Skin Picking Disorder (Dermatillomania)

What is skin picking disorder?

Skin picking disorder is just as it sounds. It’s a mental health condition in which a person compulsively excoriates certain areas of their skin (which is why it’s also called excoriation disorder).

Excoriation takes different forms, including rubbing, scratching, digging at the skin and other body-focused repetitive behavior, and usually occurs on the head, face, arms, and legs. The hands (including cuticles), feet, and back are also common picking areas.^[2]

Wherever the picking occurs on the body, it can result in epidermal damage, infection, and might even require surgery like skin grafts to address the damage.

Because its effects on the skin can be so severe, people with dermatillomania often experience anxiety, shame, and an impacted quality of life and attempt to cover the damaged areas with makeup or clothing. In more severe cases, patients can be so overwhelmed with embarrassment that it leads to depression, severe anxiety, and social isolation.^[2]

Symptoms of skin picking disorder

It's common for people to pick at their skin if they have a cracked cuticle or other dermatological conditions. However, most people resolve the issue (e.g., by trimming their cuticles) and don't give it another thought.

However, someone with skin picking disorder would obsess about the damage to their cuticle and continually pick at it. Picking is usually done with the fingers, though the teeth or an instrument like tweezers might also be used.^[2]

 As mentioned earlier, skin picking occurs on many areas of the body, from head to toe. The symptomatology is the same regardless of the specific location at which the person picks:^[1]

• Skin picking occurs regularly
• The picking typically causes lesions or tissue damage
• The resulting damage causes enough distress that it impacts daily activities, social relationships, and even occupational functioning

These symptoms might be more manageable depending on the areas in which the patient picks. For example, picked skin on the fingers and hands is much more challenging to cover up than picked skin on one's back, feet, or legs.

Still, the embarrassment and anxiety associated with how one’s skin looks can lead to isolative behaviors regardless of the location of the picking. For instance, someone with excoriation disorder might be reluctant to date for fear of exposing the picked skin to their significant other.

In addition to the symptoms outlined above, skin picking disorder involves some behaviors that may make it easier for a mental health professional to provide a diagnosis. These include:^[3]

• Repeated attempts to quit picking, with no success
• Picking focuses on freckles, moles, or scars in an attempt to make them look better
• Picking causes bruising, cuts, or bleeding
• Skin picking occurs during periods of stress or anxiety
• Skin picking may occur without conscious awareness, including during sleep

As with any mental health disorder, the specific signs, symptoms, and behaviors of excoriation may vary from one person to the next. However, mental health and medical professionals have identified general criteria for diagnosing this disorder in the Diagnostic and Statistical Manual of Mental Disorders Fifth Edition (DSM-V),^[4] which is discussed in detail below.

Causes of skin picking disorder

At this point, the cause of excoriation is unknown. It’s classified in the DSM-V with obsessive-compulsive disorders, so it could have a similar cause, such as a serotonin imbalance in the brain, which is thought to be a possible cause of OCD.^[5]

 However, this is just a theory - researchers aren’t sure what causes OCD either. Generally speaking, though, skin picking disorder is like any other human behavior and is likely the result of genetic factors, environmental factors, or a combination of the two.^[2]

 Having said that, some risk factors might lead to the development of dermatillomania. These include:^[1]

• Boredom - Some people with this disorder begin picking at their skin simply because they have nothing else to occupy their attention.
• Presence of anxiety or stress - Skin picking is used by some people to cope with stressful situations.
• Experiencing negative emotions - Emotions like shame and guilt are uncomfortable to deal with, so some people might cope with these emotions by picking at their skin.
• Presence of OCD - OCD and skin picking disorder often co-occur. Hair-pulling, or trichotillomania, often co-occurs as well.^[6]

Additionally, skin picking might be more common in people with conditions like eczema or acne. This specific type of excoriation disorder is known as acne excoriée and is far more common in women than men (as is dermatillomania as a whole).^[7]

Diagnosing skin picking disorder

Skin picking disorder necessitates an evaluation by a medical doctor or a mental health professional. An assessment includes a physical examination of the picked areas of the skin. It also consists of a series of questions intended to learn more about the behavior, such as:

• When did you begin picking at your skin?
• Why did you start picking your skin?
• Is this something you’ve done for a long time, or is it a more recent problem?
• What feelings or emotions do you experience before you begin picking your skin? What about during the picking episode?
• Do you intentionally pick at your skin, or do you not realize you’re doing it until after the fact?

These types of questions get to the heart of a clinical diagnosis of excoriation disorder. The DSM-V outlines the following criteria as necessary for a diagnosis:^[4]

1. A presence of skin lesions exists that result from recurrent picking.
2. There have been repeated, though unsuccessful, attempts to reduce or stop skin picking.
3. The picked skin causes clinically significant distress or impairment in occupational, social, or other important areas of functioning.
4. Skin picking is not better explained by the effects of a substance or a medical condition.
5. Skin picking is not better explained by another mental disorder.

It should be noted that not everyone that picks at their skin has a skin picking disorder. Occasional skin picking is entirely normal. As the criteria listed above point out, the behavior must result in physical injury to the skin and cause clinically significant distress in daily life.

Treatment for skin picking disorder

There is no known cure for dermatillomania. However, this condition responds well to treatments, particularly antidepressant medications and cognitive behavioral therapy (CBT). These and other potential treatments are outlined below.

Medications for excoriation disorder

As previously mentioned, research indicates that skin picking disorder might be caused by an imbalance of serotonin in the brain. As a result, selective serotonin reuptake inhibitors (SSRIs) like fluoxetine, escitalopram, and fluvoxamine might be prescribed to help patients manage their symptoms.^[5]

In particular, SSRIs help reduce obsessions and compulsions, which can help mitigate skin picking behaviors.

Another class of medications that might be prescribed to treat this condition is anticonvulsants. Anti-seizure medications like lamotrigine have shown promise for treating skin picking disorder.^[5] These drugs increase GABA, a neurotransmitter in the brain that has calming effects.

Therapies for excoriation disorder

Cognitive behavioral therapy is the most common treatment for skin picking disorder.^[1] CBT is a short-term therapy that focuses on a primary problem. During treatment, you and your therapist work to identify maladaptive patterns of thinking that lead to undesirable behavior, in this case, skin picking.

CBT is about more than just identifying the problem, though. It's also educational in that you learn new ways of thinking that enable you to change your behavior. CBT is highly structured to achieve this end and involves learning specific strategies for modifying your behavior. Likewise, there is a significant emphasis on homework and processing what you've learned.

More specifically, a few subtypes of CBT are commonly used for treating this disorder. They include:

• Habit Reversal Training - This form of CBT focuses on identifying triggers for skin picking and replacing skin picking behaviors with more appropriate behaviors.^[8] For example, you and your therapist might identify that stress triggers your skin picking and replace skin picking with squeezing a rubber ball instead.
• Comprehensive Behavioral Model (ComB) - ComB is a type of CBT that revolves around learning about your problematic behaviors and practicing strategies to address those behaviors more healthily. For example, if your skin picking occurs when you're alone and bored, an approach to limit picking is to occupy yourself with a hobby, hang out with friends, or the like.^[9]
• Acceptance and commitment therapy (ACT) - This type of therapy emphasizes recognizing the urge to pick at one's skin as well as the negative emotions one feels when picking while also acknowledging that the picking response does not have to occur. In other words, you learn to recognize and accept your urges and feelings without acting on them by picking at your skin.^[10]

As with most mental health conditions, treating skin picking disorder is often most effective when therapy and medications are combined. This is a general rule of thumb, though. What’s best for someone else might not be the proper course of action for you.

Self-care for skin picking disorder

If you have skin picking disorder, you must seek professional help. A mental health provider should oversee the treatments outlined above to ensure you have the best chance of managing the condition in a healthy manner.

Having said that, there are a few things you can do to care for yourself and manage the symptoms of this disorder. This includes:^[11]

• Identify your triggers - Determining what compels you to pick at your skin is the first step to overcoming this disorder. Therapy can be beneficial in identifying your triggers. Still, you can be mindful of your feelings and emotions and keep a trigger diary to help you identify possible triggers on your own.
• Avoid triggers when possible - Whether your trigger is stress, anxiety, boredom, or something else, once you’ve identified it, do your best to avoid that trigger.
• Make it more difficult to pick - Wearing long-sleeved shirts and long pants, trimming your fingernails short, and wearing gloves are all strategies to help prevent skin picking when you feel the urge to do so.
• Be honest with yourself - If you're resistant to seeking help because you're embarrassed or ashamed, don't be. Many people have mental health disorders. It's nothing to be ashamed of. Likewise, be aware if you're writing off skin picking as "no big deal." Be honest with yourself and seek help as needed.
• Go to the emergency room if needed - In some cases, skin picking can be so severe that it results in severe injuries and even life-threatening conditions like sepsis. If you experience redness or swelling of the skin, have a fever, are dizzy, or anything else out of the norm, immediately seek medical help.

Helping someone with skin picking disorder / Living with someone with skin picking disorder

If someone you know has skin picking disorder, the best thing you can do is offer your unconditional support. As mentioned earlier, skin picking can cause intense embarrassment, depression, and social withdrawal, and it can be challenging for people with this disorder to ask for, let alone, accept help.

Additionally, you can do the following to help someone with excoriation disorder: 

• Offer assistance - Whether you drive your loved one to the doctor or act as a distraction for them when they feel the urge to pick, your assistance can be vital in helping them manage this condition.
• Learn more about it - Skin picking disorder isn't something most people know much about. Educating yourself about this condition can equip you to provide the support your loved one needs to progress in living with the disorder.
• Go to therapy - If your loved one is reluctant to get the mental health treatment they need, offer to go to therapy with them. Your presence might put them at ease and be more open to seeking help and participating in their treatment.

Frequently asked questions about dermatillomania

Are there any complications of skin picking disorder?

Skin picking disorder can cause physiological, emotional, and social complications. This includes open and bleeding lesions, depression, and social isolation, among others. In severe cases, it can lead to extreme pain, disfigurement, and infections.^[2]

How common is skin picking disorder?

Recent studies have found that skin picking disorder occurs in about 1-3 percent of the population. This includes a lifetime prevalence of about 3.1 percent of adults.^[12]

Skin picking disorder vs Obsessive-compulsive disorder – What is the difference?

Skin picking disorder is one of many conditions classified with obsessive-compulsive disorders in the DSM-V. The two conditions are similar in that compulsive behaviors are performed in response to obsessive thoughts. However, OCD refers to a broad spectrum of behaviors and has its own clinical criteria for diagnosis. People with skin picking disorder are more likely to have OCD or OCD spectrum disorders than people without skin picking disorder.^[2]