8 Myths About Excoriation Disorder

Compulsive skin picking causes significant mental distress and impaired functioning for 1 in 20 people. Separating myth from fact is the first step to treatment.

Excoriation disorder, also known as dermatillomania or skin picking disorder, is a serious mental health disorder that some studies suggest affects up to 5.4% of the population. It involves compulsive, repeated picking of the skin to the point of causing skin damage. As a mental health disorder, it is characterized by:

• Compulsive, injurious skin picking
• Inability to stop the behavior despite repeated earnest attempts
• Significant negative effects, such as psychological distress and impairments in normal functioning (social, occupational, family, recreational, etc.)
• Picking not caused by substance use or other mental health disorders (such as psychosis)

Skin picking disorder is classified as an obsessive-compulsive and related disorder (OCRD) in the official diagnostic manual of the American Psychological Association (the “DSM-5”). As such, it is included with and shares features with the following OCRD disorders:

• Body dysmorphic disorder
• Hoarding disorder
• Trichotillomania (compulsive hair-pulling and chewing) — co-occurs in 38% of people who skin pick
• Nail-biting

Understanding excoriation disorder requires differentiating the myths from the facts about skin picking.

Myth #1: Skin picking is just a bad habit.

Fact: Skin picking is a disorder that has known genetic, anatomical, physiological and environmental causes.

Recent research has demonstrated that compulsive skin picking appears to be related to anatomical changes in the brain. Specifically, changes in the thickness of the brain cortex in the parietal and occipital regions appear to be related to obsessive skin picking.

Skin picking appears to be associated with changes in nerve conduction in certain parts of the brain. This is known as a physiological change in the brain. While these results are very preliminary, they do suggest that skin picking disorder is much more than a bad habit; it may well be related to anatomical and physiological changes in the brain.

The fact that skin picking disorder has been correlated with structural and functional brain changes strongly suggests a genetic component to the disorder. A study of twins demonstrated a strong heritable component to skin picking disorder, which accounted for about 40% of the disorder. The genes involved appear to affect the brain chemical (neurotransmitter) serotonin, which explains the obsessive-compulsive and anxiety-inducing nature of skin picking.

Besides the anatomical and genetic causes of skin picking disorder, certain environmental factors have been implicated in causing the disorder:

• Birth complications
• Streptococcal (bacterial) infections
• Traumatic life events
• Exposure to bullying
• Exposure to domestic violence

So, although research is just beginning to uncover these factors, it is already apparent that skin picking is not simply a bad habit. Rather, it is a disorder caused by structural and physiological brain changes, genetics and environmental factors.

Myth #2: Excoriation is a type of self-harm.

Fact: While compulsive skin picking is harmful to the picker, it is not a self-harm disorder.

Self-harm, officially known as “non-suicidal self-injury” (NSSI), is a psychological disorder where affected individuals deliberately inflict destruction on their own body tissue. They usually do this by biting, cutting, scratching or burning themselves.

Self-harm is a separate psychological entity from compulsive picking disorder. Unlike compulsive picking, which usually starts out as a subconscious behavior, self-harm is a deliberate, planned action, with different psychological features. Also unlike self-picking disorder, which is related to OCD and anxiety, NSSI is closely associated with borderline personality disorder. In fact, non-suicidal self-injury is classified in the DSM-5 as a symptom of borderline personality disorder.

So, although compulsive skin picking can be harmful and associated with some very harmful co-occurring problems, it is not a self-harm disorder.

Myth #3: Dermatillomania is caused by an underlying skin condition.

Fact: Skin picking results in skin damage, but is not itself caused by any skin abnormalities.

Skin picking disorder is psychological impulse control and obsessive-compulsive disorder where the individual picks at normal skin. They are not picking because their skin is itchy or sore, or because the skin is bumpy or in any way abnormal. Rather, they are driven by anxiety that is only relieved by picking.

Unfortunately, people who self-pick can develop serious skin problems, especially as their picking progresses. They can cause open sores, serious skin staph infections from open wounds, and permanent scarring. They can develop thickened, rough skin. They can even damage underlying structures, such as tendons and bones. When their skin wounds are in visible areas, such as the face, neck, upper chest, hands and arms, they can develop permanent disfiguration.

If by chance, skin pickers do have any skin abnormalities, such as eczema or acne, they usually pick at that area of skin. However, these skin problems do not cause the picking compulsion, they merely become a focus of it. It is the picking that causes skin problems, not skin problems that cause the picking.

Myth #4: Excoriation mainly affects women.

Fact: Skin picking disorder affects both genders.

While the majority of people who suffer from this mental health disorder are female, men are definitely not immune. One large study looked specifically at statistics of gender differences in excoriation disorder and found that it affects 5.8% of females and 2.0% of men.

The same study identified other gender differences in people with skin picking disorder:

• Men tend to pick at less noticeable areas of the body
• Men report deriving more pleasure from the habit
• Women are at increased risk of having co-occurring depression, anxiety, substance use, and compulsive shopping disorders
• Men engaging in skin picking are more likely to be overweight

Myth #5: Individuals struggling with excoriation can stop at any time.

Fact: If people with skin picking disorder could stop, they would.

People with skin picking disorder suffer mental and physical pain and lose out on social, vocational and educational opportunities due to their disorder. In fact, they spend so much time picking that they often miss or are late for appointments, social activities, work, and school. Many are chronically fatigued because they can’t sleep because they need to pick. 

People who skin pick compulsively are also often ashamed of their picking and the appearance of scars, sores, and infections on their skin. They tend to have low self-esteem, to begin with, and the skin picking and skin sores make their self-esteem worse. They are so embarrassed that they often miss out on important events — such as work, social engagements, etc. — because they don’t want people to see them, or because they are spending too much time picking or trying to camouflage their skin sores.

Skin picking disorder eats up a great deal of time, energy and brain power. People who pick generally want nothing more than to be free of the compulsive behavior.  

Myth #6: Excoriation isn’t a serious issue.

Fact: Skin picking disorder is a serious impediment to good mental health and normal life function, and is associated with a number of other serious conditions.

Skin picking disorder has been associated with some serious issues, such as:

• Low self-esteem
• Depression (66% report depression from their picking)
• Anxiety (86%)
• Poor body image
• Poor general health
• Poor sleep (due to picking)
• Decreased immune function

People with skin picking disorder tend to spend inordinate amounts of time trying to hide or camouflage their scars, infections, and sores, using clothing and make-up. This preoccupation can take enough of their time to interfere with normal daily activities. As well, they may avoid social situations, including in the workplace, because of their low self-esteem and shame over their picking and their skin. 

Skin picking disorder is also a serious risk factor for substance use disorders. People who skin pick are seen to have the following rates of co-occurring substance abuse issues:

• Alcohol use: 25%
• Tobacco: 23%
• Illicit drugs of addiction: 17%

Many people develop this disorder in childhood or adolescence. This can have serious negative effects on their social, academic and vocational development and transition into adulthood. Children and adolescents are especially sensitive to social criticism, rejection or bullying, and their skin picking behaviors and unsightly skin lesions often lead to them being socially rejected. They may avoid school as a result. The stress and anxiety may worsen their skin picking, and predispose them to depression, suicide and substance use.

Myth #7: People who pick at their skin do it for attention.

Fact: Skin pickers avoid attention.

Skin picking disorder usually begins with unconscious picking. A significant period of time may pass before an individual even becomes aware of the behavior. Even when the picking is causing them serious problems and they have been diagnosed, they are not always aware that they are doing it (about 30% of the time they are unaware that they are picking).

People whose skin pick will often try the hardest to suppress their picking when other people are present because they are embarrassed by the behavior. They are also embarrassed by the resulting skin damage, which they go to great lengths to cover up. If they can’t hide their sores, they may completely avoid social situations. They are definitely not seeking attention; they are avoiding attention.

Myth #8: There is no treatment for excoriation disorder.

Fact: Skin picking disorder is treatable, and recovery is possible.

Unfortunately, some studies suggest that fewer than 20% of people with skin picking disorder end up seeking treatment because they are embarrassed about it, or they think it’s just a bad habit. However, there is effective treatment available. Recovery is not a matter of willpower or just stopping skin picking. If that was possible, the person would have done that long ago. Rather, the underlying psychological problems must be addressed.

The most effective way to address excoriation disorder is to start with a comprehensive assessment to identify the underlying causes (such as past traumas, etc.) and any co-occurring disorders (such as depression and substance use disorders). Treatment involves designing a personalized holistic treatment program that addresses the underlying and co-occurring problems, especially the obsessive-compulsive and anxiety components of the disorder.

Psychological therapy with techniques such as cognitive behavioral therapy (CBT), and pharmacological therapy with anti-depressant/anti-anxiety medications such as SSRIs, are the mainstays of treating excoriation. Treatment of the skin damage by a dermatologist is important for general health and to help reduce the individual’s embarrassment from the unsightly skin lesions. Treatment of underlying substance use may also be necessary.

The Recovery Village offers comprehensive treatment plans that can help those who are suffering from co-occurring excoriation and substance abuse disorder. Please feel free to contact us for a free, confidential discussion with an admissions counselor.

Editor – Renee Deveney

As a contributor for Advanced Recovery Systems, Renee Deveney is passionate about helping people struggling with substance use disorder. With a family history of addiction, Renee is committed to opening up a proactive dialogue about substance use and mental health. Read more

Medically Reviewed By – Dr. Andrew Proulx, MD

Andrew Proulx holds a Bachelor of Science in Chemistry, an MD from Queen's University, and has completed post-graduate studies in medicine. He practiced as a primary care physician from 2001 to 2016 in general practice and in the ER. Read more