Skin picking (excoriation)

Excoriation (also known as skin picking disorder and dermatillomania) is characterized by recurrent picking of the skin that interferes with daily life. Under the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5), the manual used for diagnosing mental illness, skin picking disorder is a type of obsessive-compulsive disorder (OCD).

Not everyone who picks their skin has excoriation, and it’s common for people to pick at their skin once in a while (at pimples, for instance). In contrast, skin picking disorder is more than just a bad habit—it is a diagnosable mental disorder. Individuals with excoriation disorder engage in skin picking as repetitive behavior, leading to tissue damage, infection, scabs, and possible scarring. Individuals with excoriation disorder also have trouble reducing or stopping their skin picking behavior.

Prevalence of Skin Picking Disorder

According to the International OCD Foundation, approximately 2–4 percent of the general population has a skin picking disorder. Researchers have found that excoriation typically arises around the onset of puberty and may be accompanied by other mental health challenges. According to a twin study on the heritability of skin picking, some environmental factors that may lead to skin picking disorder include genetics, stress, and the presence of other psychiatric conditions.

Excoriation disorder can affect children, adolescents, or adults. Individuals with skin picking disorder may also experience co-occurring mental health conditions, which may contribute to compulsive or self-injurious skin picking. Some related conditions include:

• Anxiety disorders
• Major depressive disorder
• Dysmorphic disorder
• Developmental disabilities
• Substance use disorders
• Psychiatric disorders
• Impulse control disorders
• Attention deficit hyperactivity disorder (ADHD)

Skin Picking Disorder Diagnosis

Excoriation disorder is a type of behavior known as body-focused repetitive behaviors (BFRBs), self-grooming behaviors in which individuals scratch, pick, bite, or pull at their hair, skin, or fingernails. Under the DSM-5, the diagnostic criteria of skin picking disorder include:

• Repetitive and compulsive behaviors that result in lesions
• Repeated attempts to stop chronic skin picking
• Clinical distress or impairment due to chronic skin picking

Additionally, pathologic skin picking behaviors must not be caused by substance use or a medical or dermatological condition such as eczema or psoriasis. For a diagnosis of excoriation disorder, skin picking behaviors must not be better explained by another psychiatric disorder.

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Symptoms of Skin Picking Disorder

Skin picking behaviors vary from person to person. Some people may pick skin from various areas of the body using their fingernails or tweezers, targeting both healthy skin and damaged skin. Others may focus on a specific body part, such as their cuticles.

The reasons behind picking behavior can also vary. Skin picking behavior might be related to boredom, impulses, or negative emotions. Like trichotillomania (hair pulling), individuals with dermatillomania may find relief from stress or tension after picking their skin. Meanwhile, other people don’t realize that they’re engaging in picking behaviors at all.

Depending on its severity, dermatillomania may cause significant distress and impact functioning in daily life. Individuals with skin picking disorder may spend a considerable amount of time trying to conceal their skin lesions and scabs, for example, by avoiding social situations. People with skin picking disorder may also experience feelings of shame, embarrassment, or guilt, low self-esteem, depression, or anxiety.

Medical Complications of Excoriation Disorder

Medical complications related to compulsive skin picking are not uncommon. Individuals who engage in repetitive picking may experience:

• Infection, which may require medical treatment with antibiotics
• Open wounds and noticeable tissue damage
• Minor skin irregularities, such as scabs, sores, blemishes, or lesions
• Discoloration
• Scarring
• Disfigurement

Treatment Options for Excoriation Disorder

Although overcoming the compulsive urge to pick your skin can feel impossible, help is available. With a combination of therapy and medication, many individuals with mental illness notice significant reductions in their symptoms, allowing them to live more fulfilling lives. Some helpful treatment options for excoriation include:

• Therapy: Working with a psychologist, counselor, or therapist can help individuals with excoriation identify their triggers and develop new skills to cope with compulsive skin picking. CBT, an effective treatment for other types of repetitive behavior disorders, has shown success in treating skin picking disorder, according to the Oxford University Press.
• Medication. According to research published in the American Journal of Psychiatry, in more severe cases of excoriation disorder, your clinician may recommend medication to help improve symptoms. Medications commonly prescribed to treat excoriation disorder and related disorders include antidepressants such as selective serotonin reuptake inhibitors (SSRIs, i.e., fluoxetine). Clinical trials are also investigating the use of anticonvulsant medicines such as Lamictal, supplements such as N-acetyl cysteine, and naltrexone, an opioid-blocking medication, to treat excoriation.
• Check-ups. It’s important to schedule regular check-ups with your clinician, who can rule out medical conditions that may contribute to your symptoms. If you have a skin condition such as psoriasis, be sure to see your dermatologist for treatment.
• Hotlines. If you’re experiencing a mental health crisis, call the  National Suicide Prevention Lifeline at 1-800-273-8255.

Therapy for Obsessive-Compulsive Disorders

Although excoriation disorder is a chronic condition, behavioral interventions can help improve symptoms and help individuals cope with obsessions and compulsions. Some helpful types of therapy for obsessive-compulsive disorders such as dermatillomania include:

• Habit reversal therapy. In  habit reversal training, you’ll work with a psychologist or counselor to identify situations, stressors, or other factors that trigger compulsive picking. Then, your therapist will help you find other behaviors to do instead of picking, such as squeezing a rubber ball.
• Stimulus control.  Stimulus control involves changing your environment to minimize skin picking behaviors. For example, you might try wearing bandages to prevent the urge to pick. Alternatively, you might cover mirrors if seeing acne or pimples triggers picking.
• Cognitive-behavioral therapy (CBT). CBT, which involves a combination of cognitive therapy and behavior therapy, promotes cognitive flexibility by replacing unhelpful thoughts with more helpful ones. CBT is also an effective treatment for several other related psychiatric conditions, according to the Trichotillomania Learning Center Foundation (TLC Foundation).
• Acceptance and commitment therapy (ACT). ACT helps reduce compulsive picking by adopting an ‘acceptance’ approach toward negative emotions and thoughts while finding new ways to respond.
• Psychodynamic therapy. Psychodynamic therapy can help explore past experiences to reveal the reasons behind skin picking behaviors.

To find a therapist, reach out to a mental health professional through WithTherapy. We’ll connect you to someone you feel comfortable with, regardless of your personal preferences and requirements. One of the licensed mental health providers on the WithTherapy platform will help you navigate your mental health to live a happier, healthier life.

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