Excoriation Disorder

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

Practice Essentials

Excoriation (skin-picking) disorder involves conscious creation of neurotic excoriations through repetitive scratching. Neurotic excoriations can be initiated by some minor skin pathology (eg, insect bite, folliculitis, or acne), but it can also be independent of any pathology. See the image below.

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

Signs and symptoms

Findings from the history may include the following:

  • History of picking, digging, or scraping the skin
  • Presence or absence of an inciting incident
  • Personal problems (eg, history of abuse)
  • Psychiatric history that includes a comorbid mental disorder
  • Nasal ulcerations
  • Facial acne

Psychiatric and medical diagnoses that should be considered include the following:

  • Depression
  • Trichotillomania
  • Anxiety
  • Tic disorder
  • Obsessive-compulsive disorder (OCD)
  • Body dysmorphic disorder
  • Somatoform disorders
  • Borderline personality disorder
  • Delusions of parasitosis
  • Scabies
  • Dermatitis herpetiformis
  • Renal disease
  • Cocaine use
  • Opiate use
  • Medication reactions
  • Multiple sclerosis
  • Hepatic disease
  • Lymphoma
  • Pregnancy
  • Internal cancers
  • Uremia
  • Carcinoid
  • Delirium
  • Polycythemia vera
  • Diabetes mellitus
  • Hypothyroidism
  • Iron deficiency anemia
  • Hyperthyroidism
  • Xerosis
  • Urticaria
  • Intestinal parasitosis

Physical findings may include the following:

  • Crusted or noncrusted lesions
  • Erosions and scars with angulated borders
  • Variable quantity of erosions and scars (from several to hundreds)
  • Occasional evolution into frank ulcers

See Presentation for more detail.

Diagnosis

Specific DSM-5 criteria for excoriation disorder are as follows:

  • Recurrent skin-picking, resulting in lesions
  • Repeated attempts to decrease or stop skin picking
  • The skin picking causes clinically significant distress or impairment in important areas of functioning
  • The skin picking cannot be attributed to the physiologic effects of a substance or another medical condition
  • The skin picking cannot be better explained by the symptoms of another mental disorder

Diagnostic studies that may be considered for ruling out other conditions include the following:

  • Complete blood count (CBC) with differential
  • Chemistry profile
  • Determination of thyrotropin levels
  • Fasting plasma glucose level
  • Cancer workup
  • Chest radiography
  • Skin biopsy

See Overview and DDx for more detail.

Management

General management principles include the following:

  • Setting limits for the protection of both the physician and patient
  • Creating an accepting, empathic, and nonjudgmental environment
  • Closely supervising symptomatic dermatologic care
  • Attempting to develop a therapeutic relationship in which psychological issues may be addressed and which may permit referral to a psychiatrist as appropriate
  • Avoidance of issues of etiology (confrontation is counterproductive)

Pharmacotherapy may include the following:

  • Antipsychotic agents
  • Antianxiety agents
  • Antidepressants
  • Topical cortisone agents
  • Antiepileptic agents

Other treatment methods that may be considered are as follows:

  • Hypnosis
  • Physical barriers (eg, an Unna sleeve)

See Treatment and Medication for more detail.

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Background

Excoriation (skin-picking) disorder involves the conscious creation of neurotic excoriations by means of repetitive scratching. Neurotic excoriations should be distinguished from dermatitis artefacta, in which patients create lesions for secondary gain. Neurotic excoriations can be initiated by some minor skin pathology, such as an insect bite, folliculitis, or acne, but it can also be independent of any pathology.

Because no significant underlying pathology is present in the skin, neurotic excoriations are best understood as a psychological process with dermatologic manifestations. Many doctors lack an extensive understanding of neurotic excoriations and their treatment. [1] The complex dynamic underlying the urge to create a neurotic excoriation is yet to be fully explained. [2] Dermatologists are aware of this complex dynamic and continue to grapple with it. [1]

Because patients create neurotic excoriations, the lesions have the quality of an "outside job"—that is, clean, linear erosions, crusts, and scars that can be hypopigmented or hyperpigmented. The erosions and scars of neurotic excoriations often have irregular borders and are usually similar in size and shape. They occur on areas that the patient can scratch, particularly the extensor surfaces of the extremities, the face, and the upper part of the back. The distribution is bilateral and symmetric.

The manifestations of neurotic excoriations vary widely, ranging from unconscious picking at the skin to uncontrollable picking at lesions to remove imaginary foreign bodies. Picking is usually episodic and irregular, but it can be constant. The picking can have the quality of a ritual and may take place in a state of dissociation.

Researchers gave 5,000 Israeli students questionnaires screening for excoriation (skin-picking) disorder, body dysmorphic disorder, depression, OCD, and disruptive, impulse control and conduct disorders. Of the 5,000 students contacted, 2,176 (43.6%) responded; 64.3% were women and 35.7% were men. Mean age of respondents was 25.1±4.8 years. The proportion of students who screened positive for excoriation (skin-picking) disorder was 3.03%, with a nearly equal gender distribution (3.0% in women and 3.1% in men). Those with excoriation (skin-picking) disorder had higher rates of psychiatric problems (e.g., generalized anxiety, eating disorders, and compulsive sexual behavior). Women with excoriation (skin-picking) disorder perceived themselves as less attractive. Men with excoriation (skin-picking) disorder consumed more alcohol. Depression was not linked to excoriation (skin-picking) disorder. Within first-degree relatives of study participants there was a high prevalence of skin picking. [3]

A scale for evaluating skin picking, the Skin Picking Reward Scale (SPRS), helps to define a patient's "wanting" and "liking" of skin picking. Initial findings validate the scale as a psychometrically sound measure. [4]

Diagnostic criteria (DSM-5)

The American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5), places excoriation (skin-picking) disorder in the category of obsessive-compulsive and related disorders and notes that it is characterized by recurrent body-focused repetitive behavior (skin picking) and repeated attempts to decrease or stop the behavior.

The specific DSM-5 criteria for excoriation (skin-picking) disorder are as follows [5] :

  • Recurrent skin-picking, resulting in skin lesions
  • Repeated attempts to decrease or stop skin picking
  • The skin picking causes clinically significant distress or impairment in social, occupational, or other important areas of functioning
  • The skin picking cannot be attributed to the physiologic effects of a substance (eg, cocaine) or another medical condition (eg, scabies)
  • The skin picking cannot be better explained by the symptoms of another mental disorder (eg, delusions or tactile hallucinations [psychotic disorder], attempts to improve a perceived defect or flaw in one’s appearance [body dysmorphic disorder], stereotypies [stereotypic movement disorder], or intention to harm oneself [nonsuicidal self-injury])
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Pathophysiology and Etiology

Neurotic excoriations are due either to an underlying psychopathology or to the formation of habit. Accordingly, their pathophysiology is poorly understood.

Shah and Fried found neurotic excoriations to be among the most common factitious skin diseases in children; they further noted that factitious skin disease is less common in children and can often be linked to comorbid psychiatric diagnoses or a psychosocial stressor that can be identified. [6] Subsequently, a task force of dermatologists, psychiatrists, and psychologists worked to place neurotic excoriations in their proper category in dermatology and psychology, finding that mental disorders with pathologic activities could underline the disease. [7]

The causes of neurotic excoriations are manifold and can relate to picking as a means of resolving stress or, as noted, to some underlying psychopathology. [8] Some believe neurotic excoriations to be a physical manifestation of obsessive-compulsive disorder (OCD).

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Epidemiology

Neurotic excoriations are thought to be common and underreported. The rate of neurotic excoriations among patients at dermatologic clinics is 2%. The rate of neurotic excoriations in patients with pruritus is 9%. According to DSM-5, the lifetime prevalence of excoriation disorder is at least 1.4% in the general population. [5]

Most studies have found the mean patient age at onset to be in the range of 30-45 years. Andreoli et al suggest that adolescence is the most common age at which patients pick their skin. [9] In studies, 52-92% of patients with neurotic excoriations have been female. According to DSM-5, at least three quarters of patients are female. [5]

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Prognosis

Except in mild transient cases triggered by an immediate stress, the prognosis for cure is poor. The condition tends to wax and wane with the circumstances of the patient’s life. Often, however, excoriation disorder can be controlled if the underlying psychological illness is controlled. Patients need intervention but sometimes have difficulty in changing the habit of picking. Without medical and psychiatric treatment, excoriation disorder tends to be a chronic condition. Untreated excoriations can result in scarring.

Research studies are necessary to more accurately document the expectable cause, treatment outcome, and prognosis for this group of patients.

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