Excoriation disorder is a condition characterized by excessive skin picking that can dramatically impact a person’s physical and mental well-being. Currently, it’s estimated that excoriation disorder affects about 1.4 percent of the population.
What Is Excoriation?
Individuals with excoriation disorder pick or scratch at their skin to the degree that causes significant personal distress. Some pick at skin that is healthy, while others target skin that appears flawed from scabs, pimples or calluses. This picking behavior can lead to significant lesions in various spots on the person’s body.
Excoriation disorder may be referred to by several names, including:
- Skin-picking disorder (SPD)
- Neurotic excoriation
- Psychogenic excoriation
Who Is Affected by Excoriation?
While anyone can develop excoriation disorder, women are more likely to have this condition, outnumbering men with excoriation by a rate of three to one. However, this disparity may be inaccurate because women are more likely to identify the issue and seek treatment for their symptoms than men.
Anyone can show symptoms of excoriation at any point in their life, but the condition most commonly affects teens and young adults and tends to begin around puberty. Once the disease takes hold, it usually becomes a chronic condition with periods of worsening and improving symptoms if left untreated.
Excoriation Signs and Symptoms
Though the condition presents differently in different people, there are three main signs and symptoms of excoriation:
- Picking the skin to the extent that it produces cuts, scratches, sores or open wounds
- Repeatedly attempt to stop or limit skin picking without success
- Experiencing stress from the condition that hinders a person’s ability to work, go to school or maintain relationships
For an excoriation diagnosis to be made, the need to pick the skin must not be due to another medical condition, like scabies or an allergic reaction, or be caused by substance intoxication or another mental health condition.
A person with excoriation may spend long periods inspecting their body to find a place to pick and pull. They may use also use tools during the act, like tweezers, scissors or pins. Others will rub, squeeze, cut or bite the skin.
Many people with excoriation will not pick in front of others. While most people with this condition pick in private, several symptoms of excoriation are visible to outside observers, including:
- Sores on the face, hands, arms and legs
- Significant scarring from previous picking
- Frequent skin infections that require antibiotics to treat
- Wearing seasonally inappropriate clothing to conceal sores
- Using makeup to hide picking marks
Causes of Excoriation
Currently, the exact causes of skin picking disorder are unknown. Like most mental health conditions, this disorder likely develops due to a combination of environmental and biological factors.
Excoriation Risk Factors
Without clear causes of excoriation, people look to study factors that can increase an individual’s risk of having excoriation. Some of the most common risk factors associated with excoriation include:
- Gender: Research suggests that this condition occurs more often in women than in men.
- Intense Stress: For some, skin picking becomes a way to relieve stress and tension from outside influences. In these cases, picking tends to increase when a person is stressed.
- Boredom: Others with excoriation engage in the behavior when stress is low, but boredom is high. Without stimulation, picking becomes a way to pass the time.
- Dissatisfaction with Appearance: Another risk factor for excoriation is an intense focus on the part of the body. The person may begin picking to modify to distract from their physical form.
Professionals evaluating a person for excoriation must pay special attention to context and motivations for picking to diagnose excoriation accurately. For example, while a person cutting, burning or scratching themselves with the intention of self-injury may have many outward symptoms of excoriation, excoriation is different from self-harm.
The professional will also have to differentiate between typical skin-picking behaviors and pathological ones. To determine this, the evaluator will ask about:
- Frequency: How often does someone pick?
- Intensity: How much damage is done from picking behaviors?
- Duration: How much total time is spent picking?
The answers to these questions will help clarify if a person meets the criteria for excoriation disorder.
Excoriation and Co-Occurring Disorders
Some mental health conditions usually occur independently. Others commonly present with one or more additional conditions. Excoriation disorder frequently co-occurs with other mental health conditions, especially other disorders that focus on the body and repetitive behaviors. Mental health conditions that commonly co-occur with excoriation include:
- Body dysmorphic disorder
- Mood disorders, such as depressive and bipolar disorders
- Anxiety disorders
The connection between excoriation disorder and substance use disorders is unclear. At times, people with substance use disorders may have symptoms related to excoriation. Certain substances, like cocaine or methamphetamine, can trigger skin-picking behaviors. However, the presence of these behaviors doesn’t mean someone has excoriation. In these cases, skin picking is usually a side effect of substance abuse, rather than a separate mental health condition.
Since excoriation disorder is a relatively new diagnosis, it currently does not have the depth of research that other conditions like depression and anxiety do. However, there is still enough evidence to support a combination of therapy and medications as effective ways to manage the disorder. Cognitive behavioral therapy (CBT) is usually employed as a way to encourage education, change thought patterns and prevent relapses. Professionals frequently use a specific type of CBT in excoriation treatment called habit reversal therapy (HRT). The two primary focuses of HRT are:
- Awareness Training: During awareness training, the therapist teaches the client to pay close attention to their body and thoughts.
- Competing Response Training: This section focuses on finding a behavior to participate in when the urge to pick is strong. A person could clinch their fist or clap their hands when they feel like picking to keep their hands busy and avoid the unwanted behavior.
Another form of CBT that has shown favorable outcomes for treating excoriation is called acceptance and commitment therapy (ACT). ACT strives to help the client accept that unwanted thoughts and behaviors are part of being human and commit to an alternative set of actions that are not as destructive or self-defeating.
Medications may also be incorporated into treatment for excoriation disorder. Someone with this condition may be prescribed:
- Selective Serotonin Reuptake Inhibitors (SSRIs): Studies of SSRIs have shown mostly good results in lowering picking behaviors to some degree.
- Lamotrigine: A medication sold under the name brand Lamictal and used for bipolar disorder, Lamotrigine has shown to help relieve excoriation symptoms in some studies.
- Opioid Blockers: Blocking opioid receptors of people with excoriation disorder seems to help lower symptoms.
- Glutamate Agents: NAC and other drugs that interact with glutamate, a brain chemical, may reduce the symptoms of skin-picking disorder.
Along with therapy and medication, other techniques like meditation and yoga may also help limit the impact of excoriation.
Getting Help for Skin Picking
Getting help for skin picking may seem like an overwhelming process, but it doesn’t need to be. By noticing the problem and seeing the benefit from treatment, a person can improve the symptoms of an excoriation disorder.
Scheduling an appointment with a family doctor or local mental health agency is an excellent first step for anyone with symptoms of skin-picking disorder. From there, attending individual, group or family sessions with a therapist while meeting with a psychiatrist can lower stress, decrease symptoms and improve overall quality of life.
If your life is being affected by excoriation or other obsessive-compulsive disorders, seek out professional treatment. Evidence-based care is particularly important for individuals impacted by co-occurring disorders, including drug or alcohol addiction. If you or a loved one lives with co-occurring excoriation and substance use disorder, The Recovery Village can help. Reach out to a representative today for more information.
American Psychiatric Association. “Diagnostic and Statistical Manual of Mental Disorders.” 2013. Lochner C, Roos A, Stein DJ. “Excoriation (Skin-Picking) Disorder: A Systematic Review of Treatment Options.” U.S. National Library of Medicine. July 14, 2017. Accessed on March 17, 2019. Massachusetts General Hospital OCD and Related Disorders Program. “Excoriation.” (n.d.) Accessed on March 17, 2019. Philips, K.A. and Stein, D.J. “Excoriation (Skin-Picking) Disorder.” Merck Manual. June 2018. Accessed on March 17, 2019. International OCD Foundation. “Skin Picking Disorder Fact Sheet.” Accessed March 26, 2019. Child Mind Institute. “Excoriation: Risk Factors.” Accessed March 26, 2019.
American Psychiatric Association. “Diagnostic and Statistical Manual of Mental Disorders.” 2013.
Lochner C, Roos A, Stein DJ. “Excoriation (Skin-Picking) Disorder: A Systematic Review of Treatment Options.” U.S. National Library of Medicine. July 14, 2017. Accessed on March 17, 2019.
Massachusetts General Hospital OCD and Related Disorders Program. “Excoriation.” (n.d.) Accessed on March 17, 2019.
Philips, K.A. and Stein, D.J. “Excoriation (Skin-Picking) Disorder.” Merck Manual. June 2018. Accessed on March 17, 2019.
International OCD Foundation. “Skin Picking Disorder Fact Sheet.” Accessed March 26, 2019.
Child Mind Institute. “Excoriation: Risk Factors.” Accessed March 26, 2019.