Patients with excoriation disorder repeatedly pick at or scratch their skin; the picking is not triggered by appearance or health concerns (eg, 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 (which may be a symptom of body dysmorphic disorder Body Dysmorphic Disorder Body dysmorphic disorder is characterized by preoccupation with perceived defects in physical appearance that are not apparent or appear only slight to other people. The preoccupation with appearance... read more ). However, the skin picking 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 3% of people have the disorder. About 75% of them are female (1 General reference 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; the picking... read more ).
1. Farhat LC, Reid M, Bloch MH, et al: Prevalence and gender distribution of excoriation (skin-picking) disorder: A systematic review and meta-analysis. J Psychiatr Res161:412-418, 2023. doi: 10.1016/j.jpsychires.2023.03.034.
Symptoms and Signs of Excoriation Disorder
Skin picking is usually chronic, with waxing and waning of symptoms if untreated. 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 makeup.
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 repeatedly try to stop picking their skin or to pick 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 perhaps 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 Body-Focused Repetitive Behavior Disorder Body-focused repetitive behavior disorder is characterized by body-focused repetitive behaviors other than skin picking (excoriation) or hair pulling (trichotillomania) (eg, nail biting, lip... read more , such as hair pulling Trichotillomania Trichotillomania is characterized by recurrent pulling out of one's hair resulting in hair loss. Patients with trichotillomania repeatedly pull or pluck out their hair for noncosmetic reasons... read more 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 Obsessive-Compulsive Disorder (OCD) Obsessive-compulsive disorder (OCD) is characterized by recurrent, persistent, unwanted, and intrusive thoughts, urges, or images (obsessions) and/or by repetitive behaviors or repetitive mental... read more or major depressive disorder Major depressive disorder (unipolar depressive disorder) Depressive disorders are characterized by sadness severe enough or persistent enough to interfere with function and often by decreased interest or pleasure in activities. Exact cause is unknown... read more .
Diagnosis of Excoriation Disorder
Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, Text Revision (DSM-5-TR) criteria
To meet diagnostic criteria for excoriation disorder, patients must typically
Cause visible skin lesions by picking (although some patients try to camouflage lesions with clothing or makeup)
Make repeated attempts to decrease or stop the picking
Experience significant distress or impairment in functioning 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 of Excoriation Disorder
Cognitive-behavioral therapy (usually habit reversal training)
Selective serotonin reuptake inhibitors (SSRIs) or clomipramine
N-acetylcysteine or memantine (glutamate modulators)
Cognitive-behavioral therapy that is tailored to treat the specific symptoms of excoriation disorder is the psychotherapy of choice. Habit reversal training, 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 picking)
Competing response training (teaching patients to substitute other behaviors, such as clenching their fist, knitting, or sitting on their hands, for skin picking)
SSRIs Selective Serotonin Reuptake Inhibitors (SSRIs) Several drug classes and drugs can be used to treat depression: Selective serotonin reuptake inhibitors (SSRIs) Serotonin modulators (5-HT2 blockers) Serotonin-norepinephrine reuptake inhibitors... read more or clomipramine may be useful for coexisting depression or anxiety disorders, and limited evidence suggests that these medications can also reduce skin picking (1, 2 Treatment references 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; the picking... read more ).
The glutamate modulators N-acetylcysteine and memantine appear to help reduce symptom severity, but more data are needed to support the long-term efficacy and safety of these approaches. In small randomized trials, N-acetylcysteine and memantine resulted in reduced skin-picking symptoms compared with placebo (3, 4 Prognosis references Influenza is a viral respiratory infection causing fever, coryza, cough, headache, and malaise. Mortality is possible during seasonal epidemics, particularly among high-risk patients (eg, those... read more ).
1. Simeon D, Stein DJ, Gross S, et al : A double-blind trial of fluoxetine in pathologic skin picking. J Clin Psychiatry 58(8):341-347, 1997. doi: 10.4088/jcp.v58n0802
2. Bloch MR, Elliott M, Thompson H, et al: Fluoxetine in pathologic skin-picking: open-label and double-blind results. Psychosomatics 42(4):314-319, 2001. doi: 10.1176/appi.psy.42.4.314
3. 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
4. Grant JE, Chesivoir E, Valle S, et al: Double-blind placebo-controlled study of memantine in trichotillomania and skin-picking disorder. Am J Psychiatry 180(5):348-356, 2023. doi: 10.1176/appi.ajp.20220737
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 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 training) and/or an SSRI, clomipramine, N-acetylcysteine, or memantine.
Drugs Mentioned In This Article
|Drug Name||Select Trade|
|Acetadote, CETYLEV, Mucomyst, Mucosil Acetylcysteine|
|Namenda, Namenda XR|
|Prozac, Prozac Weekly, Sarafem, Selfemra|