Excoriation Disorder (Skin-Picking Disorder)

Excoriation Disorder, also known as Skin-Picking Disorder or dermatillomania, is a mental health condition characterised by the recurrent picking at one's own skin, resulting in skin lesions and significant distress or impairment. People with this disorder often pick at healthy skin, minor skin irregularities, or lesions such as acne, scabs, or calluses.

The picking is not done for cosmetic reasons but rather as a response to emotional states, urges, or sensations. Excoriation disorder affects 1-5% of the population, is more common in females, and typically begins during adolescence.

Table of Contents | Jump Ahead

• Understanding Excoriation Disorder
• How Excoriation Disorder Develops
• Signs and Symptoms
• Impact on Daily Life
• Diagnosis and Assessment
• Treatment and Recovery
• Strategies for Daily Life
• For Family and Friends
• Skin Healing and Cosmetic Concerns
• Support and Community
• Hope and Recovery
• Finding Help
• Myths and Misconceptions
• Remember
• References

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Understanding Excoriation Disorder

Key Features:

• Recurrent skin picking - resulting in skin lesions
• Repeated attempts to stop - trying to decrease or stop picking
• Significant distress - emotional pain about the behaviour
• Functional impairment - problems in social, work, or other areas
• Not due to substances - not caused by drugs or medical conditions
• Not cosmetic - not done to improve appearance

Common Areas of Picking:

• Face - most common area, including acne and blemishes
• Arms and hands - easily accessible areas
• Legs - especially around scabs or bumps
• Back and shoulders - often picked in front of mirrors
• Scalp - picking at scabs or dry skin
• Lips and cuticles - around nails and mouth
• Any area with perceived imperfections

Types of Picking:

• Focused picking - deliberate, conscious picking with tools or fingers
• Automatic picking - unconscious picking while doing other activities
• Mixed type - combination of both focused and automatic picking

How Excoriation Disorder Develops

Possible Contributing Factors:

• Genetics - family history of skin picking or related disorders
• Brain differences - abnormalities in areas controlling impulses and habits
• Stress and trauma - difficult life events or ongoing stress
• Emotional regulation - difficulty managing emotions
• Sensory factors - seeking specific textures or sensations
• Perfectionism - desire to remove "imperfect" skin
• Skin conditions - acne, eczema, or other skin problems

Common Triggers:

• Stress or anxiety
• Boredom or inactivity
• Negative emotions (sadness, anger, frustration)
• Positive emotions (excitement, relief)
• Skin irregularities or perceived flaws
• Certain activities (studying, watching TV, talking on phone)
• Specific locations (bathroom, bedroom)
• Particular times of day

Signs and Symptoms

Physical Signs:

• Visible skin lesions, scabs, or scars
• Infections from repeated picking
• Discoloration or hyperpigmentation
• Open wounds that don't heal properly
• Tissue damage or permanent scarring
• Bleeding or bruising
• Swelling or inflammation

Behavioural Signs:

• Spending significant time picking skin
• Using tools to pick (tweezers, needles, pins)
• Examining skin closely in mirrors
• Picking in specific locations or positions
• Avoiding activities that might expose skin damage
• Wearing makeup or clothing to cover lesions
• Repeatedly checking or touching skin

Emotional Symptoms:

• Shame and embarrassment about appearance
• Guilt about inability to stop picking
• Anxiety about others noticing skin damage
• Depression and low self-esteem
• Feeling out of control
• Relief or satisfaction during picking
• Tension or urges before picking
• Frustration with healing process

Impact on Daily Life

Social Functioning:

• Avoiding social situations due to embarrassment
• Difficulty with intimate relationships
• Problems at work or school
• Isolation and loneliness
• Avoiding activities like swimming or wearing certain clothes
• Spending excessive time and money on skincare products

Emotional Well-being:

• Chronic shame and self-criticism
• Depression and anxiety
• Low self-esteem and confidence
• Feeling different or abnormal
• Stress about hiding the condition
• Frustration with inability to stop

Physical Health:

• Risk of infections and scarring
• Delayed wound healing
• Permanent skin damage
• Pain and discomfort
• Sleep problems from nighttime picking
• Repetitive strain injuries in hands/fingers

Diagnosis and Assessment

Professional Evaluation: Diagnosis requires assessment by a qualified mental health professional:

• Detailed clinical interviews about picking behaviours
• Assessment of emotional triggers and consequences
• Evaluation of functional impairment
• Medical examination to rule out skin conditions
• Sometimes psychological testing

Diagnostic Criteria (DSM-5):

• Recurrent skin picking resulting in skin lesions
• Repeated attempts to decrease or stop skin picking
• Skin picking causes significant distress or impairment
• Skin picking is not due to substance use or medical condition
• Skin picking is not better explained by another mental disorder

Related Conditions:

• Other body-focused repetitive behaviours - hair pulling, nail biting
• Obsessive-compulsive disorder - similar repetitive behaviours
• Anxiety disorders - often co-occur with skin picking
• Depression - common in people with excoriation disorder

Treatment and Recovery

Therapy Approaches:

• Acceptance and Commitment Therapy (ACT) - accepting urges without acting
• Dialectical Behaviour Therapy (DBT) - emotional regulation and distress tolerance
• Cognitive Behavioural Therapy (CBT) - changing thoughts and behaviours
• Habit Reversal Training (HRT) - awareness and competing responses
• Comprehensive Behavioural Treatment (ComB) - combines multiple approaches

Key Treatment Components:

• Awareness training - recognising picking urges and behaviours
• Stimulus control - modifying environment to reduce triggers
• Competing responses - alternative behaviors when urges arise
• Emotional regulation - managing underlying emotions
• Acceptance strategies - accepting urges without acting on them
• Skin care education - proper wound care and healing

Medication:

• SSRIs may help with associated anxiety and depression
• N-acetylcysteine (NAC) - supplement that may reduce picking urges
• Topical treatments - for healing and preventing infection
• No FDA-approved medications specifically for excoriation disorder
• Work with psychiatrist and dermatologist for comprehensive care

Strategies for Daily Life

Awareness Building:

• Keep a picking diary to identify triggers
• Notice early warning signs of urges
• Track emotions and situations that lead to picking
• Use apps or reminders to increase awareness
• Practice mindfulness to stay present

Environmental Modifications:

• Remove or limit access to picking tools
• Wear gloves or bandages on fingertips
• Keep fingernails short and smooth
• Improve lighting to reduce focus on skin imperfections
• Use barriers like clothing or adhesive bandages

Alternative Behaviours:

• Squeeze stress ball when feeling urges
• Use fidget toys or textured objects
• Apply lotion or moisturiser instead of picking
• Exercise or do physical activity
• Practice deep breathing or relaxation

Skin Care:

• Develop gentle, consistent skincare routine
• Use appropriate treatments for underlying skin conditions
• Keep skin moisturised and healthy
• Protect healing areas with bandages
• Work with dermatologist for skin health

For Family and Friends

How to Help:

• Learn about excoriation disorder to understand it's not a choice
• Offer emotional support without judgment
• Help identify triggers and warning signs
• Support their treatment efforts
• Be patient with the recovery process
• Focus on the person, not just the skin picking

What Not to Do:

• Don't tell them to "just stop" picking
• Don't criticise or shame them
• Don't constantly monitor their behaviour
• Don't make comments about their appearance
• Don't take their picking personally
• Don't enable complete avoidance of triggering situations

Skin Healing and Cosmetic Concerns

Promoting Healing:

• Keep wounds clean and protected
• Use appropriate topical treatments
• Avoid further trauma to healing areas
• Stay hydrated and eat nutritious foods
• Get adequate sleep for healing
• Follow dermatologist recommendations

Cosmetic Options:

• Makeup to cover lesions and scars
• Clothing choices to cover affected areas
• Scar treatment options (creams, procedures)
• Professional skincare treatments
• Camouflage techniques and products

Support and Community

Finding Support:

• TLC Foundation for Body-Focused Repetitive Behaviours
• Online support groups and forums
• Local support groups
• Mental health professionals specialising in BFRBs
• Skin picking support communities
• Family support resources

Peer Support Benefits:

• Reduces feelings of isolation and shame
• Provides practical tips and strategies
• Offers hope and inspiration from others in recovery
• Creates sense of community and understanding
• Helps normalise the experience

Hope and Recovery

Recovery from excoriation disorder is possible. Many people have successfully reduced or stopped their skin picking and gone on to live fulfilling lives. Recovery often involves:

• Learning to manage urges without picking
• Developing healthy coping strategies
• Building self-compassion and acceptance
• Creating supportive relationships
• Finding meaning and purpose beyond the disorder

Recovery Process:

• Progress is often gradual with ups and downs
• Setbacks are normal and part of the process
• Small improvements can lead to bigger changes
• Support from others is crucial
• Professional treatment is usually helpful
• Self-compassion is essential throughout

Finding Help

Look for therapists who:

• Have specific experience with excoriation disorder or BFRBs
• Use evidence-based treatments like ACT or DBT
• Understand that skin picking is not a choice
• Are patient and non-judgmental
• Can help with both the behavioural and emotional aspects

Medical Team:

• Dermatologist - for skin health and healing
• Mental health professional - for behavioural treatment
• Primary care physician - for overall health monitoring
• Psychiatrist - if medication is needed

Myths and Misconceptions

• Myth: Skin picking is just a bad habit that can be easily stopped
• Reality: It's a complex mental health condition requiring professional treatment
  
• Myth: People pick their skin for attention
• Reality: Most people feel shame and try to hide their picking
  

• Myth: Only people with "bad skin" develop this disorder
• Reality: People with healthy skin can also develop excoriation disorder
  

• Myth: It's the same as normal grooming behaviours
• Reality: The picking is excessive and causes significant distress and impairment

Remember

Excoriation disorder is not a choice, a bad habit, or a sign of poor hygiene. It's a real medical condition that affects millions of people. You are not alone, and you are not broken. With proper understanding, treatment, and support, recovery is possible. Be patient and compassionate with yourself as you work toward healing.

References

American Psychiatric Association. (2013). Excoriation (Skin-Picking) Disorder. In Diagnostic and statistical manual of mental disorders (5th ed.). https://doi.org/10.1176/appi.books.9780890425596

Grant, J. E., et al. (2012). Skin picking disorder. American Journal of Psychiatry, 169(11), 1143-1149. https://pubmed.ncbi.nlm.nih.gov/23128921/

Mental Health America. (n.d.). Excoriation disorder (skin-picking or dermatillomania). https://mhanational.org/conditions/excoriation-disorder-skin-picking-or-dermatillomania/

National Health Service. (2024). Skin Picking Disorder. https://www.nhs.uk/mental-health/conditions/skin-picking-disorder/

Cleveland Clinic. (2024). Dermatillomania (Skin Picking). https://my.clevelandclinic.org/health/diseases/22706-dermatillomania-skin-picking