Excoriation (skin picking) disorder is part of a cluster of diagnoses called the obsessive-compulsive and related disorders. Obsessive-compulsive and related disorders are a group of psychiatric conditions that include:
These disorders are characterized by the occurrence of repetitive behaviors, often called compulsions. Individuals with obsessive-compulsive disorder might engage in compulsive behaviors such as excessive washing, checking, arranging, or counting. Individuals with body dysmorphic disorder might engage in frequent checking of their appearance in the mirror, or excessive grooming-related behaviors. Individuals with hoarding disorder may engage in excessive acquiring of objects, combined with a strong need to save items. Individuals with trichotillomania engage in excessive hair pulling, and individuals with excoriation disorder engage in excessive skin picking.
In some cases, the obsessive-compulsive and related disorders are also characterized by intrusive, unwanted, or distressing thoughts, called obsessions, which come to mind again and again. People with obsessive-compulsive disorder might have obsessive thoughts about dirt or germs, thoughts of harming others, fears of making mistakes, or distress about things being out of order. People with body dysmorphic disorder have repetitive, negative thoughts about their own appearance. However, people with certain other obsessive-compulsive and related disorders (such as trichotillomania or excoriation disorder) often do not experience obsessive thoughts.
Excoriation (skin picking) disorder is a psychiatric disorder that can arise at any age, often after the onset of a dermatological condition. Estimates of the prevalence in young adults range from 2-9%. The prevalence among children remains largely unknown. Excoriation disorder is characterized by two main symptoms:
Individuals with excoriation disorder may pick at healthy skin, skin irregularities (such as pimples or calluses), or scabs. The most common picking sites are the face, arms, and hands, but individuals may pick at skin any place on the body.
The lesions resulting from picking may be fairly minor or very noticeable. The person may disguise the skin injuries with makeup, bandages, or clothing.
A person with excoriation disorder may pick in response to an urge, after noticing a skin irregularity, or in response to boredom or anxiety. Individuals with excoriation disorder often report feeling gratification, satisfaction, or relief after picking. Many people with excoriation disorder also report that they often pick without being fully aware that they are picking. Adults with childhood onset skin picking have been found to report less awareness compared to those with later symptom onset.
For excoriation disorder to be diagnosed, the picking or its consequences needs to be distressing (upsetting) or impairing (getting in the way of the person's life).
Excoriation disorder severity can range from mild to very severe. Most people with excoriation disorder spend at least an hour per day thinking about or engaging in skin picking. In severe cases, picking and picking-related thoughts can last many hours per day. Youth with the disorder may try to avoid social events or peer interactions. Interference at school is also common.
In severe cases, medical complications can arise, including tissue damage, scarring, and infection.
Although little is known about comorbidity with other psychiatric conditions among children and adolescents, research suggests that children and adolescents with skin picking can have moderate psychological difficulties (e.g., depression, anxiety, and stress). In children, skin picking is sometimes associated with a pervasive developmental disorder or Prader-Willi syndrome, a rare genetic disorder that is often associated with hyperphagia, hypogonadism, and frequent skin picking. Picking in children and adolescents with Prader-Willi syndrome or with developmental disabilities may require specialized treatment interventions.
The neurobiology of excoriation disorder is not well understood, but it has been proposed that abnormalities in certain brain regions, particularly those regions that play a role in habit formation, may contribute to skin picking. Skin picking behavior may be maintained by positive reinforcement, or a sense of gratification or satisfaction that occurs after the individual picks at his or her skin. The disorder appears to have a genetic link to obsessive-compulsive disorder (OCD), although having a genetic predisposition to excoriation disorder or OCD does not necessarily mean that someone will develop either disorder.
Excoriation (skin picking) disorder is treatable. The Trichotillomania Learning Center(TLC) and the Society of Clinical Child and Adolescent Psychology has published guidelines on the treatment of excoriation.
First Line Treatments
Other Treatments to Consider
There are no published guidelines on second- and third-line treatments for excoriation (skin picking) disorder in children and adolescents. However, clinical research suggests that the following interventions might be considered:
First Line Treatments
Other Treatments to Consider
There are no published guidelines on second- and third-line treatments for excoriation (skin picking) disorder in children and adolescents. However, clinical research suggests that the following interventions might be considered: