What is skin picking disorder

Skin picking disorder is also known as excoriation disorder, neurotic excoriation or dermatillomania, is where you can’t stop picking at your skin leading to skin lesions and significant distress or functional impairment ¹. Dermatillomania is characterized by the compulsive and constant rubbing, scratching, and picking of skin that can result in discoloration, scarring, and infection ². Compulsive skin picking is a pathological skin picking disorder characterized by the repetitive picking of one’s own skin to the point of causing open sores that may bleed and leave scarring. People suffering from compulsive skin picking may pick at normal skin variations such as freckles and moles, at pre-existing skin defects such as scabs, sores or acne blemishes, or in some cases imagined skin defects that are not actually visible by others. Individuals with skin picking disorder not only use their fingernails to pick and scratch but may also use their teeth and/or other instruments such as tweezers, blades and pins. The compulsion to scratch, pick or peel pimples is called acne excorie and could be considered a subtype of compulsive skin picking. Although any part of the body may be attacked, often the face is the targeted area.

Although documented in the medical literature since the 19th century ³, excoriation disorder has only recently been included as a distinct entity in mainstream psychiatric nosology. In the the American Psychiatric Association Diagnostic and Statistical Manual of Mental Disorders, 5th Edition (DSM-5) ¹ and the proposed International Classification of Diseases, Eleventh Revision (ICD-11), excoriation disorder or skin-picking disorder, also known as neurotic excoriation, psychogenic excoriation, or dermatillomania, is described as recurrent picking of skin, leading to skin lesions and significant distress or functional impairment. Excoriation disorder is listed as one of the obsessive–compulsive and related disorders, given its overlap with conditions such as trichotillomania (hair-pulling disorder). Arguably, its inclusion and delineation in the American Psychiatric Association Diagnostic and Statistical Manual of Mental Disorders nomenclature will lead to increased awareness of the condition, more research, and ultimately in treatment advances.

Skin damage caused from compulsive skin picking can range from mild to extreme. Bleeding, bruising and secondary infections are not uncommon. In severe cases, patients may create wounds so large that they require hospitalized care. Compulsive skin picking often leads to permanent disfigurement, shame and social impairment. Sufferers will often try to hide the damaged caused to their skin by wearing make-up and/or clothes to cover the marks and scars. In extreme cases, they will avoid social situations to hide their condition from those around them.

The prevalence of excoriation disorder is not known, but it accounts for about 1–2% of dermatology clinic visits ⁴. Skin picking disorder is more common in females with a female-to-male ratio of approximately 8:1 ⁵. Skin picking disorder is most common in patients between the age of 15 and 45 years old ⁶.

Dermatillomania is also commonly associated with other major psychiatric disorders (see Table ​1 below) ⁷. Clinical manifestations include excoriation and polymorphic lesions of varying sizes with a wide variation in severity and extent due to different stages of healing ⁸. The most commonly affected sites are the face, scalp, shoulders, and back. As observed, the perianal and genitals may also be potential sites for compulsive skin picking. Patients often attributed this incessant picking to an urge that lasted about 6–10 minutes. These urges occur frequently throughout the day, leading to picking and scratching for multiple hours in a day.

In the mildest skin picking disorder, it is self-limiting. However, some people suffering from compulsive skin picking have a psychological inability to control the pickings and can continue to subconsciously pick their skin for multiple hours a day, which may impact one’s social and work life as well as lead to skin ulcers, scars or even physical deformities.There are things you can try to help yourself, but some people may need professional treatment.

Things you can try to stop you picking your skin

DO

• keep your hands busy – try squeezing a soft ball or putting on gloves
• identify when and where you most commonly pick your skin and try to avoid these triggers
• try to resist for longer and longer each time you feel the urge to pick
• care for your skin when you get the urge to pick it – for example, by applying moisturizer
• tell other people – they can help you recognize when you’re picking
• keep your skin clean to avoid infection

See a doctor if:

• you can’t stop picking your skin
• you’re causing serious damage to your skin by picking it, like cuts that don’t heal within a few days
• picking your skin is causing you emotional distress or affecting your daily life

DO NOT

• do not let your nails grow long – keep them trimmed
• do not keep things like tweezers and pins where you can easily get at them

What causes compulsive skin picking?

The exact pathophysiology of skin picking disorder is unknown, but magnetic resonance imaging (MRI) of the brain has found abnormal activation in areas involving inhibition, habit formation, and action monitoring ⁹. Individuals with compulsive skin picking often have a co-existing psychiatric disorder. The most common co-existing psychiatric conditions are major depression and anxiety disorders, especially obsessive-compulsive disorder (OCD). In one study, 52% of patients with compulsive skin picking were also diagnosed with OCD. An organic disease such as anemia, uremia or liver disease may also cause compulsive skin picking. It is essential for the doctor to consider all possible causes.

Compulsive skin picking can be triggered by:

• boredom
• stress or anxiety
• negative emotions, such as guilt or shame
• skin conditions, such as acne or eczema
• other blemishes that the person wants to get rid of – these may not be noticeable to other people

It’s sometimes called a body-focused repetitive behavior and is similar to repetitive hair pulling disorder (trichotillomania).

It’s also related to other obsessive compulsive disorders, such as body dysmorphic disorder, where the person is excessively preoccupied with their appearance.

People with skin picking disorder often also have other obsessive compulsive disorders. These may require their own assessment and treatment.

Table 1. Psychiatric comorbidities associated with dermatillomania

Psychiatric conditions	Percentage
Concurrent major mental disorders	38%
Bipolar disorder
Attention-deficit/hyperactivity disorder
Eating disorder
Depression	42%
Obsessive-compulsive disorder	15–68%
Alcohol abuse/dependence	40%
Body dysmorphic disorder	12–32%
Trichotillomania	5–37%
Onychophagia	27%

[Source ¹⁰ ]

In many sufferers of dermatillomania, skin picking is preceded or accompanied by a high level of tension, anxiety or stress and a strong urge to itch or scratch. Often certain events or situations trigger skin-picking episodes. For some, the act of skin picking provides a feeling of relief or pleasure. Skin-picking episodes can be a conscious response to anxiety or may be done as an unconscious habit.

Skin picking disorder appears to be more common in women than in men, and often starts in adolescence.

Skin picking disorder may also be associated with methamphetamine or cocaine abuse.

How to check if you have skin picking disorder

Most people pick at their skin from time to time, but you may have skin picking disorder if you:

• can’t stop picking your skin
• cause cuts, bleeding or bruising by picking your skin
• pick moles, freckles, spots or scars to try to “smooth” or “perfect” them
• don’t always realise you’re picking your skin or do it when you’re asleep
• pick your skin when you feel anxious or stressed

You may pick your skin with your fingers, fingernails, teeth or with tools like tweezers, pins or scissors.

Dermatillomania treatment

Treatment for compulsive skin picking depends on the cause and the level of awareness the patient has regarding the problem. Compulsive skin picking stemming from a psychological disorder is best treated with psychotherapy. When compulsive skin picking is generally an unconscious habit the treatment of choice is a form of cognitive behavior therapy called habit reversal training.

Habit reversal training works by helping you:

• recognize and be more aware of your skin picking and what’s triggering it
• replace skin picking with a less harmful behavior

Talking therapy

Talking therapy is currently thought to be an effective treatment to help change skin picking behavior.

If you’re offered this, it’ll usually be given through community mental health services.

The most common type of talking therapy offered for skin picking disorder is cognitive behavioral therapy (CBT) and may include habit reversal training.

Psychological treatments

Habit Reversal Training – this is a form of psychotherapy that helps patients to become more consciously aware of situations and events that trigger skin-picking episodes. Patients are then taught alternative behaviors in response to these situations and events.

Exposure and Response Prevention – this is commonly used in the treatment of obsessive-compulsive disorders and is useful in cases of compulsive skin picking where the patient is already aware of the situations and events that cause skin-picking episodes. Most patients using this technique have already made significant recovery using habit reversal training.

Medication for skin picking disorder

Medications used for the treatment of OCD (obsessive compulsive disorder) are also frequently used in compulsive skin picking. They are often used in conjunction with cognitive behaviour therapy. The drugs of choice are the selective serotonin reuptake inhibitors (SSRIs) such as fluoxetine, paroxetine, sertraline and fluvoxamine. N-acetyl cysteine (glutamatergic agents) has also been reported to be effective.

Selective serotonin reuptake inhibitors

A number of SSRIs (selective serotonin reuptake inhibitors) have demonstrated improvement on measures of skin-picking behavior in skin picking disorder.2 Nevertheless, study methods, including outcome measures, have varied. There have been two trials of fluoxetine (one an randomized controlled trial and the other open-label), with both using a flexible dosing schedule up to either 80 mg/day over 10 weeks ¹¹ or 60 mg/day over 6 weeks ¹², respectively. The randomized controlled trial suggested that fluoxetine improved symptoms significantly more than placebo, at a mean dosage of 55 mg/day; however, this improvement was supported by only one of the three outcome measures used ¹¹. In the second fluoxetine study, 6 weeks of open-label fluoxetine was prescribed, followed by a 6-week double-blind discontinuation phase for responders. About half (53.3%) of the participants in the first open-label treatment phase were responders. Responders who were randomized to fluoxetine maintained their improvement during the double-blind discontinuation phase, whereas those on placebo returned to previous levels of picking severity ¹². Some case reports also provide support for the use of fluoxetine in skin picking disorder ¹³.

One of the largest double-blind randomized controlled trials of an SSRI in skin picking disorder to date (n=45) found some support for the efficacy of citalopram (20 mg/day, over 4 weeks) ¹⁴. Here, the total score on the Yale-Brown Obsessive-Compulsive Scale decreased significantly more with citalopram than with placebo. However, no significant differences were observed between the citalopram and placebo groups in terms of the primary outcome measure (a visual analogue scale).

An open-label trial of escitalopram, with a flexible dosing schedule of up to 30 mg/day over 18 weeks, suggested that this agent may also be efficacious in reducing pathological skin-picking ¹⁵. In this trial (n=29), almost half of the sample (44.8%) showed full remission of picking symptoms, with an additional 27.6% showing partial response. Significant main treatment effects were observed for all skin picking disorder measures used. Another uncontrolled study using fluvoxamine, with a flexible dose range of 25–50 mg/day to a maximum total dose of 300 mg/day over a period of 12 weeks, reported that all participants (14/14) had a significant reduction in behaviors involving the skin (e.g., scratching, picking, gouging, or squeezing), increased control over skin behavior, and a significant improvement in the presence of skin sensations, skin appearance, and lesions ¹⁶. Sertraline, at flexible dose, using a flexible study timeline in another open-label trial, has also showed promise as an SSRI that can reduce skin-picking (68% response rate) ¹⁷.

Lamotrigine

Data on the efficacy of lamotrigine (an anti-epileptic agent) in skin picking disorder are inconsistent. To date, there have been two trials of lamotrigine in skin picking disorder, both following a flexible dosing schedule over 12 weeks ¹⁸. The first, an open-label trial (n=16) ¹⁹, found a 67% response rate, suggesting some benefit for this agent in skin picking disorder. The second, a randomized controlled trial (n=7) ¹⁸, had a response rate of 43.8%, thus failing to demonstrate greater benefit than placebo.

Glutamatergic agents

There is growing interest in the use of glutamatergic agents in OCD, trichotillomania (hair-pulling disorder), and other obsessive–compulsive and related disorders ²⁰. Glutamate is a key excitatory central nervous system (CNS) neurotransmitter, and the glutamatergic system has been targeted for pharmacologic manipulation in obsessive–compulsive and related disorders. N-acetyl cysteine, for example, is a nutraceutical agent that modulates the glutamatergic and neuroinflammatory systems. The potential benefit of N-acetyl cysteine in skin picking disorder has been suggested by case reports ²¹. In addition, a recent randomized, double-blind trial (dosing range 1,200–3,000 mg/day) over 12 weeks found that N-acetyl cysteine significantly reduced symptoms of skin picking disorder ²². Almost half of the sample (15/32, 47%) receiving N-acetyl cysteine were much or very much improved compared to 19% (4/21) of participants receiving placebo. There were, however, no significant differences in psychosocial functioning between the active and placebo trial arms. There also is anecdotal evidence for the efficacy of the glutamate-modulating agent riluzole in reducing skin-picking ²³.

Opioid antagonists

In acral lick dermatitis, a condition found in dogs and that constitutes a possible animal model of skin picking disorder, a role for opioid antagonists such as naltrexone has been suggested ²⁴. In humans with skin picking disorder, the efficacy of opioid antagonists is supported by case reports only ²⁵.

Inositol

Inositol, an isomer of glucose that has traditionally been considered a B vitamin, is another neutraceutical intervention that may be of use in skin picking disorder; to date, there has been only one published uncontrolled study (n=3) that showed reduced picking at 16 weeks post follow-up ²⁶. The mechanism by which this agent exerts its therapeutic effects remains to be elucidated, but it is possibly linked to a modulatory effect on 5-HT (serotonin) transporter activity.

Augmentation strategies

There have been no randomized controlled trials to investigate the efficacy of augmentation strategies in skin picking disorder ²⁷. However, a number of case studies have provided support for augmentation with atypical and typical antipsychotic agents in reducing skin-picking. For example, addition of aripiprazole to the serotonin–norepinephrine reuptake inhibitor venlafaxine (the latter prescribed for anxiety and depression) ended picking in one case of treatment-resistant skin picking disorder ²⁸. In two other cases, fluoxetine was augmented with olanzapine ²⁹ or paliperidone ³⁰, resulting in reduced picking. Furthermore, case studies also support augmentation of SSRIs with typical antipsychotic agents such as haloperidol in skin picking disorder ³¹.

Combined treatment

There are no rigorous studies that have investigated the efficacy of combinations of psychotherapy and pharmacotherapy in skin picking disorder yet ²⁷.

Alternative interventions

Alternative treatments, such as yoga, aerobic exercise, acupuncture, and hypnosis, either as monotherapy or as an adjunct to psychotherapy and/or pharmacotherapy, have been proposed for the treatment of excoriation disorder ³². However, no randomized controlled trials with these modalities have been undertaken.

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