{{Lead too short|date=April 2024}} {{Infobox medical condition | name = Excoriation disorder | synonyms = Dermatillomania,<ref>The term derives from the [[Ancient Greek|Greek]]: δέρμα ''derma'' ("skin"), τίλλειν ''tillein'' ("to pull"), and μανία ''[[mania]]'' ("madness, frenzy").</ref> skinning disorder, neurotic excoriation, acne excoriee, pathologic skin picking (PSP), compulsive skin picking (CSP), psychogenic excoriation<ref name= Feusner>{{cite journal | vauthors = Feusner JD, Hembacher E, Phillips KA | title = The mouse who couldn't stop washing: pathologic grooming in animals and humans | journal = CNS Spectrums | volume = 14 | issue = 9 | pages = 503–513 | date = September 2009 | pmid = 19890232 | pmc = 2853748 | doi = 10.1017/s1092852900023567 }}</ref><ref name=Odlaug>{{cite journal | vauthors = Odlaug BL, Grant JE | title = Pathologic skin picking | journal = The American Journal of Drug and Alcohol Abuse | volume = 36 | issue = 5 | pages = 296–303 | date = September 2010 | pmid = 20575652 | doi = 10.3109/00952991003747543 | s2cid = 20569026 }}</ref> | image = Skin picking pattern, brightened.jpg | caption = Sores as a result of skin picking on arms, shoulders and chest | pronounce = | field = {{ubl|[[Dermatology]]|[[Psychiatry]]}} | symptoms = | complications = | onset = | duration = | types = | causes = | risks = | diagnosis = | differential = | prevention = | treatment = | medication = | prognosis = | frequency = | deaths = |alt=}}
'''Excoriation disorder''', more commonly known as '''dermatillomania''', is a [[mental disorder]] on the [[obsessive–compulsive spectrum]] that is characterized by the repeated urge or impulse to pick at one's own skin, to the extent that either psychological or physical damage is caused.<ref>{{cite journal | vauthors = Deckersbach T, Wilhelm S, Keuthen NJ, Baer L, Jenike MA | title = Cognitive-behavior therapy for self-injurious skin picking. A case series | journal = Behavior Modification | volume = 26 | issue = 3 | pages = 361–377 | date = July 2002 | pmid = 12080906 | doi = 10.1177/0145445502026003004 | s2cid = 32102397 }}</ref><ref name="Lochner 1867–1872">{{cite journal | vauthors = Lochner C, Roos A, Stein DJ | title = Excoriation (skin-picking) disorder: a systematic review of treatment options | journal = Neuropsychiatric Disease and Treatment | volume = 13 | pages = 1867–1872 | date = 2017-07-14 | pmid = 28761349 | pmc = 5522672 | doi = 10.2147/NDT.S121138 | doi-access = free }}</ref> The exact causes of this disorder are unclear but are believed to involve a combination of genetic, psychological, and environmental factors, including stress and underlying mental health conditions such as anxiety or [[Obsessive–compulsive disorder|obsessive-compulsive disorder]] (OCD).<ref name="Compulsive Skin Picking" /> Individuals with excoriation disorder may also experience co-occurring conditions like depression or [[body dysmorphic disorder]] (BDD).<ref name="DellOsso" /><ref name="Stein" /> Treatment typically involves cognitive behavioral therapy and may include medications. Without intervention, the disorder can lead to serious medical complications.<ref name="Lochner 1867–1872" /><ref name="Lang" />
==Signs and symptoms== Episodes of skin picking are often preceded or accompanied by tension, anxiety, or stress.<ref name=DellOsso/> During these moments, there is commonly a compulsive urge to pick, squeeze, bite or scratch at a surface or region of the body, often at the location of a perceived skin defect. When picking, one may feel a sense of relief or satisfaction.<ref name=":1">{{Cite web |title=Dermatillomania: All you need to know about skin picking disorder {{!}} SkinPick.com |url=https://www.skinpick.com/dermatillomania |access-date=2022-05-22 |website=www.skinpick.com}}</ref> In some cases, following picking, the affected person may feel depressed.<ref name="Lochner 1867–1872" />
The region most commonly picked is the face,<ref name=Odlaug/><ref name=DellOsso/><ref name="Lochner 1867–1872"/> but other frequent locations include the arms, legs, back, gums, neck, shoulders, scalp, abdomen, chest, and extremities such as the fingernails, knuckles, cuticles, toenails, etc. Most patients with excoriation disorder report having a primary area of the body that they focus their picking on, but they will often move to other areas of the body to allow their primary picking area to heal.<ref name=Odlaug/> Individuals with excoriation disorder vary in their picking behavior; some do it briefly multiple times a day, while others can do one picking session that can last for hours.<ref name=Lang/> The most common way to pick is to use the fingers although a significant minority of people use tools such as tweezers or needles.<ref name=Stein/>
Skin picking often occurs as a result of some other triggering cause.<ref name="Lochner 1867–1872"/> Some common triggers are feeling or examining irregularities on the skin, and feeling anxiety or other negative feelings. This anxiety most commonly stems from a type of OCD, which can range in severity and often goes undiagnosed.<ref name=Stein/>
The act of skin picking can occur both consciously (focused picking) and unconsciously (automatic picking). Some individuals may be aware of their behavior but are unable to stop, while others may not realize they are picking until after damage has occurred. The level of awareness can fluctuate, and both forms can be present in the same person.<ref name=":1" />
Complications arising from excoriation disorder include infection at the site of picking, tissue damage, and [[sepsis]]. Damage from picking can be so severe as to require [[skin grafting]], and severe picking can cause [[abscess|epidermal abscesses]]. For example, in one reported case, a 58-year-old man with a history of OCD picked an extensive wound on his left foot, exposing underlying muscle tissue.<ref>{{Cite journal |last=Malayala |first=Srikrishna |date=2021 |title=Dermatillomania: A Case Report and Literature Review |url=https://assets.cureus.com/uploads/case_report/pdf/50427/1614397743-20210227-14828-1lkt0qm.pdf |journal=Cureus }}</ref> Severe cases of excoriation disorder can cause life-threatening injuries. According to one reported case, a woman picked a hole through the bridge of her nose, which required surgery to fix, and a 48-year-old woman picked through the skin on her neck, exposing the [[Common carotid artery|carotid artery]]. Pain in the neck or back can arise due to prolonged bent-over positions while engaging in the behavior. Besides physical injuries, excoriation disorder can cause severe physical scarring and disfigurement.<ref name=Odlaug/>
Excoriation disorder can cause feelings of intense helplessness, guilt, shame, and embarrassment in individuals, and this greatly increases the risk of [[self-harm]].<ref name=Odlaug/> Studies have shown that excoriation disorder presented [[suicidal ideation]] in 12% of individuals with this condition, [[Suicide attempt|suicide attempts]] in 11.5% of individuals with this condition, and psychiatric hospitalizations in 15% of individuals with this condition.<ref name=Odlaug/>
==Causes== There have been many different theories regarding the causes of excoriation disorder, including biological and environmental factors.<ref name="Compulsive Skin Picking">{{Cite web|title=Compulsive Skin Picking|url=http://www.brainphysics.com/skin-picking.php|website=www.brainphysics.com|date=2010-03-01|access-date=2025-12-01|language=en}}</ref>
A common hypothesis is that excoriation disorder is often a [[Coping|coping mechanism]] to deal with elevated levels of turmoil, boredom, anxiety, or stress within the individual, and that the individual has an impaired [[stress response]].<ref name=Odlaug/><ref name=Lang/> A review of behavioral studies in individuals with developmental disorders and comorbid skin-picking found support in this hypothesis, in that skin-picking appears to be maintained by automatic reinforcement within the individual.<ref name=Lang/>
===Neurological=== [[File:Dermatillomania fingers.JPG|thumb|right|Compulsive picking of the knuckles (via mouth) illustrating potentially temporary disfiguration of the [[interphalangeal articulations of hand|distal and proximal joints]] of the [[middle finger|middle]] and [[little finger|little]] fingers.]]There is limited knowledge regarding the neurobiology that drives excoriation disorder, and there have been few neuroimaging studies of those with excoriation disorder.<ref name="Schienle">{{cite journal | vauthors = Schienle A, Wabnegger A |title=Two subtypes of pathological skin-picking: Evidence from a voxel-based morphometry study |journal=Journal of Obsessive-Compulsive and Related Disorders |date=1 April 2020 |volume=25 |article-number=100534 |doi=10.1016/j.jocrd.2020.100534 |language=en |issn=2211-3649|doi-access=free }}</ref>
People who have excoriation disorder along with other diagnosed conditions report differing motivations for their picking. Those with both OCD and excoriation disorder report that they will pick their skin due to perceived contamination of the skin, while those with both BDD and excoriation disorder reportedly pick to fix perceived imperfections in the skin.<ref name=Odlaug/> Studies have shown a linkage between [[dopamine]] and the urge to pick. Drugs such as [[cocaine]] and [[methamphetamine]], which increase the pharmacological effects of dopamine, have been shown to cause uncontrollable picking in users. These drugs can create the sensation of [[formication]], which feels like something is crawling on or under the skin.<ref name=Odlaug/> Thus, excoriation disorder could result from a dysfunction in the dopamine reward functions.<ref name=Odlaug/>
There may be another neurological explanation for excoriation disorder: individuals with the condition have less motor-inhibitory control, but show no sign of a difference in [[cognitive flexibility]] when compared to individuals without the condition. Motor-inhibitory control is a function of the right-lateralized [[frontostriatal circuit]], which includes the right inferior frontal and bilateral [[Anterior cingulate cortex|anterior cingulate cortices]]. The impairment of motor-inhibitory control is similar to the neurological conditions of those who have problems suppressing inappropriate behaviors, and it has been suggested by at least one study<ref name=Odlaug/> that this may be similar to the mechanisms of substance use disorder.
=== Genetic components === There is significant evidence to suggest that skin picking disorders are due to inherited traits or genes. There have been multiple small studies with similar conclusions in regards to the [[DLGAP3|SAPAP3]] gene. Excessive grooming by mice has been observed by researchers after the deletion of the SAPAP3 gene.<ref name=":0">Monzani, Benedetta; Rijsdijk, Fruhling; Cherkas, Lynn; Harris, Juliette; Keuthen, Nancy; Mataix-Cols, David (2012-05-22). "Prevalence and heritability of skin picking in an adult community sample: A twin study". ''American Journal of Medical Genetics Part B: Neuropsychiatric Genetics''. '''159B''' (5): 605–610. {{doi|10.1002/ajmg.b.32067}}. {{ISSN|1552-4841}}.</ref> This observation led researchers to study the effects of the SAPAP3 gene on patients with [[trichotillomania]]—a disorder marked by the same behaviors directed at one's own head and body hair. This study revealed a significant link between a single [[nucleotide]] [[Polymorphism (biology)|polymorphism]] (SNP) within the [[DLGAP3|SAPAP3]] gene and trichotillomania.<ref name=":0" />
==Diagnosis==
There has been controversy over the creation of a separate category in the [[DSM-5]] for excoriation (skin picking) disorder.<ref name="Jenkins 866–877">{{cite journal | vauthors = Jenkins Z, Zavier H, Phillipou A, Castle D | title = Should skin picking disorder be considered a diagnostic category? A systematic review of the evidence | journal = The Australian and New Zealand Journal of Psychiatry | volume = 53 | issue = 9 | pages = 866–877 | date = September 2019 | pmid = 30895799 | doi = 10.1177/0004867419834347 | s2cid = 84845098 }}</ref> Two of the main reasons for objecting to the inclusion of excoriation disorder in the DSM-5 are: that excoriation disorder may just be a symptom of a different underlying disorder, e.g. OCD or BDD, and excoriation disorder is merely a bad habit and that by allowing this disorder to obtain its own separate category it would force the DSM to include a wide array of bad habits as separate syndromes, e.g., [[Nail biting|nail-biting]], nose-picking, hair pulling, etc.<ref name=Stein/> Stein has argued that excoriation disorder does qualify as a separate syndrome and should be classified as its own category because:<ref>{{Cite web |title=Excoriation Disorder DSM-5 698.4 (L98.1) - Therapedia |url=https://www.theravive.com/therapedia/excoriation-disorder-dsm--5-698.4-(l98.1) |access-date=2023-04-07 |website=www.theravive.com}}</ref> * Excoriation disorder occurs as the primary disorder and not as a subset of a larger disorder. * Excoriation disorder has well-defined clinical features. * There is gathering data on the clinical features and diagnostic criteria for this condition. * There is sufficient data to create this as a separate category for excoriation disorder. * The incidence rate for excoriation disorder is high within the population. * Diagnostic criteria for the disease have already been proposed. * The classification of excoriation disorder as a separate condition would lead to better studies and better treatment outcomes. * Classification as a separate condition would lead to more awareness of the disorder and encourage more people to obtain treatment.<ref name=Stein/> A new scale used to diagnosis excoriation was used in a recent study, and the results published in the International Journal of Environmental Research and Public Health in May 2022. The scale is titled: Diagnostic Interview for Skin Picking Problems (DISP). The DISP is designed to confirm DSM-5 criteria for the diagnosis, combined with a clinical interview to determine frequency of skin picking, and the body areas impacted.<ref name="Assessing Excoriation Skin-Picking">{{cite journal | vauthors = Snorrason I, Lee HJ | title = Assessing Excoriation (Skin-Picking) Disorder: Clinical Recommendations and Preliminary Examination of a Comprehensive Interview | journal = International Journal of Environmental Research and Public Health | volume = 19 | issue = 11 | pages = 6717 | date = May 2022 | pmid = 35682303 | pmc = 9180539 | doi = 10.3390/ijerph19116717 | doi-access = free }}</ref> Initial results from the study (n = 120) participants show clinical confirmation at a satisfactory level with 88% of participants identified through the DISP as meeting DSM-5 criteria. Additionally, researchers conducted a 5-month period of validity to determine consistency with the scale. The data shows clinicians can expect to yield consistent data with administration of the scale ranging from satisfactory to perfect levels of diagnosis.<ref name="Assessing Excoriation Skin-Picking"/>
[[File:Fingers-dermatillomania.jpg|thumb|The fingers have been compulsively picked and chewed in someone with excoriation disorder and [[dermatophagia]].]]
However, a review of the scientific literature by Jenkins et al. on excoriation disorder as a separate category in the DSM-5 concluded that such a distinction requires more evidence.<ref name="Jenkins 866–877"/> Because excoriation disorder is different from other conditions and disorders that cause picking of the skin, any diagnosis of excoriation disorder must take into account various other medical conditions as possible causes before diagnosing the patient with excoriation disorder.<ref name=Odlaug/> There are a variety of conditions that cause itching and skin picking including: [[Dermatitis|eczema]], [[psoriasis]], [[diabetes]], [[liver disease]], [[Hodgkin lymphoma|Hodgkin's disease]], [[polycythemia vera]], [[Lupus|systemic lupus]], and [[Prader–Willi syndrome|Prader]][[Prader-Willi syndrome|–]]Willi syndrome.<ref name=Odlaug/>
In order to better understand excoriation disorder, researchers have developed a variety of scales to categorize skin-picking behavior. These include the Skin-Picking Impact Scale (SPIS) and The Milwaukee Inventory for the Dimensions of Adult Skin-picking.<ref name=Lang/> The SPIS was created to measure how skin picking affects the individual socially, behaviorally, and emotionally.<ref>{{cite journal | vauthors = Keuthen NJ, Deckersbach T, Wilhelm S, Engelhard I, Forker A, O'Sullivan RL, Jenike MA, Baer L | display-authors = 6 | title = The Skin Picking Impact Scale (SPIS): scale development and psychometric analyses | journal = Psychosomatics | volume = 42 | issue = 5 | pages = 397–403 | year = 2001 | pmid = 11739906 | doi = 10.1176/appi.psy.42.5.397 | doi-access = free }}</ref>
As of the release of the fifth [[DSM-5|''Diagnostic and Statistical Manual of Mental Disorders'']] (DSM-5) in May 2013, this disorder is classified as its own separate condition under "Obsessive Compulsive and Related Disorders" and is termed "excoriation (skin-picking) disorder". The diagnostic material is as follows:<ref name = "Graham_2018">{{Cite journal | vauthors = Graham R, Soares NS, Scheinfeld NS | veditors = Elston DM |date=2018-07-10 |title= Excoriation Disorder: Practice Essentials, Background, Pathophysiology and Etiology |url=https://emedicine.medscape.com/article/1122042-overview | journal = Medscape }}</ref>
# Repeated picking of the skin, resulting in injuries # Recurring attempts to stop picking while relapses continually occur # Picking causes a substantial amount of distress and substantially impairs everyday functioning # The picking is not caused or cannot be better explained by physiological effects of a substance or a medical disorder # The picking is not more accurately attributed to another mental disorder
=== Classification === Since the DSM-5 (2013), excoriation disorder is classified as "L98.1 Excoriation (skin-picking) disorder" in [[ICD-10]],<ref>{{Cite book|title = DSM-5 Guidebook: The Essential Companion to the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition | vauthors = Black DW, Grant JE |publisher = American Psychiatric Pub|year = 2014|isbn = 978-1585624652|pages = 870}}</ref> and is no longer classified in "Impulse control disorder" (f63).
Excoriation disorder is defined as "repetitive and compulsive picking of skin which results in tissue damage".<ref name="Odlaug" />
Its most official name had been "dermatillomania" for some time. As of the release of the DSM-5 in May 2013, excoriation disorder is classified as its own separate condition under "Obsessive Compulsive and Related Disorders" and is termed "excoriation (skin-picking) disorder".{{citation needed|date=August 2021}}
====Similarities with other conditions==== The inability to control the urge to pick is similar to the urge to compulsively pull one's own hair, i.e., [[trichotillomania]]. Researchers have noted the following similarities between trichotillomania and excoriation disorder: the symptoms are ritualistic but there are no preceding obsessions; there are similar triggers for the compulsive actions; both conditions appear to play a role in modifying the arousal level of the subject; and the age of onset for both conditions is similar.<ref name=Stein>{{cite journal | vauthors = Stein DJ, Grant JE, Franklin ME, Keuthen N, Lochner C, Singer HS, Woods DW | title = Trichotillomania (hair pulling disorder), skin picking disorder, and stereotypic movement disorder: toward DSM-V | journal = Depression and Anxiety | volume = 27 | issue = 6 | pages = 611–626 | date = June 2010 | pmid = 20533371 | doi = 10.1002/da.20700 | s2cid = 16146319 | doi-access = free }}</ref> There is also a high level of [[comorbidity]] between those that have trichotillomania and those that have excoriation disorder.<ref name=Stein/> A notable difference between these conditions is that skin picking seems to be dominated by females whereas trichotillomania is more evenly distributed across genders.<ref name=Stein/> The acronym "body focused repetitive behavior disorders" (BFRB) is used to characterize excoriation and trichotillomania behaviors.<ref name="Identifying subtypes of trichotillo">{{cite journal | vauthors = Grant JE, Peris TS, Ricketts EJ, Lochner C, Stein DJ, Stochl J, Chamberlain SR, Scharf JM, Dougherty DD, Woods DW, Piacentini J, Keuthen NJ | display-authors = 6 | title = Identifying subtypes of trichotillomania (hair pulling disorder) and excoriation (skin picking) disorder using mixture modeling in a multicenter sample | journal = Journal of Psychiatric Research | volume = 137 | pages = 603–612 | date = May 2021 | pmid = 33172654 | pmc = 7610704 | doi = 10.1016/j.jpsychires.2020.11.001 }}</ref> One shared behavior is continued picking as an emotional or reward sensation. This involves the picking to resolve negative thoughts or emotions or a developed behavior of automatic picking. This automatic picking becomes habitual and is a comorbidity with ADHD.<ref name="Identifying subtypes of trichotillo"/> In 2018, a new study on Tourette Syndrome (TS), trichotillomania, and excoriation revealed cooccurrence of the same disorders.<ref name="Prevalence and predictors of hair p">{{cite journal | vauthors = Greenberg E, Tung ES, Gauvin C, Osiecki L, Yang KG, Curley E, Essa A, Illmann C, Sandor P, Dion Y, Lyon GJ, King RA, Darrow S, Hirschtritt ME, Budman CL, Grados M, Pauls DL, Keuthen NJ, Mathews CA, Scharf JM | display-authors = 6 | title = Prevalence and predictors of hair pulling disorder and excoriation disorder in Tourette syndrome | journal = European Child & Adolescent Psychiatry | volume = 27 | issue = 5 | pages = 569–579 | date = May 2018 | pmid = 29098466 | pmc = 5932289 | doi = 10.1007/s00787-017-1074-z }}</ref> Participants were screened by clinical staff in clinics supporting patients with Tourette Syndrome. Those patients included then completed self-report questionnaires. Of the total number of TS participants (n = 811), 13% revealed diagnosis of trichotillomania and excoriation.<ref name="Prevalence and predictors of hair p"/> This significance of results was reported with the recommendation of screening in children with a diagnosis of TS. This will assist clinicians in screening for trichotillomania and excoriation or the risk factors for both. As with the adult population of women, girls are more impacted by the disorders than boys.
Research has also suggested that excoriation disorder may be thought of as a type of OCD.<ref name="DellOsso" /> Excoriation disorder and OCD are similar in that they both involve "repetitive engagement in behaviors with diminished control" and also both generally decrease anxiety.<ref name="Odlaug" />
Nevertheless, Odlaug and Grant have suggested that excoriation disorder is more akin to [[substance use disorder]] than OCD.<ref name="Odlaug" /> They argue that excoriation disorder differs from OCD in the following fundamental ways:[[File:Excoriation disorder affecting face.jpg|thumb|right|Compulsive picking of the face using nail pliers and tweezers]] * There is a much greater share of females with excoriation disorder. * Excoriation disorder may be inherently pleasurable whereas OCD is not. * The treatments that are generally effective for patients with OCD (i. e., [[Selective serotonin reuptake inhibitor|SSRIs]] and [[exposure therapy]]) are not as successful in patients with excoriation disorder. * Unlike OCD, picking the skin is rarely driven by obsessive thoughts. Odlaug and Grant have recognized the following similarities between individuals with dermatillomania and patients with addictions: * Compulsion to engage in the negative behavior despite knowledge of the harm. * Lack of control over the problematic behavior. * Strong urge to engage in the behavior before engagement. * Feeling of pleasure while engaging in the behavior or a feeling of relief or reduced anxiety after engaging in the behavior.<ref name="Odlaug" /> One study that supported the addiction theory of picking found that 79% of patients with excoriation disorder reported a pleasurable feeling when picking.<ref name="Odlaug" />
Odlaug and Grant also argue that dermatillomania could have several different psychological causes, which would explain why some patients seem more likely to have symptoms of OCD, and others, of an addiction. They suggest that treating certain cases of excoriation as an addiction may yield more success than treating them as a form of OCD.<ref name="Odlaug" />
==Treatment== Knowledge about effective treatments for excoriation disorder is sparse, despite the prevalence of the condition.<ref name=Lang>{{cite journal | vauthors = Lang R, Didden R, Machalicek W, Rispoli M, Sigafoos J, Lancioni G, Mulloy A, Regester A, Pierce N, Kang S | display-authors = 6 | title = Behavioral treatment of chronic skin-picking in individuals with developmental disabilities: a systematic review | journal = Research in Developmental Disabilities | volume = 31 | issue = 2 | pages = 304–315 | year = 2010 | pmid = 19963341 | doi = 10.1016/j.ridd.2009.10.017 }}</ref><ref name="Lochner 1867–1872"/> There are two major classes of therapy for excoriation disorder: pharmacological and behavioral.<ref name=Odlaug/><ref name="Lochner 1867–1872"/> To complement these approaches, group therapy or [[support group]]s may be used to help individuals abstain from skin picking. Among them is the abstinence-based [[Twelve-step program|12-step recovery]] fellowship [https://www.osparecovery.org/ Obsessive Skin Pickers Anonymous] (OSPA).
Individuals with excoriation disorder often do not seek treatment for their condition, largely due to feelings of embarrassment, alienation, lack of awareness, or belief that the condition cannot be treated. One study found that only 45% of individuals with excoriation disorder ever sought treatment, and only 19% ever received dermatological treatment. Another study found that only 30% of individuals with this disorder sought treatment.<ref name=Odlaug/>
===Medication=== There are several different classes of pharmacological treatment agents that have some support for treating excoriation disorder: [[Selective serotonin reuptake inhibitor|SSRIs]], [[Opioid antagonist|opioid antagonists]], anti-epileptic agents, and [[glutamatergic]] agents.<ref name=Odlaug/><ref name="Lochner 1867–1872"/> In addition to these classes of drugs, some other pharmacological products have been tested in small trials as well.<ref name="Lochner 1867–1872"/>
Antipsychotic, antianxiety, antidepressant, and antiepileptic medications have all been used to treat skin picking, with varying degrees of success.<ref name = "Graham_2018" />
[[Selective serotonin reuptake inhibitor|SSRIs]] have shown to be effective in the treatment of OCD, which serves as an argument in favor of treating excoriation disorder with the same therapy. Unfortunately, clinical studies have not provided clear support for this, because there have not been large double-blind placebo-controlled trials of SSRI therapy for excoriation disorder.<ref name="Odlaug" /><ref name="Lang" /> In fact, in a meta-analysis of pharmacological treatments of excoriation disorders, it was found that selective serotonin reuptake inhibitors (SSRIs) and lamotrigine were no more effective than a placebo for longterm effects.<ref>{{cite journal | vauthors = Schumer MC, Bartley CA, Bloch MH | title = Systematic Review of Pharmacological and Behavioral Treatments for Skin Picking Disorder | journal = Journal of Clinical Psychopharmacology | volume = 36 | issue = 2 | pages = 147–152 | date = April 2016 | pmid = 26872117 | pmc = 4930073 | doi = 10.1097/JCP.0000000000000462 }}</ref> Reviews of treatment of excoriation disorder have shown that the following medications may be effective in reducing picking behavior: [[doxepin]], [[clomipramine]], [[naltrexone]], [[pimozide]], and [[olanzapine]].<ref name="Lang" /> Small studies of [[fluoxetine]], an SSRI, in treating excoriation disorder showed that the drug reduced certain aspects of skin picking compared with a placebo, but full remission was not observed.<ref name="Odlaug" /> One small study of patients with excoriation disorder treated with [[citalopram]], another SSRI, showed that those who took the drug significantly reduced their scores on the [[Yale–Brown Obsessive–Compulsive Scale|Yale–Brown Obsessive Compulsive Scale]] compared with a placebo, but that there was no significant decrease on the visual-analog scale of picking behavior.<ref name="Odlaug" />
While there have been no human studies of opioid antagonists for the treatment of excoriation disorder, there have been studies showing that these products can reduce self-chewing in dogs with [[Lick granuloma|acral lick]], which some have proposed is a good animal model for body-focused repetitive behavior.<ref name=Odlaug/> Furthermore, case reports support the use of these opioid antagonists to treat excoriation disorder.<ref name=Odlaug/> Opioid antagonists work by affecting dopamine circuitry, thereby decreasing the pleasurable effects of picking.<ref name=Odlaug/>
[[File:Dermatillomania fingers3-22.jpg|thumb|Fingers that have been “picked at” using tweezers.]]
Another class of possible pharmacological treatments is glutamatergic agents such as [[Acetylcysteine|N-acetylcysteine]] (NAC). These products have shown some ability to reduce other problematic behaviors such as cocaine addiction and trichotillomania.<ref name=Odlaug/> Some case studies and some small studies of NAC have shown a decrease in picking by treatment with NAC compared with placebo.<ref name=Odlaug/>
Excoriation disorder and [[trichotillomania]] have been treated with [[inositol]].<ref>{{cite journal | vauthors = Torales J, Barrios I, Villalba J | title = Alternative Therapies for Excoriation (Skin Picking) Disorder: A Brief Update | journal = Advances in Mind-Body Medicine | volume = 31 | issue = 1 | pages = 10–13 | year = 2017 | pmid = 28183072 }}</ref>
[[Topiramate]], an anti-epileptic drug, has been used to treat excoriation disorder; in a small study of individuals with [[Prader–Willi syndrome]], it was found to reduce skin picking.<ref name=Lang/>
===Psychological treatment=== Treatments include [[cognitive behavioral therapy]], acceptance-enhanced behavior therapy,<ref name="Odlaug" /><ref name="DellOsso" /> and [[acceptance and commitment therapy]] (ACT).<ref>{{cite journal | vauthors = Ruiz FJ |year=2010 |title=A review of Acceptance and Commitment Therapy (ACT) empirical evidence: Correlational, experimental psychopathology, component and outcome studies |journal=International Journal of Psychology and Psychological Therapy |volume=10 |issue=1 |pages=125–62 |url=http://www.ijpsy.com/volumen10/num1/256.html}}</ref>
Several studies have shown that habit reversal training associated with awareness training reduces skin-picking behavior in those individuals with excoriation disorder that do not have psychological problems.<ref name=Lang/> Habit reversal training includes awareness enhancement and competing response training.<ref name=Lang/> For example, in one study the competing response training required participants to make a closed fist for one minute instead of picking or in response to a condition that usually provokes picking behavior.<ref name=Lang/> In a recent study of participants (n = 113) diagnosed with ED, less than 50% followed through with an appointment to psychiatry.<ref name="Epidemiology and Comorbidities of E">{{cite journal | vauthors = Kwon C, Sutaria N, Khanna R, Almazan E, Williams K, Kim N, Elmariah S, Kwatra SG | display-authors = 6 | title = Epidemiology and Comorbidities of Excoriation Disorder: A Retrospective Case-Control Study | journal = Journal of Clinical Medicine | volume = 9 | issue = 9 | pages = 2703 | date = August 2020 | pmid = 32825621 | pmc = 7564859 | doi = 10.3390/jcm9092703 | doi-access = free }}</ref> In an absence of longitudinal data which follows patients with psychiatric referrals as a result of ED, little is known for the reasons patients do not follow through with the referral, or what more is needed to ensure access to care. Overall, less than 25% of participants in this study achieved long term results, highlighting the need for a collaborative team approach to treatment across several disciplines to include PCP, dermatology, psychology, and psychiatry as needed.
===Developmentally disabled=== Several different behavioral interventions have been tested to treat excoriation disorder in those with developmental disabilities.{{citation needed|date=July 2021}}
One method is to have individuals wear a form of protective clothing that limits the ability of the patient to pick at their body, e.g., gloves or face mask.<ref name=Lang/>
Other behavioral treatments attempt to change behavior by providing different incentives. Under Differential Reinforcement of Other Behavior (DRO), a patient is rewarded if able to abstain from the picking behavior for a certain amount of time.<ref name=Lang/> In contrast to DRO, Differential Reinforcement of Incompatible Behavior (DRI) rewards an individual for engaging in an alternative behavior that cannot physically occur at the same time as the problem behavior (e.g. sitting on your hands instead of picking at your skin).<ref name=Lang/> Lastly, differential reinforcement of alternative behavior rewards behavior that is not necessarily incompatible with the target behavior but serves the same function as the target behavior (e.g., providing people with a competing behavior to occupy their time instead of skin picking).<ref name=Lang/>
All of these techniques have been reported to have some success in small studies, but none has been tested in large enough populations to provide definitive evidence of their effectiveness.<ref name=Lang/>
===Biofeedback===
Tentative evidence suggests that devices that provide feedback when the activity occurs can be useful.<ref>{{cite journal | vauthors = Torales J, Barrios I, Villalba J | title = Alternative Therapies for Excoriation (Skin Picking) Disorder: A Brief Update | journal = Advances in Mind-Body Medicine | volume = 31 | issue = 1 | pages = 10–13 | date = 2017 | pmid = 28183072 }}</ref>
==Prognosis== Typically, individuals with excoriation disorder find that the disorder interferes with daily life. Hindered by shame, embarrassment, and humiliation, they may take measures to hide their disorder by not leaving home, wearing long sleeves and pants even in the heat, or covering visible damage to the skin with cosmetics and/or bandages. When untreated, excoriation disorder can last anywhere from 5 to 21 years. However, many doctors consider this disorder to be a permanent diagnosis.<ref>{{Cite journal| vauthors = Craig-Müller S, Reichenberg J |date=July 4, 2015|title=The Other Itch That Rashes: a Clinical and Therapeutic Approach to Pruritus and Skin Picking Disorders|journal=Allergic Skin Diseases}}</ref> Excoriation has been documented as showing active from an onset in childhood and remaining active through adulthood.<ref name="Epidemiology and Comorbidities of E"/>
== Epidemiology == [[File:Dermatillomania on leg.jpg|alt=Photo of a women's lower legs with scars and wounds beginning to heal after a skin-picking episode cause by excoriation disorder.|thumb|The skin begins to heal after a skin-picking episode caused by excoriation disorder.]] The prevalence of excoriation disorder is not well understood.<ref name="Odlaug" />
Estimates of the prevalence of the condition range from 1.4 to 5.4% in the general population. One U.S. telephone survey found that 16.6% of respondents "picked their skin to the point of noticeable tissue damage" and that 1.4% would qualify as meeting the requirements of excoriation disorder. Another community survey found a rate of 5.4% had excoriation disorder. A survey of college students found a rate of 4%.<ref name=Odlaug/> One study found that among non-disabled adults, 63% of individuals engaged in some form of skin picking and 5.4% engaged in serious skin picking.<ref name=Lang/> Lastly, a survey of dermatology patients found that 2% had excoriation disorder.<ref name=Odlaug/>
In some patients, excoriation disorder begins with the onset of [[acne]] in adolescence, but the compulsion continues even after the acne has gone away. Skin conditions such as keratosis pilaris, psoriasis, and eczema can also provoke the behavior. In patients with acne, the grooming of the skin is disproportionate to the severity of the acne.<ref name=Odlaug/> Certain stressful events including marital conflicts, deaths of friends or family, and unwanted pregnancies have been linked to the onset of the condition.<ref name=Odlaug/> If excoriation disorder does not occur during adolescence, another common age of onset is between the ages of 30 and 45.<ref name=Odlaug/> Additionally, many cases of excoriation disorder have been documented to begin in children under the age of 10. One small survey of patients with excoriation disorder found that 47.5% of them had an early onset of excoriation disorder that began before age 10.<ref name=Odlaug/> Traumatic childhood events may initiate the behavior.{{citation needed|date=August 2021}}
Excoriation disorder is statistically more common in females than in males.<ref name=Odlaug/><ref name=DellOsso>* {{cite journal | vauthors = Dell'Osso B, Altamura AC, Allen A, Marazziti D, Hollander E | title = Epidemiologic and clinical updates on impulse control disorders: a critical review | journal = European Archives of Psychiatry and Clinical Neuroscience | volume = 256 | issue = 8 | pages = 464–475 | date = December 2006 | pmid = 16960655 | pmc = 1705499 | doi = 10.1007/s00406-006-0668-0 }}</ref>
Excoriation disorder has a high rate of [[comorbidity]] with other psychiatric conditions, especially with mood and anxiety disorders.<ref name=Stein/> One survey of patients with excoriation disorder found that 56.7% also had a [[Diagnostic and Statistical Manual of Mental Disorders#Multi-axial system|DSM-IV Axis-I disorder]] and 38% had substance use problems.<ref name=Odlaug/> Studies have shown the following rates of psychiatric conditions found in patients with excoriation disorder: [[trichotillomania]] (38.3%), [[substance use disorder]] (38%), [[major depressive disorder]] (approximately 31.7% to 58.1%), [[Anxiety disorder|anxiety disorders]] (approximately 23% to 56%), [[Obsessive–compulsive disorder|obsessive]][[Prader-Willi syndrome|–]]<nowiki/>compulsive disorder (approximately 16.7% to 68%), and [[body dysmorphic disorder]] (approximately 26.8% to 44.9%).<ref name=Odlaug/> There are also higher rates of excoriation disorder in patients in psychiatric facilities; a study of adolescent psychiatric inpatients found that excoriation disorder was present in 11.8% of patients.<ref name=Odlaug/> It is also present at high rates with some other conditions: 44.9% of patients with body dysmorphic disorder also have excoriation disorder, 8.9% of patients with OCD have excoriation disorder, and 8.3% of patients with trichotillomania have excoriation disorder.<ref name=Odlaug/>
Skin picking is also common in those with certain developmental disabilities, for example, [[Prader–Willi syndrome]] and [[Smith–Magenis syndrome]].<ref name=Lang/> Studies have shown that 85% of people with Prader–Willi syndrome also engage in skin-picking.<ref name=Lang/> Children with developmental disabilities are also at an increased risk for excoriation disorder.<ref name=Lang/>
Excoriation disorder also correlates with "social, occupational, and academic impairments, increased medical and mental health concerns (including anxiety, depression, obsessive–compulsive disorder) ... and financial burden".<ref name=Lang/> Excoriation disorder also has a high degree of comorbidity with occupational and marital difficulties.<ref name=Stein/>
Substance use is often present, and individuals with excoriation disorder are twice as likely to have [[Degree of relationship|first-degree relatives]] who have substance use disorders than those without the condition.<ref name=Odlaug/>
Some cases of body-focused repetitive behaviors found in identical twins also suggest a hereditary factor.<ref>{{cite journal | vauthors = Monzani B, Rijsdijk F, Cherkas L, Harris J, Keuthen N, Mataix-Cols D | title = Prevalence and heritability of skin picking in an adult community sample: a twin study | journal = American Journal of Medical Genetics. Part B, Neuropsychiatric Genetics | volume = 159B | issue = 5 | pages = 605–610 | date = July 2012 | pmid = 22619132 | doi = 10.1002/ajmg.b.32067 | s2cid = 1525948 }}</ref>
In a 2020 Study of Excoriation to identify the variable's such as: demographics, SES, marital status, and gender, more than 75% of participants were identified as female, more than 45% of all participants were unemployed, and more than 60% had marital status which ranged from being single to divorced or widowed.<ref name="Epidemiology and Comorbidities of E"/> With more females accounting for diagnosis than any other group, future research should look to uncover reasons why women are more impacted by excoriation, and if excoriation has a correlation with marital status or happiness in life.
==History== In 1875, English dermatologist [[William James Erasmus Wilson|Erasmus Wilson]] introduced the term “neurotic excoriation” to describe compulsive skin-picking behaviors.<ref name=":2">{{Cite journal |last=Grant |first=Jon |date=2012 |title=Treatment in Psychiatry: Skin Picking Disorder |url=https://psychiatryonline.org/doi/pdf/10.1176/appi.ajp.2012.12040508#:~:text=Although%20skin%20picking%20has%20been,ment%20should%20include%20cognitive%2Dbehavioral |journal=American Journal of Psychiatry|doi=10.1176/appi.ajp.2012.12040508 |url-access=subscription }}</ref> The first known mention of excoriation disorder in print can be found in 1898 by the French dermatologist [[Louis-Anne-Jean Brocq]], describing an adolescent female patient who had uncontrolled picking of acne.<ref name=Odlaug/><ref>{{cite journal |author=Brocq ML |title= L'Acné excoriée des jeunes filles et son traitement |trans-title=Acne excoriee of young women and their treatment |journal= Journal des Practiciens, Revue Générale de Clinique et de Thérapeutique |volume=12 |pages=193–197 |year=1898}}</ref> Although the condition was first identified in the 19th century, it remains poorly understood. Much of the existing knowledge about the disorder comes from online surveys rather than in-person clinical evaluations.<ref name=":2" /><ref>{{Cite journal |last=Grant |first=Jon |date=2022 |title=Characteristics of 262 adults with skin picking disorder |url=https://pdf.sciencedirectassets.com/272452/1-s2.0-S0010440X22X00059/1-s2.0-S0010440X2200044X/main.pdf?X-Amz-Security-Token=IQoJb3JpZ2luX2VjEHgaCXVzLWVhc3QtMSJGMEQCIEiEoxifO9pyFGyGv4Dtrr1qd30iVR43rU0He8GDkzTyAiB8NgRi9Ux9yDBxFIWLHTsq6SoMcGVH50ECZe1B%2FeeRGSqyBQghEAUaDDA1OTAwMzU0Njg2NSIMsdhnySHkinenDTvnKo8FUq4N0volGBhPUgRnfyoGRSC%2BLXZj%2FM1yr5ZMaEq8Cy1j3Ee6Ivgueh8Xbs2xo793Q%2FfymdRcALD3Gc5R6YVvNrAG1RSwesEDEdeV96geR1ixrU5jgiLnpff8ceCf68yuj0Hl%2F6%2Fr2LabMPiD8PL9kL68WtLmGk5UeHiUXIrSaF1KSx1UELqQT%2FgIy%2BCh0tM44LTon%2B1wPVA6ZsptZwa0Xduq3nPZG1Y%2BUKh%2FttOPQMABvJ%2FNBQa%2BcKedEwm8zoWXpxrgyncBu8Pes9wqVzn1Q7i9bARocvG3dDDXwNNcFi5y32LYnuVG5fSDeriTrZ%2BBqdFWzTUOstRnrixPMb3nIdXiEY9jGJ3rXwQGd%2FFqwCnd%2BjWACQpdK3OmFUzSF3E0QAhwPq9KvOE0L4zdVIOoPm7iF2cioU%2Bbq9JCZREK7lV2ZHvMp8%2Fw6Yp0dkDcN0oaV1gKPB3G73ALoITN77z8%2FlLHoFyarpSQPWqKb0J6m%2BYAnCuj7%2F%2BtIfNhtqfTnzYY7dscZiGRqofjDObRR1EbZ%2FrP2tCKNm11RkAj32qpNDkh2sxHuCMXs8OpJARAgLFM0pui9MH9ADmPWfUIbfOYjzgpCpCGcpLuMDKFPFOvLjikmE%2FX3OIp7Tgi9JyvQ2OgLNEvI44BOhNyQPw0zdNXLTcUFxGX%2F0LZntBjXcBLA3Z95RXpzbQnnknwc%2FygI8EHx%2BP8M8hdSS9jPJIol3jLjj%2FV8YbrlgAW0xf4HQ07wNKgwJCdt8Uc4bxK38SzKCSU22QKuC8RvzkAMiPzf9IPsXQriRGpsXai2xopRe6Lt4frfMd1oAzI%2BQH2K%2FEDT%2BaChAzBkNLQ7MnAVKoA3jvSEOaScEsVFt8JZMVGL1SubzD2%2Fd%2FABjqyAYT6mWvent1Doy811OalV6yc%2B6ZsAWN5FUJktjmanapD%2FtmwGzvwTz9KU0z9Dd3T%2BdYToUzNB4IsltB919ogEjf7qqx7iDYrao6W%2Bw6UStGR7Il9cJ%2B2cky2cj45nzey1yOwM7FYuasweffV7RieuvRNqvoz9IEyhosRWXjRnkdF37rnXHqSbW0LQf0z2g5q8U3eo8ExKd5GrAfEF66S6bsvLlsY7%2B7AUL5DKoD8eOzsmb8%3D&X-Amz-Algorithm=AWS4-HMAC-SHA256&X-Amz-Date=20250505T004244Z&X-Amz-SignedHeaders=host&X-Amz-Expires=300&X-Amz-Credential=ASIAQ3PHCVTYT33F6UEI%2F20250505%2Fus-east-1%2Fs3%2Faws4_request&X-Amz-Signature=14adfcf24958a7c60fd4a3f9ce6c9652ce2e8c5c897d92cdafebe5440449bb60&hash=ec3b2087c823dae075df5c4297a7a982386010d7a5267c8bb6962a5f7bc0e7ab&host=68042c943591013ac2b2430a89b270f6af2c76d8dfd086a07176afe7c76c2c61&pii=S0010440X2200044X&tid=spdf-47db9746-6174-4030-b2ca-e0c957efeab2&sid=5c0489875160314df64b6f945708d19413b8gxrqa&type=client&tsoh=d3d3LnNjaWVuY2VkaXJlY3QuY29t&rh=d3d3LnNjaWVuY2VkaXJlY3QuY29t&ua=0f125b5406075250525d&rr=93ac331939a8764a&cc=us |journal=Comprehensive Psychiatry}}</ref>
==Society and culture== Excoriation disorder has been the subject of several episodes of ''[[Obsessed (TV series)|Obsessed]]'', a television documentary series that focuses on the treatment of anxiety disorders.
Excoriation disorder is shown as a symptom of Nina Sayers' anxiety and OCD in the movie ''[[Black Swan (film)|Black Swan]]''.{{citation needed|date=July 2021}}
During the 2021 [[Miss America]] competition, [[Miss Alaska]] 2021 [[Emma Broyles]] highlighted her vulnerability and openness on social media about having [[attention deficit hyperactivity disorder]] and dermatillomania, as well as her history with volunteering for the [[Special Olympics]]. She was crowned [[Miss America 2022]].<ref name=":02">{{Cite web | vauthors = Goldstein J |date=December 17, 2021 |title=Miss America 2022 Emma Broyles Explains How She Went From Having 'a Lot of Doubt' to Winning Crown |url=https://people.com/human-interest/miss-america-2022-emma-broyles-reflects-on-journey-to-winning-crown/ |access-date=2022-03-03 |website=PEOPLE.com |language=en}}</ref>
== See also == * [[Dermatophagia]] * [[Morgellons]] * [[Trichotillomania]], a similar compulsive behaviour, characterized by pulling out hair or eyelashes * [[Impulse-control disorder]] * [[Body-focused repetitive behavior]]
== References == {{Reflist}}
== Further reading == {{Refbegin}} * {{cite journal | vauthors = Grant JE, Odlaug BL | title = Update on pathological skin picking | journal = Current Psychiatry Reports | volume = 11 | issue = 4 | pages = 283–288 | date = August 2009 | pmid = 19635236 | doi = 10.1007/s11920-009-0041-x | s2cid = 38128908 }} * {{cite book | vauthors = Singer HS | title = Hyperkinetic Movement Disorders | chapter = Stereotypic movement disorders | series = Handbook of Clinical Neurology | volume = 100 | pages = 631–9 | year = 2011 | pmid = 21496612 | doi = 10.1016/B978-0-444-52014-2.00045-8 | isbn = 9780444520142 }} * {{cite journal | vauthors = Stein DJ, Grant JE, Franklin ME, Keuthen N, Lochner C, Singer HS, Woods DW | title = Trichotillomania (hair pulling disorder), skin picking disorder, and stereotypic movement disorder: toward DSM-V | journal = Depression and Anxiety | volume = 27 | issue = 6 | pages = 611–626 | date = June 2010 | pmid = 20533371 | doi = 10.1002/da.20700 | s2cid = 16146319 | doi-access = free }} * {{cite web | vauthors = Stratton MM |title=Stop Picking On Me | date=February 2018 | url=http://www.stoppickingonme.com}} {{Refend}}
== External links == {{Commons}} {{Medical resources | DiseasesDB =29765 | ICD11 = {{ICD11|6B25.1}} | ICD10 = {{ICD10|L|98.1}} | ICD9 = {{ICD9|312.3}} | ICDO = | OMIM = | MedlinePlus = | eMedicineSubj =article | eMedicineTopic =1122042 | MeshID = D007174 }}
{{Emotional and behavioral disorders}} {{Mental and behavioural disorders|selected = adult}} {{Authority control}}
[[Category:Body-focused repetitive behavior]] [[Category:Conditions of the skin appendages]] [[Category:Mania]] [[Category:Neurocutaneous conditions]]