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Excoriation (Skin-Picking) Disorder

By

Katharine A. Phillips

, MD, Weill Cornell Medical College;


Dan J. Stein

, MD, PhD, University of Cape Town

Last full review/revision Jun 2018| Content last modified Jun 2018
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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 with excoriation disorder typically try to stop picking their skin or to do it less often, but they are unable to do so.

Patients may feel embarrassed by or ashamed of the appearance of the skin-picking sites or of their inability to control their behavior. As a result, patients may avoid social situations in which others may see the skin lesions; they typically do not pick in front of others, except for family members. Patients may be impaired in other areas of functioning (eg, occupational, academic), mainly because they avoid social situations.

Some patients may pick the skin of other people. Many also have other body-focused repetitive behaviors, such as hair pulling or nail biting.

If severe, skin picking can cause scarring, infections, excessive bleeding, and even septicemia.

Many people with excoriation disorder also have other mental health disorders, such as obsessive-compulsive disorder or major depressive disorder.

Diagnosis

  • Clinical criteria

To meet diagnostic criteria for excoriation disorder, 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, due to loss of control of one's behavior or the cosmetic consequences of the skin lesions).

Treatment

  • N-Acetylcysteine

  • SSRIs

  • Cognitive-behavioral therapy (usually habit reversal)

In a controlled trial, N-acetylcysteine was more effective than placebo in patients with excoriation disorder (1).

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, although data are limited.

Cognitive-behavioral therapy that is tailored to treat the specific symptoms of excoriation disorder is currently the psychotherapy of choice. Habit reversal, a predominantly behavioral therapy, has been best studied; it includes the following:

  • Awareness training (eg, self-monitoring, identification of triggers for the behavior)

  • Stimulus control (modifying situations—eg, avoiding triggers—to reduce the likelihood of initiating pulling)

  • Competing response training (teaching patients to substitute other behaviors, such as clenching their fist, knitting, or sitting on their hands, for hair pulling)

Treatment reference

  • 1. Grant JE, Chamberlain SR, Redden SA, et al: N-Acetylcysteine in the treatment of excoriation disorder: A randomized clinical trial. JAMA Psychiatry 73 (5):490–496, 2016. doi: 10.1001/jamapsychiatry.2016.0060.

Key Points

  • In excoriation (skin-picking) disorder, skin 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 skin picking, often followed by a feeling of gratification.

  • Patients with excoriation disorder typically try to stop picking their skin or to do it less often, but they cannot.

  • Excoriation disorder causes visible skin lesions.

  • Treat using cognitive-behavioral therapy that is tailored to treat specific excoriation symptoms (including habit reversal) and/or N-acetylcysteine or an SSRI.

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NOTE: This is the Professional Version. CONSUMERS: Click here for the Consumer Version
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