Excoriation (Skin-Picking) Disorder
(Dermatillomania)
A compulsive, repetitive picking of the skin leading to tissue damage
DSM-5 Diagnostic Criteria
- Recurrent skin picking resulting in lesions
- Repeated attempts to stop or reduce picking
- Clinically significant distress or impairment (social, occupational)
- Not attributable to substance use, medical condition (e.g., scabies), or psychiatric disorder (e.g., psychosis, BDD)
Clinical Features
Common Picking Sites:
- Face (most common)
- Arms, hands, cuticles
- Scalp, legs
Behavioral Patterns:
✔ Focused picking: Intentional, tension-relieving (often with tools like tweezers)
✔ Automatic picking: Unconscious (e.g., while reading/watching TV)
✔ Rituals: Examining, rubbing, chewing, or swallowing picked skin
Triggers:
- Stress, boredom, anxiety
- Skin irregularities (acne, scabs)
- Sensory triggers (rough textures)
Complications:
- Scarring, infections (cellulitis, abscesses)
- Shame/embarrassment → social isolation
- High comorbidity with OCD, anxiety, depression, trichotillomania
Etiology & Risk Factors
Biological:
- Genetic predisposition (familial link with OCRDs)
- Dysregulation in basal ganglia and frontal cortex (similar to OCD)
- Low serotonin/dopamine activity
Psychological:
- Perfectionism, sensory hypersensitivity
- Maladaptive coping for stress/anxiety
Environmental:
- Childhood trauma (link with body-focused repetitive behaviors)
- Learned behavior (e.g., mimicking family members)
Assessment Tools
- Skin Picking Scale-Revised (SPS-R) – Severity measure
- Diagnostic Interview for Skin Picking (DISP)
- Clinical exam to rule out dermatologic conditions (eczema, psoriasis)
Treatment Approaches
1. Psychotherapy (First-Line)
- Habit Reversal Training (HRT):
- Awareness training (identify triggers)
- Competing response (e.g., fist-clenching instead of picking)
- Stimulus control (wear gloves, cover mirrors)
- Cognitive Behavioral Therapy (CBT):
- Address perfectionism, shame
- Stress-management techniques
- Acceptance and Commitment Therapy (ACT):
- Mindfulness of urges without acting
2. Pharmacotherapy
- SSRIs (Fluoxetine, Fluvoxamine): Moderate efficacy
- N-Acetylcysteine (NAC): Glutamate modulator (1200–2400 mg/day)
- Low-dose antipsychotics (e.g., Aripiprazole): For refractory cases
3. Adjunctive Strategies
- Dermatologic care: Wound care, acne treatment
- Sensory substitutes: Fidget toys, stress balls
- Support groups: (e.g., Picking Me Foundation)
Differential Diagnosis
| Condition | Key Distinction |
|---|---|
| Body Dysmorphic Disorder | Picking driven by perceived flaws |
| Psychotic Disorder | Picking due to delusions (e.g., parasites) |
| Neurotic Excoriation | Medically unexplained lesions, no compulsion |
Prognosis
- Chronic but manageable with treatment
- 50–60% improve with CBT/HRT
- Poorer outcomes with:
- Early onset (childhood)
- Comorbid OCD/depression
Patient Self-Help Strategies
- Barrier methods: Bandages, acrylic nails
- Journaling: Track triggers/picking episodes
- Skin care routine: Reduce triggers (e.g., moisturize dry skin)
Resource: TLC Foundation for BFRBs