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Excoriation Disorder Clinical Presentation

  • Author: Noah S Scheinfeld, JD, MD, FAAD; Chief Editor: Dirk M Elston, MD  more...
Updated: Jan 26, 2016


Patients with excoriation (skin-picking) disorder give a history of picking, digging, or scraping their skin. Sometimes an inciting incident is the cause, and sometimes no inciting incident is present. Patients might note that they do not scratch themselves consciously; rather, they pick and then notice that they are picking. Cyr and Dreher have provided an excellent summary of neurotic excoriations and their historical and clinical findings and manifestations.[10] Ultimately, neurotic excoriations are a diagnosis of exclusion.[11]

An French survey of neurotic excoriations in 10 patients found that most patients linked their initial excoriations with personal problems; 4 of the patients noted abuse in childhood or in adolescence.[12] This study appeared to suggest that skin picking was an impulsive reaction rather than an obsessive-compulsive disorder; however, the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5), currently classifies excoriation disorder among the obsessive-compulsive and related disorders.[5]

Patients can have a psychiatric history that includes a comorbid mental disorder. Most patients with excoriation disorder do not have any particular psychopathology; however, psychiatric diagnoses to be considered include the following:

Patients pick at areas until they can pull material from the skin. This may be referred to as "pulling a thread from the skin."

Setyadi et al noted that trigeminal trophic syndrome can result in ulcerations on the nose (in the nasal ala and paranasal locations), most commonly manifesting in older women after therapy for trigeminal neuralgia.[13]

Young women who pick at their faces may have a history of mild acne. Such cases are referred to as acne excoriée. This condition is not discussed in this article. The erosions can heal slowly because of recurrent picking.

It is helpful to asking patients which came first, the lesion or the urge to itch. When closely questioned, most patients say that they first scratched their skin and then saw a lesion. The lesions of neurotic excoriations have a component of an itch-scratch cycle, whereby the urge to scratch generates an even greater urge to scratch.

Because a variety of physical conditions can cause itching and then lesions, these must be excluded or, at least, established as being relatively unlikely before a firm diagnosis of excoriation disorder can be made. Such conditions include the following:

  • Renal disease
  • Cocaine use
  • Opiate use
  • Medication reactions
  • Multiple sclerosis
  • Hepatic disease
  • Lymphoma
  • Pregnancy
  • Internal cancers
  • Uremia
  • Carcinoid
  • Delirium
  • Diabetes mellitus
  • Hypothyroidism
  • Iron deficiency anemia
  • Hyperthyroidism
  • Xerosis
  • Intestinal parasitosis

Myeloma may be noted. Patients may report headache or menstrual disorders.


Physical Examination

Often, right-handed persons tend to pick at their left side, left-handed people at their right side. The erosions and scars tend to have angulated borders. The quantity of erosions and scars is variable. Several lesions to hundreds of lesions can be present. Erosions, crusts, and scars are located only where the patient can pick. Lesions can be either crusted or noncrusted (see the images below).

A picker's nodules with no crust and a scarred app A picker's nodules with no crust and a scarred appearance.
A picker's nodule with crusted lesions. A picker's nodule with crusted lesions.

Erosions can vary in morphology and can sometimes evolve into frank ulcers. Dug-out erosions or ulcers, crusted erosions, and ulcers can be present. Sometimes, erythema and scars are present around the erosions and the ulcers.

In dermatitis artefacta, the patient creates skin lesions to satisfy an internal psychological need, usually a need to be taken care of. The clinical presentation is characteristic, and it differs from that of excoriation disorder, delusional disorders, malingering, and Munchausen syndrome. Munchausen syndrome by proxy is a form of dermatitis artefacta.

Except when the lesions mimic another disease, those that do not conform to descriptions of known dermatoses are shrouded in mystery, appearing fully formed on accessible skin, within the context of a characteristic psychological constellation. The patient is friendly but bewildered, and relatives may be angry and frustrated.

Contributor Information and Disclosures

Noah S Scheinfeld, JD, MD, FAAD Assistant Clinical Professor, Department of Dermatology, Weil Cornell Medical College; Consulting Staff, Department of Dermatology, St Luke's Roosevelt Hospital Center, Beth Israel Medical Center, New York Eye and Ear Infirmary; Assistant Attending Dermatologist, New York Presbyterian Hospital; Assistant Attending Dermatologist, Lenox Hill Hospital, North Shore-LIJ Health System; Private Practice

Noah S Scheinfeld, JD, MD, FAAD is a member of the following medical societies: American Academy of Dermatology

Disclosure: Serve(d) as a speaker or a member of a speakers bureau for: Abbvie<br/>Received income in an amount equal to or greater than $250 from: Optigenex<br/>Received salary from Optigenex for employment.

Chief Editor

Dirk M Elston, MD Professor and Chairman, Department of Dermatology and Dermatologic Surgery, Medical University of South Carolina College of Medicine

Dirk M Elston, MD is a member of the following medical societies: American Academy of Dermatology

Disclosure: Nothing to disclose.


David F Butler, MD Professor of Dermatology, Texas A&M University College of Medicine; Founding Chair, Department of Dermatology, Scott and White Clinic

David F Butler, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Dermatology, American Medical Association, American Society for Dermatologic Surgery, American Society for MOHS Surgery, Association of Military Dermatologists, and Phi Beta Kappa

Disclosure: Nothing to disclose.

Rosalie Elenitsas, MD Herman Beerman Associate Professor of Dermatology, University of Pennsylvania School of Medicine; Director, Penn Cutaneous Pathology Services, Department of Dermatology, University of Pennsylvania Health System

Rosalie Elenitsas, MD is a member of the following medical societies: American Academy of Dermatology and American Society of Dermatopathology

Disclosure: Lippincott Williams Wilkins Royalty Textbook editor

Shyam Verma, MBBS, DVD, FAAD Clinical Associate Professor, Department of Dermatology, University of Virginia; Adjunct Associate Professor, Department of Dermatology, State University of New York at Stonybrook, Adjunct Associate Professor, Department of Dermatology, University of Pennsylvania

Shyam Verma, MBBS, DVD, FAAD is a member of the following medical societies: American Academy of Dermatology

Disclosure: Nothing to disclose.

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A picker's nodules with no crust and a scarred appearance.
A picker's nodule with crusted lesions.
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