Skin picking (excoriation)

What is skin picking (excoriation)?

Excoriation (skin picking) disorder is a recurrent skin picking behavior of a severity that causes distress or impacts daily life. In the DSM-5, the manual used for diagnosis of mental health conditions, the condition is listed in the category of Obsessive Compulsive Disorders (OCD).

Not all those who pick their skin have a disorder - it’s quite common for people to occasionally pick at their skin (at pimples, for example). People with skin picking disorder spend a lot of time picking skin, resulting in wounds or infections, and possible scarring. They also have difficulty reducing or stopping skin picking.

Understandably, the lives of people with skin picking disorder are affected; many experience pain, scarring, distress, or mental health challenges, such as anxiety or depression. You can learn more about his condition, as well as the most effective treatment options, below.

Prevalence of skin picking disorder

According to the American Psychiatric Association, around 2% to 4% of Americans have skin picking disorder. Excoriation disorder is a relatively new condition; it was added to the most recent edition of the DSM in 2013. As such, there is little data available and much yet to learn about its prevalence.

Researchers have found that the condition:

Usually starts in childhood
May occur in females more frequently than males
Can be accompanied by other mental health challenges, like anxiety, depression, and OCD

In these ways, skin picking disorder shares similar traits as trichotillomania.

Symptoms of skin picking disorder

The patterns of skin picking behavior can differ from person-to-person. People may pick skin from various parts of the body, with their fingers, tweezers, or by biting.

The reason for skin picking can also vary. It can be associated with boredom, as a way of coping with difficult emotions. As in trichotillomania (hair-pulling), some people experience a feeling of increased tension and then a sense of relief or pleasure after picking their skin. Others don’t even realize that they are picking at all.

The disorder is characterized by repeated attempts to stop or reduce the picking behavior.

The condition, understandably, causes distress and impacts functioning in daily life. People may spend a great deal of time trying to conceal the picking, avoid social situations, and often also experience feelings of:

Shame, guilt, or embarrassment
Anxiety
Depression
Low self-esteem

Many people with the condition are unaware that help is available. If you are concerned about skin picking, know that therapy can help; below are treatment options and what to look for in a specialist for skin picking.

Treatment options for skin picking

Many treatment options are effective in reducing skin picking behavior, such as:

Therapy: Therapy is an important component of treatment for skin picking disorder. Treatments such as Habit Reversal Therapy help people increase awareness of how and when they pick their skin, make changes to reduce triggers, and overall better manage and reduce their skin picking behavior, leading to an improved quality of life. See below for tips about types of therapy and selecting a therapist.
Check-ups: It’s important to have a check-up with your primary care doctor, who can help you to get treatment for or rule out physical conditions that may contribute to your symptoms. Your doctor will also be able to assess and treat any related medical issues, such as skin infection or scarring.
Medication: In some cases, medication may help to reduce skin picking behaviors or symptoms of other co-occurring conditions. To explore the role of medication, seek an assessment from a psychiatrist. This type of mental health professional has highly specialized medical training.
Online resources: Explore the numerous supports and self-help resources online, such as those available at the Picking Me Foundation website.
Hotlines: If you’re having thoughts of suicide or need immediate support, call the National Suicide Prevention Hotline at 1-800-273-8255.

Therapy for skin picking

Given the relative recency of the addition of this condition to the DSM-5, more research is needed to identify the most appropriate treatments. Existing research suggests that, with the help of therapy, many people can successfully reduce their skin picking behavior. Evidence-based therapy modalities for skin picking treatment include:

Habit Reversal Therapy: Habit Reversal Therapy helps reduce skin picking by increasing awareness of how and when urges to do so develop. Clients learn to intervene and make changes to their environment to reduce triggers, and learn alternative behaviors to replace the habit of skin picking.
Cognitive Behavioral Therapy (CBT): CBT for skin picking often includes behavioral therapy techniques such as habit reversal therapy. It also involves education and cognitive restructuring - replacing unhelpful thoughts and beliefs with more helpful ones.
Acceptance and Commitment Therapy (ACT): ACT, which involves elements of CBT and mindfulness, has also been found to be beneficial for treating skin picking. In this framework, therapists help clients reduce skin picking by taking an ‘acceptance’ approach to difficult thoughts and emotions, while finding new ways to respond to them.

What to look for in a therapist for skin picking

There are several factors to keep in mind when selecting a therapist, including:

Specialization: Find a therapist who has experience and specialized training in the treatment of skin picking, and specifically Habit Reversal Therapy, as this is an evidence-based therapy approach for this condition. Therapists often include their specializations in their biography on their website or online profile.

Qualifications: With so many different provider types available, it can be difficult to decide which type of mental health professional to see. The most important thing is to look for a currently licensed therapist. If you are considering medication in your treatment, see a psychiatrist, as they are medical doctors who can assess your symptoms and prescribe and manage medications if appropriate.

Personal fit: The trusting relationship between you and your therapist, known as the “therapeutic alliance” can have a huge impact on the efficacy of therapy. People with skin picking disorder often struggle with feelings of shame or embarrassment, so it’s important to work with someone you trust.

The best way to judge how you might feel about a therapist is to ask for a preliminary phone call. This also allows you to ask about their experience and what therapy with them will be like. Try to speak to a few different therapists before deciding on a provider.

Sources

American Psychiatric Association, 2013, “Obsessive Compulsive and Related Disorders”
American Psychological Association, Dictionary of Psychology
Center for Behavioral Health Statistics and Quality, Substance Abuse and Mental Health Services Administration (SAMHSA), 2016, “Impact of the DSM-IV to DSM-5 changes on the National Survey on Drug Use and Health”. PDF accessed online December 2019 at https://www.ncbi.nlm.nih.gov/books/NBK519697/pdf/Bookshelf_NBK519697.pdf
International OCD Foundation, “Skin Picking Disorder Fact Sheet”. PDF accessed online December 2019 at https://iocdf.org/wp-content/uploads/2014/10/Skin-Picking-Disorder-Fact-Sheet.pdf
Lochner, C., Roos, A., & Stein, D.J., 2017, “Excoriation (skin-picking) disorder: a systematic review of treatment options”, Neuropsychiatr Dis Treat. Accessed online December 2019 at https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5522672/
National Health Service, UK, “Skin picking disorder”, accessed online December 2019 at https://www.nhs.uk/conditions/skin-picking-disorder/