What is excoriation (skin-picking) disorder?

Updated: Jul 10, 2018
  • Author: Roxanne Graham, MD; Chief Editor: Dirk M Elston, MD  more...
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Excoriation (skin-picking) disorder involves the conscious creation of neurotic excoriations by means of repetitive scratching (although acts of rubbing skin, lancing, squeezing or biting can also be used and individuals may use tweezers, fingernails or other objects). [2]  Neurotic excoriations should be distinguished from dermatitis artefacta, in which patients create lesions for secondary gain. Neurotic excoriations can be initiated by some minor skin pathology, such as an insect bite, folliculitis, callouses, scabs, or acne, but it can also be independent of any pathology. Triggers include emotions such as stress, anger, and anxiety, and sedentary activities such as watching television, reading, boredom, and feeling tired. [1]

Because no significant underlying pathology is present in the skin, neurotic excoriations are best understood as a psychological process with dermatologic manifestations. Many doctors lack an extensive understanding of neurotic excoriations and their treatment. [3] The complex dynamic underlying the urge to create a neurotic excoriation is yet to be fully explained. [4] Dermatologists are aware of this complex dynamic and continue to grapple with it. [3]

Because patients create neurotic excoriations, the lesions have the quality of an "outside job"—that is, clean, linear erosions, crusts, and scars that can be hypopigmented or hyperpigmented. The erosions and scars of neurotic excoriations often have irregular borders and are usually similar in size and shape. They occur on areas that the patient can scratch, particularly the extensor surfaces of the extremities, the face, and the upper part of the back. The distribution is bilateral and symmetric.

The manifestations of neurotic excoriations vary widely, ranging from unconscious picking at the skin to uncontrollable picking at lesions to remove imaginary foreign bodies. Picking is usually episodic and irregular, but it can be constant. The picking can have the quality of a ritual and may take place in a state of dissociation.

The inability to stop picking despite efforts to do so can lead to feelings of shame, anxiety, and depression. Individuals often spend a large amount of time on repetitive picking and/or camouflaging (taking up several hours per day in severe cases). They often avoid situations where skin lesions can be detected that could lead to social embarrassment, or have loss of productivity at school or work due to this avoidance behaviors. Medical sequelae such as infections, scarring, and even serious physical disfigurement can occur. Excoriation (skin picking) disorder is also associated with other comorbidities including other body-focused repetitive behavior disorders – with trichotillomania being the most common. Obsessive–compulsive disorder (OCD) and body dysmorphic disorder (BDD) are also more prevalent in individuals with excoriation disorder than in the general population. Mood and anxiety disorders are also common. [1]

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