Skin Picking (Excoriation Disorder)

Nature

The key feature of Excoriation Disorder is frequent picking at one’s own skin.

Individuals with excoriation behaviors most commonly focus on areas such as the face, arms, hands, as well as multiple body areas. Individuals will often pick at healthy skin, minor skin irregularities, lesions (e.g. pimples and calluses) or scabs from previous picking. Most excoriation behaviors are performed with their fingernails, tweezers, pins, or other objects. Aside from picking skin, individuals may also engage in rubbing, squeezing, lancing, and biting behaviors. Excoriation behaviors can lead to clinically significant distress, which can impact social, occupational and other areas of functioning.

Experience

Skin picking is a compulsive behavior that is performed to achieve a sense of relief.

Individuals who meet criteria for Excoriation Disorder often spend significant amount of time, about an hour per day, fighting the urge or engaging in skin picking behaviors. This is often accompanied by unhelpful thoughts that arise from this compulsion. Individuals with an Excoriation Disorder often struggle with managing their daily living activities due to the continuous battle of managing their responsibilities while combating their compulsive thoughts.

Impact

Skin picking behaviors may also be accompanied by various other ritualistic behaviors involving skin or scabs including examining, playing with, tasting or swallowing the skin.

Skin picking can be triggered by emotional components such as anxiety, boredom, or tension. Pain in not reported to accompany these actions. Often a sense of relief, gratification, and pleasure is achieved following the skin picking. Individuals have reported skin picking in response to minor skin irritability or to relieve an uncomfortable bodily sensation.

Skin picking can be focused and conducted following tension and used as relief mechanism, or picking may be automatic, occurring without feelings of tension and without full awareness of the action. Individuals typically engage in these acts privately without others present, aside from immediate family members. There are also reports of individuals picking the skin of others.

Due to chronic skin picking, medical complications can occur which include synovitis of the wrist joint, tissue damage, scarring, and infection. Excoriation Disorder often requires antibiotic treatment to address infections and may require surgery depending on the severity of the disorder.

Prevalence of Excoriation Disorder

Excoriation Disorder is estimated to impact approximately 5% of the population. Excoriation Disorder typically begins in early adolescents, though it can begin at any age. About 75% of individuals affected by the disorder are female.

Treatment

Mental health treatment should be tailored to each individual and their presenting issues.

Evidence-based treatment for Excoriation Disorder include Cognitive Behavioral Therapy (CBT), Exposure and Response Prevention (ERP), and Habit Reversal Training (HRT).

Through Cognitive Behavioral Therapy (CBT), an individual can identify triggers and learn to alter their behaviors to eliminate or reduce skin picking. As the individual begins to learn and practice new behaviors, their brain structure begins to change, resulting in the new behaviors becoming automatic responses. In conjunction with CBT, Exposure and Response Prevention (ERP) is a technique utilized to gradually expose the individual to the anxiety-provoking situations to reduce avoidance behaviors and confront their fears. With gradual exposure, the individual increases their ability to withstand the anxiety-provoking situation. Habit Reversal Training (HRT) is a behavioral therapy technique utilized to reduce or eliminate unhealthy habits and replace them with healthier choices. There are four main components of HRT, which include awareness training, development of a competing response, building motivation, and generalization of skills.

Resources

Diagnostic and Statistical Manual of Mental Disorders (5th ed.)
American Psychiatric Association. (2013).
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Excoriation Disorder- A New Diagnosis in the DSM-5
Counseling.org
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List of Strategies for Skin-Picking
The TLC Foundation
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Recommended Reading on Dermatillomania
SkinPick
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