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Excoriation Disorder Treatment & Management

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

Approach Considerations

The patient’s denial of psychic distress and the possible negative feelings aroused in health care personnel make management of excoriation (skin-picking) disorder difficult.

Setting limits for the protection of both the physician and patient; creating an accepting, empathic, and nonjudgmental environment; and closely supervising symptomatic dermatologic care permit the development of a therapeutic relationship in which psychological issues may be gradually introduced, which may occasionally permit referral to a psychiatrist. Issues of etiology should be sidestepped because confrontation is counterproductive.

If the patient refuses referral to a psychiatrist, psychotropic drug therapy prescribed by dermatologists is helpful and appropriate. The upper dose range of selective serotonin reuptake inhibitors (SSRIs) or low-dose atypical antipsychotic agents may be effective.

Using hypnosis to facilitate resolution of psychogenic excoriations in acne excoriée has been reported. Physical barriers (eg, an Unna sleeve) can be an effective treatment for neurotic excoriations.[15]


Pharmacologic Therapy

In 2005, Krishnan and Koo reported that pathology of the opioid neurotransmitter system and the central nervous system (CNS) is the neurologic basis for neurotic excoriations, which suggested that psychiatric medications that can normalize CNS pathology can abate neurotic excoriations.[16]  In line with this, glutamate, an excitatory CNS neurotransmitter, has been reported as being potentially helpful for treating picking disorders when other conventional therapies fail.[17]

Excoriation disorder is treated with a variety of psychotropic medications. The doses can be lower than those used in treating depression, and the medications can act more quickly. Studies have shown that the serotonergic effect of SSRIs produces an antipruritic effect.[18, 19] The relief of pruritus is unrelated to changes in the patient’s mood and happens faster than would be expected for antidepressant effects.

For its sedating and antipsychotic effects, doxepin (10-25 mg orally at bedtime) is a useful medication in treating neurotic excoriations. Olanzapine may be an effective adjunctive therapy in the management of acne excoriée.[20] Paroxetine was reportedly effective in a case of psychogenic pruritus and neurotic excoriations.[21] Lithium has been used to treat neurotic excoriations, but further study is needed.[22] Dereli et al found that gabapentin is a useful treatment for recalcitrant chronic prurigo nodularis.[23]



In a study by Shenefelt, hypnotic suggestion successfully alleviated the behavioral picking aspect of acne excoriée des jeunes filles in a pregnant woman who had been picking at the acne lesions on her face for 15 years.[24] Acne excoriée is a subset of psychogenic or neurotic excoriation. Conventional topical antibiotic treatment was used to treat the acne. Compared with other treatments for uncomplicated acne excoriée, hypnosis is relatively brief and cost-effective and is nontoxic in pregnancy.



A psychiatrist and a psychologist should be consulted. Neurotic excoriations can be associated with psychopathology. Social stressors may be well hidden because of shame or a delusional belief system. Suppression, inappropriate channeling, and repression of aggression can be consequences of unmet emotional needs. Conflicts can result from past or current situations. Resolving these issues alone can be difficult.

Excoriation disorder can be associated with anxiety disorders, low self-confidence, generalized apprehension, meticulousness, depressive mood, and hypersensitivity to perceived self-negativism. Thus, the intervention of a psychiatrist or other trained mental health care professionals can be useful. Patients can benefit from psychotherapy and other forms of counseling.[25]


Long-Term Monitoring

Lesions can be kept to a minimum, the patient can be protected from unnecessary and intrusive studies, and society can be protected from escalating and unnecessary expenditure of medical resources if, rather than discharging the patient, the dermatologist continues to see the patient on an ongoing basis for supervision and support, regardless of whether lesions are present.

Patients with neurotic excoriations can be seen by psychiatrists and benefit from follow-up care to encourage the maintenance of treatment. As outpatients, patients with neurotic excoriations can be treated with low-dose psychotropic medications and cortisone creams.

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.

  1. Jafferany M, Vander Stoep A, Dumitrescu A, Hornung RL. The knowledge, awareness, and practice patterns of dermatologists toward psychocutaneous disorders: results of a survey study. Int J Dermatol. 2010 Jul. 49(7):784-9. [Medline].

  2. Brodin MB. Neurotic excoriations. J Am Acad Dermatol. 2010 Aug. 2:341-2. [Medline].

  3. Leibovici V, Murad S, Cooper-Kazaz R, Tetro T, Keuthen NJ, Hadayer N, et al. Excoriation (skin picking) disorder in Israeli University students: prevalence and associated mental health correlates. Gen Hosp Psychiatry. 2014 Nov-Dec. 36(6):686-9. [Medline].

  4. Snorrason I, Olafsson RP, Houghton DC, Woods DW, Lee HJ. 'Wanting' and 'liking' skin picking: A validation of the Skin Picking Reward Scale. J Behav Addict. 2015 Dec. 4(4):250-60. [Medline].

  5. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition. Arlington, Va: American Psychiatric Association; 2013. 254-7.

  6. Shah KN, Fried RG. Factitial dermatoses in children. Curr Opin Pediatr. 2006 Aug. 18(4):403-9. [Medline].

  7. Gieler U, Consoli SG, Tomás-Aragones L, et al. Self-Inflicted Lesions in Dermatology: Terminology and Classification - A Position Paper from the European Society for Dermatology and Psychiatry (ESDaP). Acta Derm Venereol. 2013 Jan 10. 93(1):4-12. [Medline].

  8. Koblenzer CS. Neurotic excoriations and dermatitis artefacta. Dermatol Clin. 1996 Jul. 14(3):447-55. [Medline].

  9. Andreoli E, Finore ED, Provini A, Paradisi M. [Self-inflicted dermatitis: a case in pediatric age]. Minerva Pediatr. 2008 Jun. 60(3):355-9. [Medline].

  10. Cyr PR, Dreher GK. Neurotic excoriations. Am Fam Physician. 2001 Dec 15. 64(12):1981-4. [Medline].

  11. Anetakis Poulos G, Alghothani L, Bendo S, Zirwas MJ. Neurotic excoriations: a diagnosis of exclusion. J Clin Aesthet Dermatol. 2012 Feb. 5:3-4. [Medline].

  12. Misery L, Chastaing M, Touboul S, et al. Psychogenic Skin Excoriations: Diagnostic Criteria, Semiological Analysis and Psychiatric Profiles. Acta Derm Venereol. 2012 Mar. [Medline].

  13. Setyadi HG, Cohen PR, Schulze KE, et al. Trigeminal trophic syndrome. South Med J. 2007 Jan. 100(1):43-8. [Medline].

  14. Odlaug BL, Hampshire A, Chamberlain SR, Grant JE. Abnormal brain activation in excoriation (skin-picking) disorder: evidence from an executive planning fMRI study. Br J Psychiatry. 2015 Jul 9. [Medline].

  15. Paley K, Prevost N, English JC 3rd. Unna sleeve for neurotic excoriations. Cutis. 2010 Mar. 85(3):149-52. [Medline].

  16. Krishnan A, Koo J. Psyche, opioids, and itch: therapeutic consequences. Dermatol Ther. 2005 Jul-Aug. 18(4):314-22. [Medline].

  17. Grados MA, Atkins EB, Kovacikova GI, McVicar E. A selective review of glutamate pharmacological therapy in obsessive-compulsive and related disorders. Psychol Res Behav Manag. 2015 Apr 28. 8:115-31. [Medline].

  18. Fellner MJ, Majeed MH. Tales of bugs, delusions of parasitosis, and what to do. Clin Dermatol. 2009 Jan-Feb. 27(1):135-8. [Medline].

  19. Gupta MA, Gupta AK. Fluoxetine is an effective treatment for neurotic excoriations: case report. Cutis. 1993 May. 51(5):386-7. [Medline].

  20. Gupta MA, Gupta AK. Olanzapine may be an effective adjunctive therapy in the management of acne excoriée: a case report. J Cutan Med Surg. 2001 Jan-Feb. 5(1):25-7. [Medline].

  21. Biondi M, Arcangeli T, Petrucci RM. Paroxetine in a case of psychogenic pruritus and neurotic excoriations. Psychother Psychosom. 2000 May-Jun. 69(3):165-6. [Medline].

  22. Gupta MA. Emotional regulation, dissociation, and the self-induced dermatoses: clinical features and implications for treatment with mood stabilizers. Clin Dermatol. 2013 Jan-Feb. 31(1):110-7. [Medline].

  23. Dereli T, Karaca N, Inanir I, Oztürk G. Gabapentin for the treatment of recalcitrant chronic prurigo nodularis. Eur J Dermatol. 2008 Jan-Feb. 18(1):85-6. [Medline].

  24. Shenefelt PD. Using hypnosis to facilitate resolution of psychogenic excoriations in acne excoriée. Am J Clin Hypn. 2004 Jan. 46(3):239-45. [Medline].

  25. Fried RG. Nonpharmacologic treatments in psychodermatology. Dermatol Clin. 2002 Jan. 20(1):177-85. [Medline].

  26. Turner GA, Sutton S, Sharma A. Augmentation of Venlafaxine with Aripiprazole in a Case of Treatment-resistant Excoriation Disorder. Innov Clin Neurosci. 2014 Jan. 11(1-2):29-31. [Medline].

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