Excoriation Disorder (aka Skin Picking Disorder): Information for Primary Care
- A 35 year old female comes to your office complaining of itchy skin and a lesion on her forearm that she thinks is infected.
- She describes an intense urge to scratch and pick the skin on her arms and legs, which has resulted in bleeding, scabbing and even some scars.
- She describes herself as a worrier and feels a sense of relief after the behaviour.
- She says, “I’ve tried to stop many times but I haven’t been able to.”
- The behaviour is getting worse and she is worried about developing more scars.
- She already avoids social settings throughout the spring and summer when clothing exposes the skin lesions and scarred areas of her arms and legs.
- How are you going to help your patient?
- Incidence / prevalence in the general population is not known but is thought to be common and under-reported (Cyr, 2001)
- Age of onset: Age 15-45 (Park, 2016)
- Primarily affects females (APA, 2013)
- Incidence among patients in dermatology clinics is 2% (Cyr, 2001)
- Prevalence among patients with pruritis is 9% (Cyr, 2001)
- An irresistible urge to pick, scratch, dig or scrape the skin that results in noticeable tissue damage (Park, 2016)
- A feeling of temporary relief from emotional distress after the behaviour occurs. (Selles, 2016; Mavrogiorgou, 2015)
- The behaviour may be initiated by a minor skin pathology or on healthy skin (Scheinfeld, 2016)
- Use of instruments such as tweezers, pins, scissors or knives (Mavrogiorgou, 2015)
- Considerable time spent picking, often several hours per day, and worse in the evenings (Park, 2016)
- The behaviour sometimes occurs in a dissociative state (Mavrogiorgou, 2015)
- Attempts to resist or stop the behaviour (Craig-Müller, 2015)
- Reluctance to show areas of damaged skin (Mavrogiorgou, 2015)
- Impairments in social functioning (Selles, 2016; Mavrogiorgou, 2015)
- Psychiatric comorbidities (Park, 2016; Cyr, 2001)
The Skin Picking Impact Scale
- A self-report questionnaire that measures psychosocial impact, i.e. how it affects function at school, work and home (Craig-Müller, 2015; Snorrason, 2013; Stargell, 2016)
The Skin Picking Scale
- A self-report questionnaire that may help assess severity (Craig-Müller, 2015)
Excoriation disorder is a diagnosis of exclusion.
- Primary skin disorder
- Systemic diseases that cause chronic pruritis
- Other psychocutaneous syndromes
- Medication reactions
- Illicit drug use (cocaine, opioids)
- Comorbid psychiatric conditions
The history should also include details of the picking behavior. The following questions may be helpful: (Craig-Müller, 2015)
- Location: What parts of your body do you pick?
- Timing: How often do you pick your skin? For how long do you pick?
- Method: Do you use anything besides your fingers to pick your skin?
- Severity: Has picking your skin resulted in medical complications? Do you find yourself avoid social situations as a result of your skin picking?
- Context: Can you describe how you feel before, during and after picking your skin?
- Impact: Have you ever tried to resist picking your skin? Does the behavior cause you significant distress?
Excoriation disorder is listed under the group of Obsessive-Compulsive and Related Disorders and includes the following diagnostic criteria (APA, 2013)
- Recurrent skin picking resulting in skin lesions.
- Repeated attempts to decrease or stop skin picking.
- The skin picking causes clinically significant distress or impairment in social, occupational or other important areas of functioning.
- The skin picking is not attributable to the physiologic effects of a substance (eg. cocaine) or another medical condition (eg. scabies).
- The skin picking is not better explained by the symptoms of another mental disorder (eg. delusions or tactile hallucinations in a psychotic disorder, attempts to improve a perceived defect or flaw in appearance in body dysmorphic disorder, stereotypes in stereotypic movement disorder, or intention to harm oneself in nonsuicidal self-injury).
Differential includes the following (Craig-Müller, 2015; Scheinfeld, 2016; Park, 2016):
Primary skin disorders
- Atopic dermatitis
- Contact dermatitis
- Bullous pemphigoid
- Chronic urticarial
- Dermatitis herpetiformis
- Lichen planus
Systemic conditions causing chronic pruritis
- Hematologic: iron deficiency anemia, polycythemia vera, lymphoma
- Endocrine: hypothyroidism, hyperthyroidism, diabetes mellitus
- Renal: uremia, chronic kidney disease
- Hepatic: cholestasis, primary biliary cholangitis
- Gastrointestinal: malignancy, intestinal parasitosis
- Neurologic: multiple sclerosis, post-herpetic neuralgia, Prader-Willi syndrome
- Infectious: HIV infection, Hepatitis B, Hepatitis C
- Drug induced
- Dermatitis artefacta
- Delusional parasitosis
- Body dysmorphic disorder
- Obsessive-compulsive disorder
- Body dysmorphic disorder
- Alcohol use disorder
- Obsessive compulsive personality disorder
- Borderline personality disorder
Physical exam should be performed to rule out diagnoses in the differential and should include:
- General physical exam
Detailed skin exam, which may show
- Skin lesions of various sizes ranging from mild to severe. (Grant, 2012; Park, 2016)
- New lesions appearing as linear erosions with or without a serosanguinous crust (Scheinfeld, 2016)
- Older lesions appearing as hypertrophic nodules with hypo or hyperpigmentation (Scheinfeld, 2016)
- Complications such as infection, scarring and disfigurement. (Park, 2016)
- Location of lesions: Typically located in easily accessible areas such as the scalp, face, shoulders, upper back and extensor surfaces of the extremities. (Park, 2016, Cyr, 2001)
- Distribution of lesions: Often symmetrical (Cyr, 2001)
Investigations are not diagnostic but should be used to help rule out diagnoses in the differential and may include (Craig-Müller, 2015):
- CBC, fasting glucose, Cr, liver function tests, TSH
- Serology for HIV, Hepatitis B, Hepatitis C
- Malignancy work-up
- Skin biopsy
Consider referral to professionals who can provide:
Cognitive Behavioural Therapy (CBT)
- The role of CBT is to change automatic thoughts and replace picking behavior with other healthy rituals, such as applying lubricants or distraction (Selles, 2016; Stargell, 2016; Cyr, 2001)
Habit Reversal Therapy (HRT)
- The role of HRT involves awareness training and using operant conditioning strategies to replace picking with more adaptive behaviours (Selles, 2016; Stargell, 2016; Cyr, 2001)
Acceptance/Commitment Therapy (ACT)
- ACT teaches patients how to accept unpleasant thoughts and emotions, and then use behaviour-change techniques to change those unhelpful behaviours (Capriotti et al., 2015)
- Cognitive Behavioural Therapy (CBT)
The use of mild soaps and lubricants along with decreasing the frequency of washing may help with pruritis (Park, 2016)
- The use of mild soaps and lubricants along with decreasing the frequency of washing may help with pruritis (Park, 2016)
- The use of physical barriers such as an Unna sleeve may help prevent picking easily accessible areas.
Dermatologic Therapies (Craig-Müller, 2015)
- Antihistamines to reduce pruritis
- Antibiotics to treat infection
Topical steroids to decrease redness, swelling and pruritis (Craig-Müller, 2015; Cyr, 2001)
If possible, consult psychiatry prior to initiating treatment with psychotropic medications which include:
Antidepressants (SSRIs) (Selles, 2016)
- Fluoxetine 20mg daily (can increase up to 60 mg daily)
- Citalopram 20mg daily (can increase up to 40mg daily)
- Escitalopram 10mg daily (can increase up to 20mg daily)
- Fluvoxamine 25mg daily (can increase up to 300mg daily)
- Sertraline 25mg daily (can increase up to 200mg daily)
Glutamate-modulating drugs (Grant, 2016; Craig-Müller, 2015)
- N-acetylcysteine 1200mg – 3000mg daily
- Evidence for SSRIs and N-acetylcysteine consists of relatively few trials conducted over the short-term; as excoriation disorder is typically a chronic condition, further studies are needed to evaluate long-term efficacy (Grant, 2016; Craig-Müller, 2015)
- Antidepressants (SSRIs) (Selles, 2016)
- Referral to a psychiatrist is strongly recommended if excoriation disorder is suspected due to the underlying psychological nature of the disorder.
- Referral to a psychologist or social worker for CBT and/or HRT.
- Referral to a dermatologist if there are signs of dermatologic complications (infection, scarring, disfigurement) or a co-existent primary skin disorder.
- Sally is a 35-yo who comes to your office complaining of itchy skin and a lesion on her forearm that she thinks is infected.
- She is relieved to find out that she is not alone, that other people have this condition too.
- You order some tests to rule out other medical conditions that may be contributing.
- You also recommend the local counseling/therapy services to help with her stress and coping.
- She learns how to be more self-compassionate and accept that she is not perfect.
- The urges still come from time to time, but she's able to keep herself from picking.
The Trichotillomania Learning Center
- Although there are Practice Guidelines for anxiety disorders and obsessive compulsive disorder, there are not any specific guidelines for excoriation disorder.
- American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5), American Psychiatric Association, Arlington, VA 2013.
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- Arnold LM, Auchenbach MB, McElroy SL. Psychogenic excoriation. Clinical features, proposed diagnostic criteria, epidemiology and approaches to treatment. CNS Drugs. 2001;15(5):351-9.
- Capriotti, M. R., Ely, L. J., Snorrason, I., & Woods, D. W. (2015). Acceptance-enhanced behavior therapy for excoriation (skin-picking) disorder in adults: A clinical case series. Cognitive and Behavioral Practice, 22(2), 230-239. doi:10.1016/j.cbpra.2014.01.008
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- Grant JE, Chamberlain SR, Redden SA, Leppink EW, Odlaug BL, Kim SW. N-Acetylcysteine in the Treatment of Excoriation Disorder: A Randomized Clinical Trial. JAMA Psychiatry. 2016 May 1;73(5):490-6.
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- Schumer MC, Bartley CA, Bloch MH. Systematic Review of Pharmacological and Behavioral Treatments for Skin Picking Disorder. J Clin Psychopharmacol. 2016 Apr;36(2):147-52.
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- Turner GA, Sutton S, Sharma A. Augmentation of Venlafaxine with Aripiprazole in a Case of Treatment-resistant Excoriation Disorder. Innov Clin Neurosci. 2014 Jan;11(1-2):29-31.
- Written by Dr. Tania M. Fantin, Family Medicine Resident, Class of 2017.
- Reviewed by members of the eMentalHealth.ca Primary Care Team, which includes Dr’s M. St-Jean (family physician), E. Wooltorton (family physician), F. Motamedi (family physician), and M. Cheng (psychiatrist).
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Date of Last Revision: Nov 30, 2017