Running Head: EXCORIATION DISORDER

L98.1: Excoriation (Skin-Picking) Disorder

Barrett Pope
University of North Florida

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2
Abstract

This paper explores eight published works pertaining to excoriation disorder. Areas of
exploration include the history of the disorder, disorder characteristics, disorder prevalence, and
treatment methodologies and efficacy. Newly introduced into the Diagnostic and Statistical
Manual of Mental Disorders (5th ed., DSM-5; American Psychiatric Association, 2013),
excoriation disorder is characterized by compulsive skin-picking behavior resulting in surface
irregularities. Onset usually occurs in childhood or adolescence and is most common among
females. Little is known about what causes this behavior but comorbidity with obsessivecompulsive disorder and anxiety disorders are frequently reported. Pharmaceutical monotherapy
has proven beneficial over placebos in double-blind and open-label trials. Environmental and
emotional interventions can also be implemented in attempts to control the urge to pick.

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History of the Disorder
Excoriation disorder was inducted into the DSM-5 in a new chapter concerning obsessivecompulsive related disorders which are defined as related to, but distinct from, obsessivecompulsive disorder (LeBeau et al., 2013). Although formally recognized by the DSM-5 as
excoriation disorder, it is known by many names including, but not limited to, psychogenic
excoriation, neurotic excoriation, acne excorie, pathological skin picking, compulsive skin
picking, and dermatillomania (Arnold, Auchenbach, & McElroy, 2001, p. 351). The first
recorded case of skin picking behavior was observed by Dr. Brocq, a French physician, in his
article, Lacne excoriee des jeunes filles et son traitement (which translates roughly to The
girls excoriated acne and its treatment). Brocq described a 24-year-old woman who had been
suffering from dermatosis since she was 16. She would open the small papules and pustules on
her skin daily using needles or nails. This behavior was not provoked by itching nor discomfort
but rather by the desire to excoriate as soon as an opportunity presented itself (1898, pp. 3-4).
The patients body-focused repetitive behavior mirrors that of the disorder as it is known
presently.
Disorder Characteristics
The diagnostic criteria for excoriation disorder are as follows:
A. Recurrent skin picking resulting in skin lesions.
B. Repeated attempts to decrease or stop skin picking.
C. The skin picking causes clinically significant distress or impairment in social,
occupational, or other important areas of functioning.
D. The skin picking is not attributable to the physiological effects of a substance
(e.g., cocaine) or another medical condition (e.g., scabies).

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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 boy dysmorphic disorder,
stereotypes in stereotypic movement disorder, or intention to harm oneself in
nonsuicidal self-injury). (American Psychiatric Association, 2013, p. 254)
Many patients attest to engaging in pre- and post-picking behaviors which may include stroking
the skin in search of imperfections and, [manipulating] the product afterward (rolling it between
the fingers, chewing on it, [and] eating it. Skin picking is performed for any number of reasons
(e.g., boredom, stress relief, gratification, etc.) and is often done unknowingly (Storch & McKay,
2014, p. 165). The face is the most commonly reported site of picking but other common areas
include easily reached areas such as the pubic area, legs, arms, back, and torso (Storch &
McKay, 2014, p. 29).
Disorder Prevalence
Between 75-94% of clinical populations are female and report that the behavior first presented in
adolescence or childhood (Storch & McKay, 2014, pp. 165-166). A study conducted in 2001
illustrated that sufferers of compulsive skin picking experienced a mean duration of illness of
25.19.1 years. Other small studies (n=21-31) reported similar results and concluded that picking
severity fluctuated over time (Grant, 2012, p. 28). An estimated 2.2% of college populations and
1.4% of the total population of the United States meet the diagnostic criteria of excoriation
disorder (Storch & McKay, 2014, p. 165). Large studies documenting the prevalence of
compulsive skin picking within the overall population have yet to be conducted properly but
estimates place rates as high as 5.4% (Grant, Stein, Woods, & Keuthen, 2012, p. 23).

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Medical Aspects
In cases where skin picking began in childhood or adolescence, patients reported picking as a
response to a medical condition such as acne and continued to pick even after the condition
subsided or was managed. Conversely, other patients reported that picking was the cause of
varied medical conditions (Grant et al., 2012, p. 28). As Arnold et al. asserts, medical
complications are varied and include soreness, bleeding, temporarily large excoriations, ulcers,
infections, permanent discoloration and scarring that can be disfiguring. Marked dissatisfaction
with the appearance of the skin after excoriation is common. The dissatisfaction is significant
because it leads to a vicious cycle in which patients report picking because they are dissatisfied
with an aspect of their appearance and then becoming self-conscious about picking (2001, p.
354). Comorbidities in pathological skin picking are common with the most commonly reported
conditions being, trichotillomania (38.3%), substance dependence (38%), major depressive
disorder (31.7-58.1%), anxiety disorders (23-56%), obsessive-compulsive disorder (16.7-68%),
and body dysmorphic disorder (26.8-44.9%) (Odlaug & Grant, 2010, p. 298).
Treatment Methodologies and Efficacy
Successful monotherapy treatment of pathological skin picking has been proven in double-blind
placebo-controlled trials of fluoxetine (20-80 mg/day) and citalopram (20 mg/day) as well as in
open-label trials of fluvoxamine (50-300 mg/day), escitalopram (10-30 mg/day), and lamotrigine
(25-300 mg/day). However, the studies conducted were too limited (n < 50) to account for how
clinical variables (e.g., age, sex, picking severity, etc.) affected treatment response (Storch &
McKay, 2014, p. 333). Selective serotonin reuptake inhibitors remain the most popular and most
effective course of treatment but recently, other therapies were explored in more complex cases.
A case study conducted in 2014 demonstrated that a case of treatment-resistant excoriation

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disorder was successfully treated with a combination of venlafaxine and aripiprazole. A 21-yearold woman was admitted to the hospital whereupon her psychiatric and medical history was
recorded. The patient had started taking venlafaxine 225 mg/day six months prior to
hospitalization and her medical history reflected a history of past medical treatments including,
but not limited to, antidepressants and benzodiazepines. After diphenhydramine and quetiapine
administered by the hospital were proven to be ineffective treatments for the patients anxiety,
depression, and insomnia, her doctors ultimately augmented the established venlafaxine 225 mg
with aripiprazole 10 mg. Following this treatment plan, the patient reported no urges to pick and
was shown not to have developed any new lesions. Although this is but one case, and therefore
not a significant sample size, this study presents the possibility of expansion in pharmacological
treatment of body-focused repetitive disorders (Turner, Sutton, & Sharma, pp. 29-31). Stimulus
control and habit reversal training are helpful techniques often used in conjunction with
pharmaceutical monotherapy. Habit replacement therapy consists of awareness training,
competing response training, and social support. Awareness training allows the patient to
describe all feelings, sensations, and behaviors associated with picking. This identification of
triggers and patterns in behavior helps the patient recognize when measures of impulse control
must be taken. Competing response training teaches the patient to engage in behavior that
prevents picking. This can be any action (e.g., making a fist, crossing their arms, etc.) and is
usually done at the time of the urge for one minute. If the urge persists after the initial minute,
the patient is instructed to continue the action for another minute and so on until the urge
subsides. For purposes of subtlety and convenience, it is preferable that the action is
inconspicuous and can be done in any situation. Additional measures may be taken to alter an
environment in which picking is facilitated. Limiting time spent in front of mirrors or removing

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mirrors completely, keeping lights dim to obscure detail, and removing sharp objects and tools
(e.g., pins, needles, and tweezers) are among the most widely reported interventions (Storch &
McKay, 2014, pp. 177-181).
Discussion
As a long-time sufferer of this affliction, I would like to see more discussion and recognition of
dermatillomania in professional and clinical care settings (much like its more well-known
cousin, trichotillomania). It is evident from the lack of a broad-spectrum treatment for
excoriation disorder and its comorbid diagnoses that more large-scale research into
pharmacotherapy needs to be performed. Despite having existed for over a century, this disorder
is still in its infancy. Only after a large-scale survey can be performed to accurately determine
the prevalence of this disorder in the general population can clinicians assess how to help and
treat that population.

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8
References

American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders
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Arnold, L., Auchenbach, M., & McElroy, S. (2001). Psychogenic Excoriation: Clinical Features,
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Brocq, L. (1898). Lacne excoriee des jeunes filles et son traitement. Journal Des Practiciens, 34.
Grant, J., Stein, D., Woods, D., & Keuthen, N. (2012). Trichotillomania, Skin-Picking, and Other
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LeBeau, R. T., Mischel, E. R., Simpson, H. B., Mataix-Cols, D., Phillips, K. A., Stein, D. J., &
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Turner, G. A., Sutton, S., & Sharma, A. (2014). Augmentation of Venlafaxine with Aripiprazole
in a Case of Treatment-resistant Excoriation Disorder. Innovations In Clinical
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