Excoriation (Skin-Picking) Disorder Treatment

Medscape: Excoriation Disorder Clinical Presentation

The TLC Foundation for Body-Focused Repetitive Behaviors: What is Excoriation (Skin-Picking) Disorder?

Dr. Steven Pence is an anxiety specialist in the treatment of excoriation (skin-picking) disorder for both adolescents and adults. Dr. Pence’s office is located in Oakland County, Michigan. Dr. Pence treats excoriation disorder with evidenced-based cognitive behavior therapy with emphasis on habit reversal training (HRT), cognitive restructuring, mindfulness CBT, and psychoeducation for both weekly therapy and intensive outpatient treatment programs. Excoriation Disorder, (previously called dermatillomania, skin-picking) is the medical diagnostic term used to describe skin picking disorders. This disorder is more frequently diagnosed in women and often develops in adolescence, but may not be appropriately diagnosed until adulthood. Most skin-picking disorders remain chronic if left untreated. Individuals want to alleviate the presence of an actual blemish or imperfection in the skin so the individual engages in picking to relieve the anxiety and the relief leads to more picking. The region most commonly picked is the face, but other frequent locations include the arms, legs, back, gums, lips, scalp, stomach, chest, and extremities such as the fingernails, cuticles, and toenails. Complications of excoriation disorder include infection at the site of picking, tissue damage, and septicemia. Severe cases of excoriation can cause skin grafting, life-threatening injuries, and physical scarring or disfigurement. This condition of skin picking can cause intense guilt or shame and even embarrassment.

Neurotic excoriation is persistent scratching where one is compelled to scratch to the point of damaging the skin. They may be unaware of the activity and signs include fresh wounds, scabs, scars that are clean round the edges, linear, and uniform in shape and size. 

Psychogenic Excoriation deals with the development of the habit of skin picking. With psychogenic excoriation, there is no blemish that starts the skin picking and the compulsion is psychological in nature. 

As of 2013, the official name of skin picking became Excoriation Disorder and is listed in the DSM-5 as Excoriation Disorder. 

Symptoms of this disorder may include:
Repeated skin picking, may be lip, scalp, face, acne, nails & cuticle, scabs, nose, etc.
Tension increase immediately before picking
Pleasure, gratification, tension decrease or relief when skin picking

Common causes of compulsive skin picking are:
Stress, anxiety, and other psychological factors
Chemical imbalance
Neurological imbalance
Traumatic events, and childhood events

It is important to identify whether or not skin picking is a symptom of another problem that needs treatment. In getting a proper diagnosis, one must look at the following:

 Evaluation of History:
 History of picking, digging, rubbing, or scraping skin
 Pyschiatric history that includes comorbid mental disorders
 Nasal ulcerations 
 Facial acne

Physical findings may include crusted or noncrusted lesions, erosions and scars with angulated borders and may range from several to hundreds. 

Psychiatric and medical diagnoses that should be considered by psychologists, psychiatrists, dermatologists, and physicians include the following:
Tic Disorders
Obsessive-Compulsive Disorder
Body Dysmorphic Disorder
Borderline Personality Disorder
Somatoform Disorders
Substance abuse disorders such as cocaine & opiate use
Other dermatological disorders
Autoimmune diseases such as Multiple Sclerosis,
Hypothyroidism, & Hyperthyroidism
Diabetes Mellitus
Iron Deficiency Anemia

Complete blood counts and chemistry profiles along with determination of thyrotropin levels can be following up with physicians to rule out other conditions. 

Specific DSM-5 criteria:
Recurrent skin-picking, resulting in lesions
Repeated attempts to decrease or stop skin picking
The skin picking causes clinically significant distress or impairment in important areas of functioning: social, occupational, other
The skin picking cannot be attributed to the physiologic effects of a substance or another medical condition
The skin picking cannot be better explained by the symptoms of another mental disorder

The recommended treatment for excoriation is with a trained psychologist who specializes in treating this misunderstood and often misdiagnosed condition. Effective treatment focuses on cognitive behavior therapy (CBT) with an emphasis on habit-reversal training (HRT), cognitive restructuring, mindfulness based CBT, and psychoeducation. Therapy may involve self-monitoring, stimulus control, and competing response. These are temporary in helping the patient learn to resist the urge to pick and the more the urge is resisted over time, the weaker the urge becomes. According to the CBT model, skin picking is maintained by a combination of environmental, emotional, and/or cognitive factors that either trigger or reinforce skin picking episodes. Picking can be triggered by specific settings (e.g. bedroom, bathroom mirror) or activities such as driving or watching television. Certain emotions, such as anxiety, tension, and boredom can also trigger skin picking episodes, as well as irrational beliefs about physical appearance (e.g. need to pop or pick a pimple so it looks better).

Research also suggests that skin picking may be effectively treated with SSRI’s in combination of CBT. 

Cognitive Behavior Therapy for Teens with Excoriation Disorder:
The goal of cognitive behavior therapy for excoriation disorder is to educate your teen about the disorder and teach them to become more aware of their skin picking behavior and the environmental, emotional, and cognitive factors that trigger it. He or she will keep track of their skin picking episodes and the associated triggers. He or she will monitor the consequences, emotions, and thoughts and will also learn how to self-manage strategies that prevent skin picking episodes and stop the episodes once they begin. Common goals include decreasing skin picking episodes, engaging in healthy skin care behaviors, resuming daily routine and other levels of functioning, and building coping skills for tolerating these uncomfortable emotions.