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Excoriation Disorder (aka Skin Picking Disorder): Information for Primary Care

Summary: Excoriation disorder is a condition characterized by self-inflicted skin lesions caused by repetitive picking or scratching. As there is no obvious physical cause that can be found, it is understood to be a physical manifestation of emotional distress. It is also referred to by the following names: skin picking disorder, psychogenic excoriation, neurotic excoriation and dermatillomania. Excoriation disorder results in impairments in social functioning and comorbid psychiatric disorders often exist. Skin complications such as infection, scarring and disfigurement are also common. Interventions include counseling, medication and treatment of skin complications. Patients often turn to their primary care providers when faced with emotional distress. As such, the primary care provider has an important role to play in identifying the disorder and implementing a multidisciplinary approach to management.
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Case

  • A 35 year old female comes to your office complaining of itchy skin and a lesion on her forearm that she thinks is infected.
  • She describes an intense urge to scratch and pick the skin on her arms and legs, which has resulted in bleeding, scabbing and even some scars.
  • She describes herself as a worrier and feels a sense of relief after the behaviour.
  • She says, “I’ve tried to stop many times but I haven’t been able to.”
  • The behaviour is getting worse and she is worried about developing more scars.
  • She already avoids social settings throughout the spring and summer when clothing exposes the skin lesions and scarred areas of her arms and legs.
  • How are you going to help your patient?

Epidemiology

  • Incidence / prevalence in the general population is not known but is thought to be common and under-reported (Cyr, 2001)
  • Age of onset: Age 15-45 (Park, 2016)
  • Primarily affects females (APA, 2013)
  • Incidence among patients in dermatology clinics is 2% (Cyr, 2001)
  • Prevalence among patients with pruritis is 9% (Cyr, 2001)

Signs and Symptom

  • An irresistible urge to pick, scratch, dig or scrape the skin that results in noticeable tissue damage (Park, 2016)
  • A feeling of temporary relief from emotional distress after the behaviour occurs. (Selles, 2016; Mavrogiorgou, 2015)
  • The behaviour may be initiated by a minor skin pathology or on healthy skin (Scheinfeld, 2016)
  • Use of instruments such as tweezers, pins, scissors or knives (Mavrogiorgou, 2015)
  • Considerable time spent picking, often several hours per day, and worse in the evenings (Park, 2016)
  • The behaviour sometimes occurs in a dissociative state (Mavrogiorgou, 2015)
  • Attempts to resist or stop the behaviour (Craig-Müller, 2015)
  • Reluctance to show areas of damaged skin (Mavrogiorgou, 2015)
  • Impairments in social functioning (Selles, 2016; Mavrogiorgou, 2015)
  • Psychiatric comorbidities (Park, 2016; Cyr, 2001)

Screening/Diagnostic Tools

The Skin Picking Impact Scale 

  • A self-report questionnaire that measures psychosocial impact, i.e. how it affects function at school, work and home (Craig-Müller, 2015; Snorrason, 2013; Stargell, 2016) 

The Skin Picking Scale 

  • A self-report questionnaire that may help assess severity (Craig-Müller, 2015) 

History

Excoriation disorder is a diagnosis of exclusion.

 

History should be directed to rule out the following: (Craig-Müller, 2015; Park, 2016)

  • Primary skin disorder
  • Systemic diseases that cause chronic pruritis
  • Other psychocutaneous syndromes
  • Medication reactions
  • Illicit drug use (cocaine, opioids)
  • Comorbid psychiatric conditions

The history should also include details of the picking behavior. The following questions may be helpful: (Craig-Müller, 2015)

  • Location: What parts of your body do you pick?
  • Timing: How often do you pick your skin? For how long do you pick?
  • Method: Do you use anything besides your fingers to pick your skin?
  • Severity: Has picking your skin resulted in medical complications? Do you find yourself avoid social situations as a result of your skin picking?
  • Context: Can you describe how you feel before, during and after picking your skin?
  • Impact: Have you ever tried to resist picking your skin? Does the behavior cause you significant distress?

DSM-V Criteria

Excoriation disorder is listed under the group of Obsessive-Compulsive and Related Disorders and includes the following diagnostic criteria (APA, 2013)

  • Recurrent skin picking resulting in skin lesions.
  • Repeated attempts to decrease or stop skin picking.
  • The skin picking causes clinically significant distress or impairment in social, occupational or other important areas of functioning.
  • The skin picking is not attributable to the physiologic effects of a substance (eg. cocaine) or another medical condition (eg. scabies).
  • The skin picking is not better explained by the symptoms of another mental disorder (eg. delusions or tactile hallucinations in a psychotic disorder, attempts to improve a perceived defect or flaw in appearance in body dysmorphic disorder, stereotypes in stereotypic movement disorder, or intention to harm oneself in nonsuicidal self-injury).

Differential Diagnosis

  • Differential includes the following (Craig-Müller, 2015; Scheinfeld, 2016; Park, 2016):
  • Primary skin disorders
    • Atopic dermatitis
    • Contact dermatitis
    • Psoriasis
    • Scabies
    • Bullous pemphigoid
    • Folliculitis
    • Chronic urticarial
    • Dermatitis herpetiformis
    • Xerosis
    • Lichen planus
  • Systemic conditions causing chronic pruritis
    • Hematologic: iron deficiency anemia, polycythemia vera, lymphoma
    • Endocrine: hypothyroidism, hyperthyroidism, diabetes mellitus
    • Renal: uremia, chronic kidney disease
    • Hepatic: cholestasis, primary biliary cholangitis
    • Gastrointestinal: malignancy, intestinal parasitosis
    • Neurologic: multiple sclerosis, post-herpetic neuralgia, Prader-Willi syndrome
    • Infectious: HIV infection, Hepatitis B, Hepatitis C
    • Drug induced
  • Psychocutaneous syndromes
    • Dermatitis artefacta
    • Delusional parasitosis
    • Body dysmorphic disorder 

Comorbid Diagnoses

  • Depression
  • Anxiety
  • Obsessive-compulsive disorder
  • Body dysmorphic disorder
  • Trichotillomania
  • Onychophagia
  • Alcohol use disorder
  • Obsessive compulsive personality disorder
  • Borderline personality disorder

Physical Examination

  • Physical exam should be performed to rule out diagnoses in the differential and should include:
    • General physical exam
    • Detailed skin exam, which may show
      • Skin lesions of various sizes ranging from mild to severe. (Grant, 2012; Park, 2016)
      • New lesions appearing as linear erosions with or without a serosanguinous crust (Scheinfeld, 2016)
      • Older lesions appearing as hypertrophic nodules with hypo or hyperpigmentation (Scheinfeld, 2016)
      • Complications such as infection, scarring and disfigurement. (Park, 2016)
      • Location of lesions: Typically located in easily accessible areas such as the scalp, face, shoulders, upper back and extensor surfaces of the extremities. (Park, 2016, Cyr, 2001)
      • Distribution of lesions: Often symmetrical (Cyr, 2001)

Investigations

  • Investigations are not diagnostic but should be used to help rule out diagnoses in the differential and may include (Craig-Müller, 2015):
    • CBC, fasting glucose, Cr, liver function tests, TSH
    • Serology for HIV, Hepatitis B, Hepatitis C
    • Malignancy work-up
    • Skin biopsy

Psychotherapy 

  • Consider referral to professionals who can provide:
    • Cognitive Behavioural Therapy (CBT)
      • The role of CBT is to change automatic thoughts and replace picking behavior with other healthy rituals, such as applying lubricants or distraction (Selles, 2016; Stargell, 2016; Cyr, 2001) 
    • Habit Reversal Therapy (HRT)
      • The role of HRT involves awareness training and using operant conditioning strategies to replace picking with more adaptive behaviours (Selles, 2016; Stargell, 2016; Cyr, 2001)
    • Acceptance/Commitment Therapy (ACT)
      • ACT teaches patients how to accept unpleasant thoughts and emotions, and then use behaviour-change techniques to change those unhelpful behaviours (Capriotti et al., 2015)

Management in Primary Care: Non–Pharmacological

  • Dermatologic Therapies
    • The use of mild soaps and lubricants along with decreasing the frequency of washing may help with pruritis (Park, 2016)
       
  • Physical Barriers
    • The use of physical barriers such as an Unna sleeve may help prevent picking easily accessible areas.

Management in Primary Care: Pharmacological

  • Dermatologic Therapies
    • Antihistamines to reduce pruritis
    • Antibiotics to treat infection
    • Topical steroids to decrease redness, swelling and pruritis (Craig-Müller, 2015; Cyr, 2001)
       
  • If possible, consult psychiatry prior to initiating treatment with psychotropic medications which include:
    • Antidepressants (SSRIs)
      • Fluoxetine 20mg daily (can increase up to 60 mg daily)
      • Citalopram 20mg daily (can increase up to 40mg daily)
      • Escitalopram 10mg daily (can increase up to 20mg daily)
      • Fluvoxamine 25mg daily (can increase up to 300mg daily)
      • Sertraline 25mg daily (can increase up to 200mg daily)
    • Glutamate-modulating drugs
      • N-acetylcysteine 1200mg – 3000mg daily 
    • Evidence for SSRIs and N-acetylcysteine consists of relatively few trials conducted over the short-term; as excoriation disorder is typically a chronic condition, further studies are needed to evaluate long-term efficacy (Grant, 2016; Craig-Müller, 2015)

When and Where to Refer

  • Referral to a psychiatrist is strongly recommended if excoriation disorder is suspected due to the underlying psychological nature of the disorder.
  • Referral to a psychologist or social worker for CBT and/or HRT.
  • Referral to a dermatologist if there are signs of dermatologic complications (infection, scarring, disfigurement) or a co-existent primary skin disorder.

Case: “I'm not the only one with this?"

  • Sally is a 35-yo who comes to your office complaining of itchy skin and a lesion on her forearm that she thinks is infected.
  • She is relieved to find out that she is not alone, that other people have this condition too.
  • You order some tests to rule out other medical conditions that may be contributing.
  • You also recommend the local counseling/therapy services to help with her stress and coping.
  • She learns how to be more self-compassionate and accept that she is not perfect.
  • The urges still come from time to time, but she's able to keep herself from picking. 

Useful Websites for Patients

Practice Guidelines/Algorithms

  • Although there are Practice Guidelines for anxiety disorders and obsessive compulsive disorder, there are not any specific guidelines for excoriation disorder.

References

  • American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5), American Psychiatric Association, Arlington, VA 2013.
  • Arnold LM. Phenomenology and therapeutic options for dermatotillomania. Expert Rev Neurother. 2002 Sep;2(5):725-30.
  • Arnold LM, Auchenbach MB, McElroy SL. Psychogenic excoriation. Clinical features, proposed diagnostic criteria, epidemiology and approaches to treatment. CNS Drugs. 2001;15(5):351-9.
  • Capriotti, M. R., Ely, L. J., Snorrason, I., & Woods, D. W. (2015). Acceptance-enhanced behavior therapy for excoriation (skin-picking) disorder in adults: A clinical case series. Cognitive and Behavioral Practice, 22(2), 230-239. doi:10.1016/j.cbpra.2014.01.008 
  • Craig-Müller SA, Reichenberg JS. The Other Itch That Rashes: a Clinical and Therapeutic Approach to Pruritus and Skin Picking Disorders. Curr Allergy Asthma Rep. 2015 Jun;15(6):31.
  • Cyr PR, Dreher GK. Neurotic Excoriations. Amer Fam Phy. 2001;64(12):1981-84.
  • Grant JE, Redden SA, Leppink EW, Odlaug BL, Chamberlain SR. Psychosocial dysfunction associated with skin picking disorder and trichotillomania. Psychiatry Res. 2016 May 30;239:68-71.
  • Grant JE, Chamberlain SR, Redden SA, Leppink EW, Odlaug BL, Kim SW. N-Acetylcysteine in the Treatment of Excoriation Disorder: A Randomized Clinical Trial. JAMA Psychiatry. 2016 May 1;73(5):490-6.
  • Grant JE, Odlaug BL, Chamberlain SR, Keuthen NJ, Lochner C, Stein DJ. Skin picking disorder. Am J Psychiatry. 2012 Nov;169(11):1143-9.
  • Mavrogiorgou P, Bader A, Stockfleth E, Juckel G. Obsessive-compulsive disorder in dermatology. J Dtsch Dermatol Ges. 2015 Oct;13(10):991-9.
  • Park KK, Koo J. Skin picking (excoriation) disorder and related disorders. Last updated Aug 2016. UpToDate (online). https://www.uptodate.com/contents/skin-picking-excoriation-disorder-and-related disorders (Nov 8, 2016, date last accessed).
  • Schumer MC, Bartley CA, Bloch MH. Systematic Review of Pharmacological and Behavioral Treatments for Skin Picking Disorder. J Clin Psychopharmacol. 2016 Apr;36(2):147-52.
  • 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 Jul-Aug;41:29-37.
  • Silva-Netto R, Jesus G, Nogueira M, Tavares H. N-acetylcysteine in the treatment of skin-picking disorder. Rev Bras Psiquiatr. 2014 Jan-Mar;36(1):101.
  • Snorrason I, Olafsson RP, Flessner CA, Keuthen NJ, Franklin ME, Woods DW. The Skin Picking Impact Scale: Factor structure, validity and development of a short version. Scand J Psychol. 2013 Aug;54(4):344-8.
  • Ravindran AV, da Silva TL, Ravindran LN, Richter MA, Rector NA. Obsessive-compulsive spectrum disorders: a review of the evidence-based treatments. Can J Psychiatry. 2009 May;54(5):331-43.
  • Stargell NA, Kress VE, Paylo MJ, Zins A. Excoriation Disorder: Assessment, Diagnosis and Treatment. The Prof Counselor. 2016;6(1):50-60.
  • Scheinfeld NS. Excoriation Disorder. Last updated Jan 2016. Medscape (online). http://emedicine.medscape.com/article/1122042-overview (Nov 8, 2016, date last accessed).
  • Turner GA, Sutton S, Sharma A. Augmentation of Venlafaxine with Aripiprazole in a Case of Treatment-resistant Excoriation Disorder. Innov Clin Neurosci. 2014 Jan;11(1-2):29-31.

About this Document

  • Written by Dr. Tania M. Fantin, Family Medicine Resident, Class of 2017.
  • Reviewed by members of the eMentalHealth.ca Primary Care Team, which includes Dr’s M. St-Jean (family physician), E. Wooltorton (family physician), F. Motamedi (family physician), and M. Cheng (psychiatrist).

Disclaimer

  • This information is offered ‘as is' and is meant only to provide general information that supplements, but does not replace the information from your qualified expert or health provider.
  • Always contact a qualified expert or health professional for further information in your specific situation or circumstance.

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Date Posted: Jan 13, 2017
Date of Last Revision: Feb 17, 2017

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