An Overview of Excoriation (Skin Picking) Disorder

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Excoriation (skin-picking) disorder is a psychiatric disorder where a person has a compulsion to repeatedly pick their own skin. Excoriation disorder is considered a condition related to body-focused repetitive behaviors (BFRBs).

BFRBs are self-grooming behaviors where a person pulls, picks, scrapes, or bites their own hair, skin, or nails. The frequency and intensity of these behaviors can damage the body and may lead to conditions such as trichotillomania and onychophagia.

The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5), classifies skin-picking disorders in the larger category of "Obsessive-Compulsive and Related Disorders." However, not all mental health and medical professionals agree that the disorder should be separate; rather, some assert that skin picking is usually a symptom of a mental health condition (such as obsessive compulsive disorder) or related to a skin condition like psoriasis that causes itching and discomfort.

DSM-5 Diagnostic Criteria

To be diagnosed with excoriation disorder, all of the following criteria must be met:

  1. Recurrent skin picking that results in skin lesions
  2. Repeated attempts to stop the behavior
  3. The symptoms cause clinically significant distress or impairment
  4. The symptoms are not caused by a substance or medical, or dermatological condition
  5. The symptoms are not better explained by another psychiatric disorder

Symptoms

Excoriation disorder is believed to affect between 1.4% to 5.4% of adults in the United States. It's more common in women than in men.

Skin picking that meets diagnostic criteria for excoriation disorder far exceeds the normal washing and exfoliating on the continuum of self-grooming behaviors. The repeated picking, scraping, or gouging that occurs in excoriation disorder can last for hours and may cause infection, scarring, and disfigurement.

The disorder is considered to be chronic and symptoms tend to wax and wane over time. People often pick at multiple body sites for extended periods. Both healthy and previously damaged areas of skin may be targeted.

The primary site may change over time. For example, someone may begin picking the skin of their face (the most common site) then move on to their scalp, neck, or limbs.

Most people use their fingers and fingernails to pick at their skin but some use sharp cosmetic tools such as needles and tweezers.

Causes

Excoriation disorder often begins in adolescence and may initially be associated with acne (although pathological skin picking behavior can start at any age).

It is likely that there is no single cause for the disorder, but rather, that is is the result of an interplay between genetic, biological, and environmental factors.

Skin-picking disorders have also been associated with childhood trauma and abuse, developmental disabilities, and an impaired ability to regulate emotion and manage stress.

Common triggers for skin picking reported by people with excoriation disorder include:

  • An urge or physical tension, unpleasant emotions, cognitions (which may include permission-giving thoughts or beliefs about how the skin should look and feel)
  • Skin sensations (from a bump, sore spot, etc.)
  • A displeasing aspect of one's appearance (such as a visible blemish)

After engaging in skin picking, people with the disorder usually feel relief as the urge is reduced and may even find the behavior enjoyable.

In fact, a key feature of the disorder that differentiates it from other compulsive disorders is that people with excoriation disorder often do find the act of picking their skin to be pleasurable—whereas the compulsions of OCD are distressing and intrusive.

However, they also experience the consequences of skin picking, such as:

  • Scarring
  • Skin infections
  • Depression and anxiety
  • Social avoidance and isolation
  • Reduced productivity (especially when skin picking sessions are prolonged)

Excoriation disorder can have a significant effect on someone's life. A person who has been picking their skin may go to great lengths to cover or hide the damaged areas. Feelings of shame and embarrassment may cause them to completely avoid social situations and activities. When people with the disorder become isolated, they may even fail to seek medical care. 

Treatment

Evidence-based treatment for excoriation disorder includes a type of cognitive-behavioral therapy (CBT) called habit reversal training (HRT).

Habit Reversal Training

HRT aims to help people develop skills to reduce their harmful behaviors such as:

  • Self-monitoring (awareness training)
  • Identification of behavior triggers
  • Modifying the environment to decrease the likelihood of picking behavior (stimulus control)
  • Identifying a substitution behavior that is incompatible with skin picking (competing for response training)

Acceptance and commitment therapy (ACT) and dialectical behavior therapy (DBT) have also been shown to help some people with trichotillomania, a disorder similar to skin picking.

Skin picking and other BFRBs are common symptoms of developmental disabilities and may also occur in people with autism. People in these groups sometimes have success wearing gloves or using behavioral interventions (such as sitting on their hands, for example) to curb skin picking.

As of 2020, there is no FDA-approved pharmacological treatment for excoriation disorder. Some studies have suggested certain antidepressants called selective-serotonin reuptake inhibitors (SSRIs) might help some people with the disorder but the research is limited and results have been mixed. It may be that SSRIs are most helpful if someone also has depression or anxiety that is contributing to the skin picking behaviors. 

N-Acetylcysteine (NAC), an amino acid that affects brain levels of a neurotransmitter called glutamate, is also being explored as a potential treatment. When taken as a dietary supplement, NAC has shown some promise results for decreasing skin picking behavior in adult women.

A Word From Verywell

Excoriation disorder can significantly impact a person's life. The chronic, intense skin picking can lead to infections and scarring, which can contribute to feelings of shame and embarrassment about the condition. If you or a loved one has symptoms of a skin-picking disorder, know that a doctor or mental health professional can use specific criteria to diagnose the condition—which is the first step to getting treated. OCD-related disorders can often be managed using a combination of methods, such as therapy, medication, mindfulness, and behavior modification. People with excoriation disorder or other OCD-related conditions may find support groups to be beneficial, especially when they are first learning to live with the condition and are exploring treatment options.

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Article Sources

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