Excoriation disorder, also referred to as skin-picking disorder or dermatillomania, is a form of nonsuicidal self-injury. It involves a person picking and probing at a section of skin. The excoriation can lead to cuts, scrapes, sores, infections, and scarring if behaviors continue long-term. Like other disorders, a professional treatment plan using medication and therapy can limit symptoms and improve outcomes.
What Is Excoriation Disorder?
Excoriation disorder (skin-picking disorder) is a type of body-focused repetitive behavior (BFRB) marked by the individual picking, scratching, and poking at skin, as well as frequent, unsuccessful attempts to stop engaging in these behaviors.1 The individual feels a sense of relief and comfort after engaging in skin-picking.
Cali Werner, OCD Clinician at Houston OCD Program, states: “Excoriation disorder can become physically and emotionally debilitating if left untreated. Individuals with this disorder may pick at all areas of the skin such as the scalp, cuticles, face, back and more, typically leaving open wounds that are painful and embarrassing, often leaving the sufferer to be filled with guilt and shame. The primary treatments for body-focused repetitive behaviors include habit reversal training and stimulus control. Combined, these treatment strategies create opportunities for an individual to find new ways to relieve anxiety or engage in behaviors that do not damage the skin such as squeezing a stress ball or wearing gloves that make it difficult to pick.”6
Left untreated, excoriation disorder can become physically and emotionally debilitating. People with the disorder may pick at all areas of the skin, such as the scalp, cuticles, face, and back, thus leaving open wounds that are painful and embarrassing. As such, the sufferer often experiences feelings of guilt and shame.
Skin-picking behaviors may be done mindlessly and without intention, or they could be deliberate and orchestrated. Behaviors could last for only a few minutes between each session, or they could last many hours each day.1
Why Do People Pick Their Skin?
Werner states, “People will pick at their skin in hopes of smoothing the skin out, removing dry skin, or getting rid of scabs. However, the habit becomes difficult to break for individuals with the disorder, often making the skin worse and unable to fully heal. Skin picking may also take place when an individual is anxious or stressed. Body-focused repetitive behaviors, such as skin picking, are said to provide a sense of relief during times of stress. Individuals with excoriation disorder may also find themselves picking purely out of boredom. These individuals are often not even aware that they are picking at their skin in the first place.”
Signs of Skin Picking Disorder
Unlike other mental health conditions, signs of excoriation are outwardly visible. The most obvious signs are scratches, scabs, sores, scars, and lesions in one or more areas of the skin. Since the picking is ongoing, these areas will be at different stages of healing.
Although the marks of excoriation disorder may be obvious, witnessing the act is unlikely. Due to feelings of shame and guilt, people with skin-picking disorder often only pick in private or in the presence of close friends or family members.1 While differentiating excoriation from common injuries can be challenging, repeated injuries in the same area serve as a signal of the disorder.
Other signs of excoriation disorder include:1,2,3
- Spending a lot of time focused on or speaking about skin blemishes or condition
- Frequently using tools and other implements to squeeze, pop, cut, or lance areas of skin
- Wearing clothing that is inappropriate for the season to cover lesions
- Being secretive or increased lying about the behavior
- Unpredictable mood changes
- Holding, playing with, collecting, or eating scabs or pieces of skin
Because the skin-picking behaviors can consume large amounts of time, the individual may be late for work, class, or appointments. They may be failing in school or struggling to meet the demands of their job and may become more isolated as a result.4
Frequently seeking medical care for open sores or being on antibiotics to treat infections could be a sign of excoriation. In more severe cases, picking may cause disfiguration that requires surgery to resolve.
Symptoms of Skin-Picking Disorder
Skin-picking and sores will be the main visible symptoms linked to the condition; however, symptoms of skin-picking disorder may be frequently confused for other mental or medical conditions. It’s important for mental health experts to look thoroughly to differentiate.
Other symptoms of excoriation disorder include:1
- Repeated and unsuccessful attempts to decrease or eliminate all picking
- Picking causes significant distress to social, occupational, or educational functioning
- Picking provides a sense of pleasure or gratification during the picking process
- Picking serves as a way to reduce or eliminate stress, anxiety, or physical tension
Excoriation disorder can be diagnosed only if the picking is connected to mental health concerns. If a medical issue or other mental health condition is present, it may eliminate the possibility of diagnosis. For example, if a person is scratching at their skin due to stimulant use disorder or schizophrenia, professionals can’t diagnose skin-picking disorder.1
What Causes Excoriation Disorder to Develop?
Excoriation and skin-picking behavior can be caused by genetic or environmental triggers. It seems that the most significant risk factor for excoriation disorder is heredity. Those who have a close family member with OCD or a related condition will have a much higher risk of having excoriation disorder.1
Other common risks factors of dermatillomania are:1
- Being female: About 75% of people with excoriation disorder are women
- Being an adolescent: Many cases of the condition begin in the early stages of puberty
- Having acne: Often, excoriation disorder begins with a dermatological condition, like acne, that becomes a focus for the individual
Common Co-Occurring Disorders
Excoriation may frequently co-occur with other mental health conditions, especially other body-focused repetitive behaviors. Often, the combination of disorders makes symptoms worse and treatment more complicated.
Common co-occurring disorders for skin picking include:
- OCD
- Trichotillomania (TTM), also known as hair-pulling disorder
- Major depressive disorder
- Body dysmorphic disorder
- Substance use disorders
How to Stop Skin Picking
Since the nature of skin-picking disorder makes behavioral change difficult, people will be well served to seek out appropriate lifestyle changes and coping skills to stop their picking.
Here are nine ways to stop your skin picking habits:3
1. Reduce & Prevent Stress
For many people, high stress contributes to skin-picking. By limiting stress, a person can take action to indirectly reduce their desire to pick. Of course, reducing stress is a complicated and multifaceted quest, so people should focus on prevention as well as damage control. A person completing daily mindfulness, relaxation, or physical exercise is taking preventive action. A person taking deep breaths to deal with current stress is performing damage control. Both methods are essential in reducing stress and diminishing picking behaviors.
2. Understand Your Emotional Triggers
Stress is just one emotional trigger of excoriation, but there are other feelings that may produce a stronger desire to pick. Some people find that even low levels of anger, boredom, frustration, embarrassment, or sadness create the urge to scratch their skin. Others may find happiness or periods of joy spark cravings to pick. Triggers are personal. The goal is to identify these feelings, note the warning signs, and take action as needed.
3. Understand Your Physical Triggers
Physical triggers are just as important to identify as emotional ones. Rather than having certain feelings produce picking, physical triggers can involve a certain skin condition (like acne), location, temperature, or other physical/environmental cue. Each person should spend some time listing the times, places, and conditions that increase their unwanted behaviors, so they can avoid triggers and plan accordingly.
4. Tell on Yourself
So much of excoriation disorder is centered around ideas of secrecy, isolation, guilt, and shame. People may hide their condition for fear of judgment or mental health stigma, but those who make the bold choice to share the information will be rewarded. First, trusted supporters will likely rally around the individual to provide reassurance, guidance, and love. Second, telling others helps to alleviate the perceived need for shame and guilt.
5. Control the Triggers
Once a person lists and studies their triggers, they can begin engaging in situations and settings that don’t support picking. If they tend to pick only in their bedroom, they should only go there to sleep. If they pick only when they are alone, they should find ways to be with friends as much as appropriate. When a person controls the situation, engaging in compulsive skin-picking becomes more difficult. Controlling emotional triggers is more challenging, but the same principles apply.
6. Seek Out Skin Care
Since an occurrence of acne can spark the onset of excoriation, doing everything you can to address skin health may limit the presentation of long-term skin-picking behaviors. Healthy and simple skin care routines and an evaluation with a dermatologist can help avoid or reduce excoriation while boosting self-esteem and confidence.
7. Use Fidget Toys & Other Distractions
Finding ways to occupy your time and keep your hand busy can help avoid picking behaviors. Using fidget toys and other distractions is a great option. This way, your hands are too busy being engaged in picking.
8. Seek Therapy
When symptoms of excoriation are mild, a person can make modest behavioral changes to control the condition. When symptoms are severe, people will need the direction, strategies, and interventions that only a professional mental health therapist can provide. Social workers, counselors, psychologists, and psychiatrists are just some of the experts available to assist with this condition.
9. Consider Medication
Medication will not be a great fit for everyone with excoriation disorder, but some people find great benefit from it. Medication can help to decrease symptoms independently, but it can also work to boost the effectiveness of therapy. Psychiatrists, nurse practitioners, and primary care doctors can recommend helpful medications to end picking.
Getting a Diagnosis for Dermatillomania
Skin-picking disorder is a complex and multifaceted condition, but the diagnostic process is straightforward. If a person is compulsively picking, scratching, or poking at their skin and they have been unable to stop on their own, they likely have excoriation disorder. This means that complicated tests or quizzes are usually unnecessary.
Rather than a test, a mental health provider will ask a few questions regarding the picking as well as the thoughts and feelings associated. They may ask to see the sites of excoriation to understand the severity of the condition.
Treatment of Skin-Picking Disorder
Primary treatments for body-focused repetitive behaviors include habit reversal training and stimulus control. When combined, these strategies create opportunities for people to find new ways to relieve anxiety or engage in behaviors that don’t damage the skin (e.g., squeezing a stress ball or wearing gloves that make picking difficult).
Due to its chronic nature, professional treatment of excoriation disorder is often needed as symptoms rarely disappear independently. Specialized behavioral treatment and medications can help with skin-picking disorder by giving the individual guidance and direction to adjust their thoughts and actions.
Therapy
Psychotherapy for excoriation is a great first-line treatment to safely and effectively limit symptoms. Meeting with a counselor, social worker, or psychologist in an outpatient setting to discuss the problem, its impact, and various solutions has been proven beneficial.
Common types of therapy used to treat skin-picking disorder are:2, 4
- Acceptance and commitment therapy (ACT): An orientation of psychotherapy that works to promote mindfulness strategies to accept the unwanted facets of life while also building a commitment to changing thoughts, actions, and emotions that are undesired.
- Cognitive behavioral therapy (CBT): A broad therapeutic style grounded in the interrelated aspect of thoughts, feelings, and behaviors. By changing thoughts and managing feelings, CBT aims to end picking behaviors.
- Habit reversal training (HRT): A specific version of CBT that has become the core approach when working with excoriation disorder and other body-focused repetitive behaviors. This type of therapy includes habit awareness training, competing motor responses, relaxation techniques, and social support.5
Medications
Rather than offering just one medication, professionals sometimes use a variety of psychotropic medications to address skin-picking symptoms. As always, it is important to take all medications as prescribed and maintain clear communication with the provider to limit the risk from adverse effects.
Medications regularly prescribed for skin-picking disorder include:2,4,5
- Antidepressants: By targeting the serotonin system in the brain, this class of drugs have exhibited some success in limiting picking. Options include fluoxetine (Prozac), citalopram (Celexa), escitalopram (Lexapro), fluvoxamine (Luvox), and sertraline (Zoloft).
- Opioid antagonists: Medications often used in medication-assisted treatment for people with substance use disorders can help with picking as well. Naltrexone is one widely used example.
- N-acetylcysteine (NAC): Research shows that NAC and other drugs that interact with the brain chemical glutamate can help with OCD and related disorders.
- Lamotrigine (Lamictal): A drug used for several mental health conditions, like bipolar disorder, lamotrigine, has demonstrated mixed results in research, but it may be a helpful medication for skin-picking.
How to Get Help for Dermatillomania
A person can find treatment for skin-picking by talking to their doctor, insurance company, or a trusted individual. Since excoriation disorder is best treated by specific forms of therapy, people who are looking for treatment may also consider using an online therapist directory to search for available providers in their area who specialize in excoriation and similar disorders. With the proven success of self-guided treatments, it is possible to find relief from self-help or online programs, too.
Final Thoughts on Skin-Picking Disorder
Skin-picking disorder has the power to produce intense unwanted feelings and dangerous medical effects, so people should take this condition seriously. Fortunately, there is reason for hope because excoriation disorder is a well-treated mental health concern. That means that getting help for yourself or a loved one can be quick and effective.
For Further Reading
Excoriation (Skin-Picking Disorder) Infographics
