Excoriation Disorder in Children and Adolescents

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).

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.

First Line Treatments

• At this time, there is emerging though still tentative evidence to support the use of individual behavior therapy for excoriation disorder in children and adolescents. Behavior therapy for skin picking primarily includes awareness training (increasing the person’s awareness of their picking behaviors), stimulus control (using barriers like gloves to create “speed bumps” to reduce the likelihood of picking), and competing response training (practicing using an incompatible behavior, like balling one’s hand into a fist, when the urge to pick arises). Together, these interventions are sometimes called habit reversal training. With children and adolescents, it is important to consider the role of the family. Parents are usually included in treatment, particularly with younger children. Reward systems are often used to help initiate and strengthen behavior change by increasing the child’s motivation to engage in treatment.

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:

• N-acetylcysteine
• Treatment of certain skin irregularities (e.g., acne) with topical or oral medications to reduce urges to pick
• Note: Despite its efficacy for treating obsessive-compulsive disorder, there is no research to date showing efficacy for SSRIs in reducing skin picking among children and adolescents.  However, SSRIs may reduce associated symptoms of anxiety and depression.