Dermatillomania (Skin Picking)
Dermatillomania, also known as excoriation disorder (per the DSM-5) or skin-picking disorder, is a psychological condition that manifests as repetitive, compulsive skin picking. It is one of a category of disorders known as body-focused repetitive behaviors (BFRBs) that are currently classified in the DSM-5 under Obsessive-Compulsive and Related Disorders.
There is a difference between excoriation disorder and occasional picking at skin imperfections and irregularities, which most people engage in from time to time. In the case of excoriation disorder, the behavior is chronic, causes the individual marked distress and dysfunction, and can result in severe tissue damage. Treatment often requires a mix of therapy, medication, and self-help strategies.
According to the DSM-5, excoriation disorder can be diagnosed when the following criteria are met:
- recurrent skin picking results in skin lesions
- repeated attempts are made to decrease or stop the skin picking
- the skin picking causes clinically significant distress—including a feeling of loss of self-control, embarrassment, and shame—or impairment in functioning
In most cases, skin picking does not generally occur in the presence of other individuals.
Repetitive skin picking extends to pulling, squeezing, scraping, lancing, and even biting both healthy and damaged skin from various parts of the body. People with dermatillomania often target their face, hands, fingers, arms, and legs; they may use either their fingers or an instrument, like tweezers or pins. This behavior may also be accompanied by rituals, such as examining or playing with skin that’s been pulled off.
Some individuals spend hours a day on their picking behavior, which can last for months or even years. Excoriation disorder can result in visible skin damage and disfigurement from lesions, discoloration, open wounds, scars, and infections. It is generally a chronic condition, though symptoms may arise and disappear from time to time.
In addition to physical damage, excoriation disorder is characterized by the psychological distress it causes. Individuals with this condition can spend hours thinking about picking and trying to resist the urge before giving in; similar to impulse control disorders such as kleptomania, they may describe a feeling of “tension” that is temporarily relieved once they give in to the urge to pick. Anxiety, depression, shame, fear of exposure, and embarrassment over the condition usually lead to attempts at covering up the skin with makeup, clothing, or other means; such emotions, and other consequences of the disorder, can also interfere with normal social interactions, resulting in uncomfortable relationships with family and friends.
Dermatillomania is not diagnosed when the symptoms are caused by another medical or psychiatric condition. For instance, skin picking can also occur with dermatological conditions, autoimmune disorders, opiate withdrawal, and developmental disorders such as autism.
Trichotillomania, or hair-pulling disorder, is characterized by a compulsive need to pull out one’s own hair; dermatillomania/excoriation disorder, by contrast, is characterized by a drive to pick or otherwise damage one’s own skin. The two disorders otherwise share symptoms—psychological distress, repeated attempts to stop the behavior, etc.—and may co-occur.
To learn more about hair-pulling disorder, see Trichotillomania.
Excoriation disorder is relatively rare but is thought to affect up to 1.4 percent of the total population. Approximately 75 percent of those diagnosed with the disorder are female.
Experts believe that gender differences in diagnosis rates are largely reflective of the disorder’s true incidence in men vs. women. However, an increased emphasis on women’s physical appearance in many cultures may compel more women to seek treatment for the condition, thus skewing diagnosis rates slightly.
Most experts consider dermatillomania to be distinct from self-harm. Self-harm often involves the deliberate infliction of pain upon oneself, usually as a means to seek relief from upsetting emotions or thoughts. While dermatillomania can be triggered by negative emotions such as anxiety, it isn’t always; boredom, for example, is just as common a trigger. What’s more, any pain caused by skin-picking is rarely the intention; instead, the behaviors often are experienced as soothing or relaxing, at least in the moment.
There may be a genetic component to excoriation disorder, since some people appear to have an inherited tendency to BFRBs such as skin picking and hair pulling, as well as higher-than-average rates of mood and anxiety disorders in first-degree relatives. Other factors that may play a role in the development of this condition include individual temperament, stress, and age.
Chronic skin picking behavior often coincides with the onset of puberty, as well as a dermatological problem, such as acne. Dermatillomania can be associated with perfectionism, which leads to over-grooming; it can also be used as a means of avoiding stressful events or releasing tension that builds up as a result of negative emotions such as impatience, frustration, dissatisfaction, and even boredom.
As with other BFRBs, different individuals may report different triggers for the behavior. Some with dermatillomania, for example, report picking when they’re anxious; while the behavior may temporarily relieve anxiety, it often exacerbates it and other negative emotions in the long run. Others may pick when they’re bored or distracted. Some individuals pick while they’re engrossed in another activity and may not immediately notice that they have started picking their skin.
Most experts believe that BFRBs are to some extent genetic; the disorders tend to run in families, and twin studies have suggested an inherited component. However, genes are likely only one potential cause of BFRBS, including excoriation disorder/dermatillomania. Other factors—such as stress levels, family environment, and temperament—are thought to play a role as well.
Anxiety disorders often co-occur with dermatillomania, and episodes of anxiety—whether they constitute a diagnosable disorder or not—are a common trigger of skin-picking episodes.
Individuals who pick their own skin often make repeated, unsuccessful attempts to stop on their own, as the shame and embarrassment associated with excoriation disorder may prevent them from seeking professional treatment. In fact, fewer than one in five people with dermatillomania are thought to seek treatment.
For those who do, small-scale psychological studies of interventions such as cognitive behavioral therapy, acceptance and commitment therapy, and habit reversal training (HRT) have been shown to reduce the symptoms of excoriation disorder. While no medications are approved as a first-line treatment for skin picking, limited studies have found that some antidepressants, such as selective serotonin reuptake inhibitors (SSRIs), and nutraceuticals, such as n-acetyl cysteine (NAC), may help. People with this condition may require antibiotics to treat potential infections or, in extreme cases, surgery.
There is no known “cure” for dermatillomania, but the disorder can become highly manageable with treatment—to the point where many individuals are able to go long stretches of time without picking at their skin.
Medication—particularly SSRIs—may provide some relief for symptoms of excoriation disorder, especially for individuals who are also struggling with anxiety, depression, or OCD. Supplements have also been tested in small studies, with a few appearing to help reduce symptoms a significant amount. Overall, however, medication is not considered the first-line treatment for BFRBs; therapy tends to be significantly more effective and does not come with the same risk of side effects.
Behavioral interventions are thought to be the most effective way to treat BFRBs, including dermatillomania. One often effective intervention is habit reversal training (HRT), which focuses on identifying triggers and devising prevention strategies specifically aimed at those triggers. CBT and ACT have also proven valuable for many, especially over the longer term; these approaches typically target the unpleasant thoughts and emotions that may compel someone to pick at their skin.