Excoriation disorder, also known as skin picking disorder, dermatillomania, or neurotic excoriation, is a mental health condition where individuals compulsively pick at their skin, causing tissue damage and significant distress. Despite affecting millions of people, this condition remains widely misunderstood and under-recognized.
What is Excoriation Disorder?
Excoriation disorder is classified under obsessive-compulsive and related disorders in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5). The condition involves repetitive skin picking that results in skin lesions and causes significant distress or impairment in daily functioning.
People with excoriation disorder may pick at healthy skin or target perceived imperfections such as pimples, scabs, calluses, or minor skin irregularities. This behavior often becomes automatic and difficult to control, despite repeated attempts to stop.
The term “dermatillomania” comes from three Greek words: “derma” (skin), “tillo” (pulling or picking), and “mania” (excessive behavior). While everyone picks at their skin occasionally, excoriation disorder is distinguished by its compulsive nature and the significant problems it creates.
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How Common is Excoriation Disorder?
Research indicates that excoriation disorder affects between 1.4% and 5.4% of the general population, making it more common than many people realize. Studies show that approximately 87% of individuals with the condition are female, though this gender disparity may reflect differences in help-seeking behavior rather than actual prevalence.
The condition typically begins during adolescence, with the average age of onset being around 12-13 years. Most affected individuals (over 90%) experience symptom onset before age 20, though it can develop at any age.
Recognizing the Signs and Symptoms
Primary Diagnostic Criteria
To receive a diagnosis of excoriation disorder, an individual must meet five specific criteria:
- Recurrent skin picking resulting in skin lesions
- Repeated attempts to decrease or stop the behavior
- Clinically significant distress or impairment in social, occupational, or other important areas of functioning
- Not caused by substances or another medical condition
- Not better explained by another mental health condition
Observable Signs
Family members and friends may notice several warning signs:
- Visible cuts, scratches, sores, or open wounds on accessible body areas
- Significant scarring from previous picking episodes
- Frequent skin infections requiring antibiotic treatment
- Wearing seasonally inappropriate clothing to conceal affected areas
- Using excessive makeup to hide picking marks
- Spending long periods examining their body for places to pick
- Using tools like tweezers, pins, or scissors during picking episodes
Most Commonly Affected Areas
Picking typically focuses on easily accessible body areas:
- Face (most common site, affecting 55% of individuals)
- Arms and hands (28% and 18% respectively)
- Scalp (21%)
- Torso and back (both around 20%)
- Legs and feet (20% and 10% respectively)
Most people with excoriation disorder pick from multiple sites, though they often have one primary area of focus.
Types of Skin Picking Behavior
Experts identify two main patterns of picking behavior:
Automatic Picking
This unconscious behavior often happens during sedentary activities like watching television, reading, or studying. People may not realize they’re picking until they notice bleeding or pain. This type is sometimes called “scanning” because it involves running fingers across the skin to find irregularities.
Focused Picking
This intentional behavior can last for hours and typically targets specific areas or perceived imperfections. Individuals are fully aware of their actions and may experience tension before picking and relief or satisfaction afterward.
Many people experience both types of picking, and the behavior can shift between automatic and focused depending on circumstances.
Common Triggers
Research has identified several factors that commonly trigger picking episodes:
- Texture of skin (feeling bumps, roughness, or irregularities) – 67% of individuals
- Stress – 55% of individuals
- Visual cues (seeing imperfections in mirrors) – 43% of individuals
- Boredom – 38% of individuals
- Anxiety or worry – 24% of individuals
- Sedentary activities – 35% of individuals
Understanding personal triggers is crucial for developing effective management strategies.
Understanding the Causes
Biological Factors
Research suggests several biological contributors to excoriation disorder:
Genetics: Family studies indicate a hereditary component. Individuals with excoriation disorder are more likely to have first-degree relatives with the condition or related disorders like trichotillomania.
Brain structure differences: Neuroimaging studies have found differences in brain areas responsible for habit formation, impulse control, and motor inhibition. These regions include the frontal cortex and striatum.
Neurotransmitter imbalances: The condition may involve disruptions in dopamine and serotonin systems, which regulate mood, impulse control, and reward processing.
Psychological Factors
Stress and emotional regulation: Many individuals use skin picking as a coping mechanism for managing stress, anxiety, or other negative emotions. The behavior may provide temporary relief or a sense of control.
Perfectionism: Some people pick to “fix” perceived skin imperfections, driven by perfectionist tendencies or dissatisfaction with their appearance.
Boredom and understimulation: Picking can serve as a form of stimulation during periods of low activity or boredom.
Environmental Triggers
Skin conditions: Underlying dermatological conditions like acne, eczema, or keratosis pilaris can provide initial targets for picking, which then becomes habitual.
Stressful life events: Traumatic experiences, major life changes, or ongoing stressors may trigger the onset or worsening of symptoms.
Substance use: Certain substances, particularly stimulants like cocaine or methamphetamines, can trigger skin-picking behaviors, though this is different from excoriation disorder itself.
Co-occurring Conditions
Excoriation disorder frequently occurs alongside other mental health conditions:
Most Common Comorbidities
- Trichotillomania (hair-pulling disorder) – 24% of cases
- Major depressive disorder – 22% of cases
- Generalized anxiety disorder – 22% of cases
- Attention-deficit/hyperactivity disorder (ADHD) – 8% of cases
- Obsessive-compulsive disorder – 7% of cases
Family History Patterns
Family studies reveal common psychiatric conditions among relatives:
- 22% have relatives with trichotillomania
- 24% have relatives with major depressive disorder
- 17% have relatives with substance use disorders
- 13% have relatives with excoriation disorder
This pattern suggests shared genetic vulnerabilities across related conditions.
Physical and Medical Complications
Excoriation disorder can lead to serious medical consequences:
Immediate Complications
- Infections: Open wounds create entry points for bacteria, leading to localized infections
- Scarring: Repeated picking and poor healing result in permanent scarring
- Bleeding: Active picking can cause significant bleeding requiring medical attention
Severe Complications
In extreme cases, the condition can cause:
- Deep tissue damage: Picking can expose underlying muscle or bone
- Sepsis: Serious infections can spread throughout the bloodstream
- Need for surgical intervention: Severe damage may require skin grafts or reconstructive surgery
Research indicates that 38% of individuals with excoriation disorder experience medical complications requiring professional treatment.
Psychological Impact
Beyond physical consequences, excoriation disorder significantly affects mental health and quality of life:
Emotional Consequences
- Shame and embarrassment: The visible nature of skin damage often leads to intense feelings of shame
- Social isolation: Many individuals avoid social situations, intimacy, or activities that might expose affected areas
- Depression and anxiety: The condition frequently co-occurs with mood and anxiety disorders
- Low self-esteem: Visible scarring and perceived loss of control contribute to poor self-image
Functional Impairment
The condition can significantly impact:
- Work performance: Difficulty concentrating due to picking urges or shame about appearance
- Relationships: Avoidance of intimate relationships or social activities
- Daily activities: Time spent picking and treating wounds interferes with normal routines
Studies indicate that individuals with excoriation disorder report moderate impairment in social, occupational, and personal functioning.
Getting an Accurate Diagnosis
Professional Evaluation
Diagnosing excoriation disorder requires a comprehensive evaluation by a qualified mental health professional. The assessment typically includes:
Clinical interview: Discussion of picking behaviors, triggers, frequency, and impact on daily life
Physical examination: Assessment of skin damage, scarring, and current lesions
Medical history: Review of any underlying skin conditions or medical factors
Psychological assessment: Evaluation for co-occurring mental health conditions
Differential Diagnosis
Healthcare providers must rule out other conditions that may cause skin picking:
- Medical conditions: Scabies, eczema, psoriasis, or other dermatological conditions
- Substance-induced picking: Effects of stimulant drugs or medications
- Other mental health conditions: Body dysmorphic disorder, OCD, or psychotic disorders
Assessment Tools
Mental health professionals may use standardized questionnaires such as:
- Skin Picking Scale-Revised (SPS-R): Measures symptom severity and impact
- Yale-Brown Obsessive Compulsive Scale modified for Neurotic Excoriation: Assesses picking behaviors specifically
Evidence-Based Treatment Options
Effective treatment for excoriation disorder typically involves a combination of approaches tailored to individual needs.
Psychotherapy
Cognitive Behavioral Therapy (CBT) is considered the gold standard treatment. CBT for excoriation disorder includes:
Habit Reversal Training (HRT): This specialized technique helps individuals:
- Increase awareness of picking behaviors and triggers
- Develop competing responses (like clenching fists) when urges arise
- Create environmental modifications to reduce picking opportunities
Acceptance and Commitment Therapy (ACT): This approach focuses on:
- Accepting uncomfortable emotions without using picking as avoidance
- Developing psychological flexibility and mindfulness skills
- Committing to values-based actions despite difficult feelings
Dialectical Behavior Therapy (DBT): Particularly helpful for individuals with emotional regulation difficulties, DBT teaches:
- Distress tolerance skills
- Emotion regulation techniques
- Interpersonal effectiveness
Medication Options
While no medication is FDA-approved specifically for excoriation disorder, several have shown promise:
Selective Serotonin Reuptake Inhibitors (SSRIs): Medications like fluoxetine, sertraline, and citalopram may help reduce picking urges and associated anxiety or depression.
N-acetylcysteine (NAC): This supplement has shown effectiveness in reducing picking behaviors in clinical trials. It works by modulating brain chemistry related to habit formation.
Other medications: Depending on individual circumstances, providers may consider:
- Lamotrigine (mood stabilizer)
- Aripiprazole (antipsychotic)
- Naltrexone (opioid antagonist)
Combined Treatment Approaches
Research consistently shows that combining therapy and medication tends to be more effective than either approach alone. Treatment plans should be individualized based on:
- Severity of symptoms
- Co-occurring conditions
- Personal preferences
- Response to previous treatments
Self-Help Strategies
While professional treatment is important, individuals can implement several strategies to support their recovery:
Environmental Modifications
Stimulus control involves changing your environment to make picking more difficult:
- Keep fingernails short and smooth
- Wear gloves, especially during high-risk times
- Remove or limit access to picking tools (tweezers, magnifying mirrors)
- Use fidget toys or stress balls to keep hands occupied
- Apply bandages or skin protectants to common picking sites
Mindfulness and Awareness Techniques
- Body scanning: Regular check-ins to notice tension or picking urges
- Mindful breathing: Using breath awareness to manage stress and urges
- Urge surfing: Observing picking urges without acting on them, allowing them to pass naturally
Skincare and Wound Care
- Establish a gentle skincare routine to improve skin texture
- Use moisturizers to reduce dryness and bumps that may trigger picking
- Properly care for existing wounds to promote healing
- Consider professional dermatological treatment for underlying skin conditions
Stress Management
- Regular exercise to reduce overall stress levels
- Adequate sleep to improve emotional regulation
- Relaxation techniques like progressive muscle relaxation or yoga
- Time management to reduce daily stressors
Finding Professional Help
When to Seek Treatment
Consider professional help if you:
- Cannot stop picking despite repeated attempts
- Experience significant distress about your picking behavior
- Have visible scarring or frequent infections
- Avoid social situations due to skin damage
- Spend significant time each day picking
- Feel that picking interferes with work, relationships, or daily activities
Types of Mental Health Professionals
Psychologists: Provide therapy and psychological testing
Psychiatrists: Can prescribe medication and provide therapy
Clinical social workers: Offer therapy and case management services
Specialized therapists: Some professionals specialize specifically in body-focused repetitive behaviors
Finding the Right Provider
Look for professionals who:
- Have experience treating excoriation disorder or related conditions
- Are trained in evidence-based treatments like CBT or ACT
- Understand the medical aspects of the condition
- Take a collaborative, non-judgmental approach
Resources like the TLC Foundation for Body-Focused Repetitive Behaviors maintain directories of qualified professionals.
The Role of Family and Friends
Support from loved ones plays a crucial role in recovery:
How to Help
Educate yourself about the condition to understand that it’s not simply a “bad habit”
Avoid criticism or comments about picking, as shame often worsens the behavior
Support treatment by helping with appointments and encouraging adherence to therapy
Help with environmental modifications like keeping shared spaces free of picking tools
Practice patience as recovery is often gradual with potential setbacks
What Not to Do
- Don’t constantly remind the person to stop picking
- Avoid expressing disgust or horror at visible damage
- Don’t minimize the condition or suggest it’s just a matter of willpower
- Avoid taking over all aspects of the person’s life or treatment
Living with Excoriation Disorder
Managing Daily Life
Develop routines that minimize risk times and maximize protective factors
Build a support network of understanding friends, family, and professionals
Practice self-compassion rather than self-criticism when setbacks occur
Focus on progress rather than perfection in recovery
Long-term Outlook
With appropriate treatment, many individuals with excoriation disorder experience significant improvement in their symptoms and quality of life. However, the condition is often chronic, requiring ongoing management strategies.
Recovery typically involves:
- Reduced frequency and intensity of picking episodes
- Better awareness of triggers and urges
- Improved coping strategies for stress and emotions
- Enhanced self-esteem and social functioning
While some individuals achieve complete remission, others learn to manage their symptoms effectively while living fulfilling lives.
Prevention and Early Intervention
Risk Factor Awareness
Understanding risk factors can help with early identification:
- Family history of excoriation disorder or related conditions
- Underlying skin conditions that provide picking targets
- High stress levels or poor coping skills
- Perfectionist tendencies or anxiety disorders
Early Warning Signs
Parents, teachers, and healthcare providers should watch for:
- Excessive concern with skin imperfections
- Frequent skin injuries without clear cause
- Avoidance of activities that expose skin
- Declining academic or social performance
Early intervention can prevent the condition from becoming entrenched and reduce long-term complications.
Current Research and Future Directions
Research into excoriation disorder continues to evolve, with several promising areas of investigation:
Neurobiological Research
Scientists are studying brain structure and function differences to better understand the condition’s biological basis. This research may lead to more targeted treatments.
Treatment Development
Ongoing clinical trials are testing new medications and therapy approaches, including:
- Novel pharmacological interventions
- Technology-assisted therapy delivery
- Mindfulness-based interventions
Genetic Studies
Researchers are investigating the genetic factors that contribute to excoriation disorder, which may lead to personalized treatment approaches.
Conclusion
Excoriation disorder is a serious but treatable mental health condition that affects millions of people worldwide. While it can cause significant physical and emotional distress, effective treatments are available. The key to successful management lies in:
- Recognizing that this is a legitimate medical condition, not a character flaw
- Seeking professional help from qualified providers
- Implementing evidence-based treatments like cognitive behavioral therapy
- Considering medication when appropriate
- Developing effective self-management strategies
- Building a strong support network
Recovery is possible, and many individuals with excoriation disorder go on to live healthy, fulfilling lives with proper treatment and support. If you or someone you know is struggling with skin picking, remember that help is available and recovery is achievable.
The most important step is reaching out for professional help. With appropriate treatment, individuals can learn to manage their symptoms, heal both physically and emotionally, and reclaim their quality of life.
