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Excoriation Disorder (aka Skin Picking, Dermatillomania): Information for Healthcare Providers

Summary: Excoriation disorder is a condition where individuals develop an irresistible urge to pick or scratch their skin to the point that it causes skin damage. It can become quite severe with complications such as infection, scarring and disfigurement. It can cause severe impairment of function, and individuals may also be coping with other co-occurring conditions as well, such as anxiety and depression. Patients often turn to their primary care providers when faced with emotional distress. Interventions include counseling, medication and treatment of skin complications.
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Case

Identifying data

Sally is a 35-yo female

Chief complaint

“I just can’t stop picking!”

HPI

She comes to see you reporting 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?

Terms

Other terms include:

  • Skin picking disorder, 
  • Psychogenic excoriation, 
  • Neurotic excoriation 
  • Dermatillomania

Epidemiology

Likely 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

Triggers

  • Patients may describe a minor skin pathology or noticing an imperfection (e.g. seeing blemishes, or feeling bumps in the skin). 
  • There may also be no obvious trigger (Scheinfeld, 2015). 

Feeling / behaviour 

  • Irresistible urge to pick, scratch, dig or scrape the skin that results in noticeable tissue damage. (Scheinfeld, 2015).
  • A feeling of temporary relief from emotional distress after the behaviour occurs. (1,5)
  • They may use instruments such as tweezers, pins, scissors or knives. (5,13)
  • Considerable time spent picking, often several hours per day, and worse in the evenings. (16)
  • Patients may report doing the behaviour while they are ‘dissociated’ (Mavrogiorgou, 2015). 
  • Attempts to resist or stop the behaviour. (6)
  • Reluctance to show areas of damaged skin (Mavrogiorgou, 2015). 
  • Impairments in social functioning (Mavrogiorgou, 2015).

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

Consider asking the following (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?
  • Context:
    • How do you feel before picking?
    • How do you feel during picking?
    • How do you feel after picking?
  • Strategies / Interventions
    • Have you ever tried to resist picking your skin?
    • How easy is it to resist
  • Distress / impairment
    • Medical: Has picking your skin resulted in medical complications e.g. scarring, infections?
    • Function: Do you find yourself avoid social situations as a result of your skin picking?
  • Distress:
    • Does the behavior cause you significant distress?

Interviewing Tool

Questions about Skin Picking

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?

Context:

● How do you feel before picking?

● How do you feel during picking?

● How do you feel after picking?

Strategies / Interventions

● Have you ever tried to resist picking your skin?

● How easy is it to resist

Distress / impairment

● Medical: Has picking your skin resulted in medical complications e.g. scarring, infections?

● Function: Do you find yourself avoid social situations as a result of your skin picking?

● Distress: Does the behavior cause you significant distress?

DSM-5 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

Rule out Contributory Medical Conditions

Rule out medical diagnoses (Craig-Müller, 2015)

Primary skin disorder

  • Neurodermatitis: People have an intense itch that leads to scratching in the same spot. The primary intent of neurodermatitis is to relieve itching, whereas skin picking is largely a response to stress or anxiety.

Systemic diseases that cause chronic pruritis (Itchiness)

Medication reactions: Any medications that can cause itchiness, such as

  • Opoioids
  • Antibiotics
  • Antifungal medications
  • Antimalarial drugs
  • ACE Inhibitors
  • Diuretics
  • Statins
  • Allopurinol
  • NSAIDs
  • Chemotherapy

Other psychocutaneous syndromes (i.e. other conditions with psychological factors and skin symptoms)

● Psychogenic Pruritus (Psychogenic Itching): Itching that is caused primarily by psychological factors, such as stress or anxiety, rather than a direct skin condition

● Dermatillomania (Skin Picking Disorder): A condition where individuals compulsively pick at their skin, which can lead to skin lesions. It's often associated with anxiety or stress.

● Trichotillomania (Hair Pulling Disorder): This involves recurrent, irresistible urges to pull out hair from one’s scalp, eyebrows, or other areas of the body, despite trying to stop.

● Body Dysmorphic Disorder: This disorder involves a preoccupation with one or more perceived defects or flaws in physical appearance, which are not observable or appear slight to others.

● Delusional Parasitosis: A person believes they are infested with parasites, insects, or bugs, despite there being no medical evidence of such infestation.

● Neurotic Excoriations: Lesions that occur when an individual repetitively scratches normal skin based on various underlying psychological reasons.

● Factitious Dermatitis (Dermatitis Artefacta): This is self-inflicted skin damage designed to attract medical attention, often due to an underlying psychiatric disorder.

● Acne Excoriée: Over-picking or squeezing of acne lesions, often worsened by stress or emotional disturbances, which can lead to significant scarring.

Comorbid psychiatric conditions

Illicit drug use (cocaine, opioids)

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). 
    • Stimulus control focuses on modifying the environment to reduce the risk of picking. 
  • 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

Is there itchiness?

  • Consider antihistamines.
  • Consider topical cream such as a steroid cream.

Is there a skin infection?

  • Consider antibiotics.

Antidepressants (SSRIs)* (Selles, 2016)

Glutamate-modulating drugs* (Grant, 2016; Craig-Müller, 2015)

  • N-acetylcysteine 1200mg – 3000mg daily
    • NOTE
      • It is generally available from drug stores in the nutraceutical section, or health food stores.

    Naltrexone

    • A case report with a 51-year old female with skin picking showed response at a low dose of only 5 mg daily.
    • A case report of a adolescent with Prader Willi and skin picking who responded to 50 mg daily (Banga, 2012).

    Memantine

    • An RCT showed that memantine may be helpful for both trichotillomania and skin-picking disorder in a study looking at n=86 women (Grant, 2023).
    • The study showed that memantine is more effective than other treatments studied thus far, including behavioral therapy, the drug olanzapine (used to treat schizophrenia and bipolar disorder), the drug clomipramine (used to treat obsessive-compulsive disorder), and N-acetylcysteine (an over-the-counter supplement) (Grant, 2023).
    • Memantine was dosed at 10-20 mg daily.

    When and Where to Refer

    Are there any comorbid issues such as anxiety, depression? 

    • If so, consider referral to a psychiatrist. 

    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 do the following: 
      • 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/conte... 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/... (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: May 10, 2024
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