Approach Considerations
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. [15]
To rule out systemic disease, the following tests are indicated:
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Complete blood count (CBC) with differential
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Chemistry profile
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Determination of thyrotropin levels
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Fasting plasma glucose level
The appropriate workup for cancer can be performed if indicated by the patient’s history. A chest radiograph can help to rule out suspected lymphoma. Patients can be assessed for contact dermatitis or food allergies. A skin biopsy can be helpful to rule out other pathologic conditions.
Diagnosis
Diagnostic criteria (DSM-5-TR)
The American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, Text Revision (DSM-5-TR), 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: [2]
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Recurrent skin-picking, resulting in skin lesions
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Repeated attempts to decrease or stop skin picking
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The skin picking causes clinically significant distress or impairment in social, occupational, or other important areas of functioning
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The skin picking cannot be attributed to the physiologic effects of a substance (eg, cocaine) or another medical condition (eg, scabies)
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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])
Associated features supporting the diagnosis include a range of behaviors or rituals involving the skin that has been picked. Examples include examining, playing with or even swallowing the skin after it has been pulled off. Picking can be accompanied by different emotional states. The act of picking can be triggered by anxiety or boredom and be preceded by a sense of tension. Afterwards individuals might feel a sense of pleasure, relief or gratification. Pain is not routinely reported. [2]
Histologic Findings
Biopsy samples of neurotic excoriations generally reveal epidermal ulceration with a mild superficial mixed infiltrate and crusts formed from fluid and red blood cells (RBCs). In older lesions, superficial dermal scar tissue and changes of lichen simplex chronicus (eg, irregular epidermal hyperplasia with hyperkeratosis, hypergranulosis, and vertical streaking of papillary dermal collagen) may be observed.
Imaging Studies
Functional MRI can define abnormal brain activation in picking disorders. [16]
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A picker's nodules with no crust and a scarred appearance.
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A picker's nodule with crusted lesions.
