Excoriation (Skin Picking) Disorder

Primer

Excoriation (Skin-Picking) Disorder is an obsessive-compulsive and related disorder characterized by the repeated urge to pick at one's own skin, often to the extent that significant skin damage is caused.

Epidemiology
  • Prevalence is 1-2% in the general population.
    • It affects significantly more females (75%) than males.
  • There is a high comorbidity with OCD, trichotillomania, depression, body dysmorphia, and tics.
Prognosis
  • Skin picking most often develops an onset during adolescence, commonly coinciding with or following the onset of puberty.[1]
    • Commonly, it begins with a dermatological condition such as acne.
  • The usual course of skin picking is chronic, with waxing and waning symptoms if left untreated (lasting weeks, months, or years at a time).[2]
  • Medical complications of skin picking include tissue damage, scarring, and infection which can rarely become life-threatening. Rarely, synovitis of the wrists due to chronic picking has been reported.[3]
    • Skin picking can result in significant tissue damage and scarring, and may require antibiotic or surgical treatment for infection.
Comorbidity
Risk Factors

DSM-5 Diagnostic Criteria

Criterion A

Recurrent skin picking resulting in skin lesions.

Criterion B

Repeated attempts to decrease or stop skin picking.

Criterion C

The skin picking causes clinically significant distress or impairment in social, occupational, or other important areas of functioning.

Criterion D

The skin picking is not attributable to the physiological effects of a substance (e.g. - cocaine) or another medical condition (e.g. - scabies).

Criterion E

The skin picking is not better explained by symptoms of another mental disorder (e.g. - delusions or tactile hallucinations in a psychotic disorder, attempts to improve a perceived defect or flaw in appearance in body dysmorphic disorder, stereotypies in stereotypic movement disorder, or intention to harm oneself in nonsuicidal self-injury).

Signs and Symptoms

  • The majority of individuals spend at least 1 hour per day picking, thinking about picking, and/or resisting urges to pick.
  • The most commonly picked sites are the face, arms, and hands, but many individuals pick from multiple body sites.
    • Individuals may pick at healthy skin, at minor skin irregularities, at lesions such as pimples or calluses, or at scabs from previous picking.
    • In addition to skin picking, there may be skin rubbing, squeezing, lancing, and biting.
  • Most individuals pick with their fingernails, although some use tweezers, pins, or other objects.[6]
  • Skin picking can last anywhere from months to years.
  • Individuals may search for a particular kind of scab to pull, and they may examine, play with, or mouth or swallow the skin after it has been pulled.[7]
  • Skin picking may also be preceded or accompanied by various emotional states and triggered by feelings of anxiety or boredom, or may be preceded by an increasing sense of tension (either immediately before picking the skin or when attempting to resist the urge to pick)
  • There may also be a sense of gratification, pleasure, or a sense of relief when the skin or scab has been picked.
    • Some individuals report picking in response to a minor skin irregularity or to relieve an uncomfortable bodily sensation.
  • Skin picking does not usually occur in the presence of other individuals, except in the presence immediate faniily members.[8]

Screening and Rating Scales

Excoriation Disorder Scales

Name Rater Description Download
Skin Picking Impact Scale (SPIS) Patient The SPIS is a self-report instrument developed to assess the psychosocial consequences of repetitive skin picking. An initial 28-item scale was administered to 31 individuals with severe self-injurious skin picking and 78 individuals with non-self-injurious skin picking. Download
Yale–Brown Obsessive Compulsive Scale Modified for Neurotic Excoriation (NE-YBOCS) Clinician The NE-YBOCS is a modification of the Yale–Brown Obsessive Compulsive Scale (Y-BOCS), a reliable and valid scale for obsessive-compulsive disorder.
Skin Picking Scale - Revised (SPS-R) Patient The SPS-R is an 8-item self-report scale that assesses clinical severity of excoriation behaviours.

Pathophysiology and Psychopathology

  • From a psychopathology perspective, skin picking may help regulate emotional states or stressful events
    • Skin picking may function as a means of escaping from or avoiding aversive experiences, and provide temporary relief from negative emotions. These behaviours may be maintained through a negative reinforcement cycle

Differential Diagnosis

  • Psychotic disorders
    • Skin picking may occur in response to a delusion (i.e. - delusional parasitosis) or tactile hallucination (i.e. - formication) in a psychotic disorder. In such cases, excoriation disorder should not be diagnosed.
  • Obsessive-compulsive disorder
    • Excessive washing compulsions in response to contamination obsessions in individuals with OCD may lead to skin lesions
  • Body dysmorphic disorder
    • Skin picking may occur in individuals with body dysmorphic disorder who pick their skin solely because of appearance concerns; in these cases, excoriation disorder should not be diagnosed.
  • Body-focused repetitive behavior disorder
    • This disorder excludes individuals whose symptoms meet diagnostic criteria for excoriation disorder.
  • Neurodevelopmental disorders
    • While stereotypic movement disorder may be characterized by repetitive self-injurious behaviour, onset is in the early developmental period. For example, individuals with the neurogenetic conditions such as Prader-Willi syndrome may have early onset of skin picking, and their symptoms may meet criteria for stereotypic movement disorder. While tics in individuals with Tourette's disorder may lead to self injury, the behaviour is not tic-like in excoriation disorder.
  • Somatic symptom and related disorders
    • Excoriation disorder is not diagnosed if the skin lesion is primarily attributable to deceptive behaviors in factitious disorder.
  • Self-harm (nonsuicidal self-injury)
    • Excoriation disorder is not diagnosed if the skin picking is primarily attributable to the intention to harm oneself that is characteristic of nonsuicidal self-injury.
  • Other medical conditions
    • Excoriation disorder is not diagnosed if the skin picking is primarily due to another medical condition. For example, scabies is naturally associated with severe itching and scratching. However, excoriation disorder may be precipitated or exacerbated by an underlying dermatological condition.
    • For example, acne may lead to some scratching and picking, which may also be associated with comorbid excoriation disorder. Differentiating between these two situations (acne with some scratching and picking vs. acne with comorbid excoriation disorder) requires an detailed assessment of the extent to which the skin picking has become independent of the underlying dermatological condition.
  • Substance/medication-induced disorders
    • Skin-picking symptoms may also be induced by certain substances (e.g. - cocaine), in which case excoriation disorder should not be diagnosed. If such skin picking is clinically significant, then a diagnosis of substance/medication-induced obsessive-compulsive and related disorder should be considered.

Physical Exam

  • Dermatopathological diagnosis is rarely required, but skin picking has characteristic features on histopathology.[9]

Treatment

Medications

  • Similar to other OCD-related disorders, SSRIs may be helpful for compulsive skin picking but with limited effects.
  • N-acetylcysteine and naltrexone have more robust effects, though habit reversal training remains the main treatment with such individuals.

Psychotherapy

Cognitive behavioural therapy (CBT) (including habit reversal, and acceptance-enhanced therapy) is the first-line therapy.[10]

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References

1) American Psychiatric Association. (2013). Diagnostic and Statistical Manual of Mental Disorders (5th ed.). Arlington, VA.
2) American Psychiatric Association. (2013). Diagnostic and Statistical Manual of Mental Disorders (5th ed.). Arlington, VA.
3) American Psychiatric Association. (2013). Diagnostic and Statistical Manual of Mental Disorders (5th ed.). Arlington, VA.
4) American Psychiatric Association. (2013). Diagnostic and Statistical Manual of Mental Disorders (5th ed.). Arlington, VA.
5) American Psychiatric Association. (2013). Diagnostic and Statistical Manual of Mental Disorders (5th ed.). Arlington, VA.
6) American Psychiatric Association. (2013). Diagnostic and Statistical Manual of Mental Disorders (5th ed.). Arlington, VA.
7) American Psychiatric Association. (2013). Diagnostic and Statistical Manual of Mental Disorders (5th ed.). Arlington, VA.
8) American Psychiatric Association. (2013). Diagnostic and Statistical Manual of Mental Disorders (5th ed.). Arlington, VA.
9) American Psychiatric Association. (2013). Diagnostic and Statistical Manual of Mental Disorders (5th ed.). Arlington, VA.
10) Grant, J. E., Odlaug, B. L., Chamberlain, S. R., Keuthen, N. J., Lochner, C., & Stein, D. J. (2012). Skin picking disorder. American Journal of Psychiatry, 169(11), 1143-1149.