Many also have other body-focused repetitive behaviors (see Body-Focused Repetitive Behavior Disorder), such as hair pulling ( Trichotillomania (Hair-Pulling Disorder)) or nail biting.

Diagnosis

  • Clinical criteria

To meet diagnostic criteria, patients must typically

  • Cause visible skin lesions (although some patients try to camouflage lesions with clothing or makeup)

  • Make repeated attempts to stop the picking

  • Experience significant distress or impairment from the activity

The distress can include feelings of embarrassment or shame (eg, at loss of control of one's behavior, at the cosmetic consequences of the skin lesions).

Treatment

  • SSRIs

  • Cognitive-behavioral therapy

SSRIs may be useful for coexisting depression or anxiety disorders, and some evidence suggests that these drugs can also reduce skin picking to some degree.

Cognitive-behavioral therapy that is tailored to treat the specific symptoms of skin-picking disorder is currently the psychotherapy of choice. For example, habit reversal, a predominantly behavioral therapy, can be used; it includes awareness training (eg, self-monitoring, identification of triggers for the behavior), stimulus control (modifying situations—eg, avoiding triggers—to reduce the likelihood of initiating picking), and competing response training (substituting other behaviors for skin picking).

* This is a professional Version *