Excoriation disorder is characterized by recurrent picking of one's skin, resulting in skin lesions. Treatment is with habit reversal training, glutamate modulators, and/or selective serotonin reuptake inhibitors.
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). 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, approximately 2 to 3% of people have the disorder; 60 to 75% of them are female (1–3).
General references
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 Res.161:412-418, 2023. doi: 10.1016/j.jpsychires.202T3.03.034.
2. Torales J, Díaz NR, Barrios I, Navarro R, García O, O'Higgins M, Castaldelli-Maia JM, Ventriglio A, Jafferany M. Psychodermatology of skin picking (excoriation disorder): A comprehensive review. Dermatol Ther. 33:e13661, 2020.
3. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 5th ed, Text Revision. American Psychiatric Association Publishing; 2022:284-287.
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 picking and sometimes 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, such as hair pulling or nail biting, as well as obsessive-compulsive disorder or major depressive disorder (1).
If severe, skin picking can cause scarring, infections, excessive bleeding, and even sepsis.
Symptoms and signs reference
1. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 5th ed, Text Revision. American Psychiatric Association Publishing; 2022:284-287.
Diagnosis of Excoriation Disorder
Psychiatric assessment
General medical evaluation to exclude other causes
Clinical criteria for diagnosis of excoriation disorder from the Diagnostic and Statistical Manual of Mental Disorders, 5th edition, Text Revision (DSM-5-TR) include (1) the following:
Visible skin lesions caused by recurrent picking (although some patients try to camouflage lesions with clothing or makeup)
Repeated attempts to decrease or stop the picking
Significant distress and/or impairment in functioning from the activity
The skin picking must not be due to the physiologic effects of a substance (eg, cocaine, stimulants) or another medical condition (eg, scabies). It also must not be better explained by another mental disorder (eg, delusions or tactile hallucinations in a psychotic disorder, or attempts to remove or improve a perceived defect or flaw in appearance in body dysmorphic disorder).The skin picking must not be due to the physiologic effects of a substance (eg, cocaine, stimulants) or another medical condition (eg, scabies). It also must not be better explained by another mental disorder (eg, delusions or tactile hallucinations in a psychotic disorder, or attempts to remove or improve a perceived defect or flaw in appearance in body dysmorphic disorder).
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).
Diagnosis reference
1. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 5th ed, Text Revision. American Psychiatric Association Publishing; 2022:284-287.
Treatment of Excoriation Disorder
Cognitive-behavioral therapy (specifically, habit reversal training)
N-acetylcysteine (NAC) or memantine (glutamate modulators/antagonists)-acetylcysteine (NAC) or memantine (glutamate modulators/antagonists)
Sometimes selective serotonin reuptake inhibitors (SSRIs) or clomipramineSometimes selective serotonin reuptake inhibitors (SSRIs) or clomipramine
Cognitive-behavioral therapy that is tailored to treat the specific symptoms of excoriation disorder is the psychotherapy of choice (1, 2). 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)
The glutamate modulators/inhibitors N-acetylcysteine (NAC) and memantine may reduce symptom severity and are increasingly considered the first-line medication treatment for excoriation (skin-picking) disorder. In small randomized trials, -acetylcysteine (NAC) and memantine may reduce symptom severity and are increasingly considered the first-line medication treatment for excoriation (skin-picking) disorder. In small randomized trials,N-acetylcysteine and memantine resulted in reduced skin-picking symptoms significantly more often than placebo (-acetylcysteine and memantine resulted in reduced skin-picking symptoms significantly more often than placebo (1, 2).
SSRIs may be useful for coexisting depression or anxiety disorders, and limited evidence suggests that these medications can also reduce skin picking (3, 4).
Treatment references
1. Lochner C, Roos A, Stein DJ. Excoriation (skin-picking) disorder: a systematic review of treatment options. Neuropsychiatr Dis Treat. 2017;13:1867-1872. Published 2017 Jul 14. doi:10.2147/NDT.S121138
2. Selles RR, McGuire JF, Small BJ, Storch EA. A systematic review and meta-analysis of psychiatric treatments for excoriation (skin-picking) disorder. Gen Hosp Psychiatry. 2016;41:29-37. doi:10.1016/j.genhosppsych.2016.04.001
3. Simeon D, Stein DJ, Gross S, et al. A double-blind trial of fluoxetine in pathologic skin picking. . A double-blind trial of fluoxetine in pathologic skin picking.J Clin Psychiatry. 58(8):341-347, 1997. doi: 10.4088/jcp.v58n0802
4. Bloch MR, Elliott M, Thompson H, et al. Fluoxetine in pathologic skin-picking: open-label and double-blind results. . 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
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 try to stop picking their skin or do it less often, but they cannot.
Excoriation disorder causes visible skin lesions (although they may be hidden—–eg, by clothes, hair, or makeup).
Treat using cognitive-behavioral therapy that is tailored to treat specific excoriation symptoms (specifically habit reversal training) and/or N-acetylcysteine, memantine, or an SSRI.-acetylcysteine, memantine, or an SSRI.
Drugs Mentioned In This Article
