What Is Skin-Picking or Excoriation Disorder?

Many people pick at their skin occasionally, but people with excoriation disorder — also called skin-picking disorder — develop a chronic compulsion that lies on the obsessive-compulsive spectrum. Individuals with the disorder feel regular impulses to pick at their skin, eventually causing physical or psychological damage. While the condition is uncommon, there is a significant amount of research detailing its effects. The cause is unknown, though it has many links to various mental disorders.

Picking Episodes

People with excoriation disorder have episodes where they feel driven to pick their skin. Tension, stress, and anxiety often precede these episodes, and many individuals learn to predict when the impulses are approaching. Skin picking often follows a specific trigger, such as noticing a perceived flaw on the skin. During these episodes, people with the condition pick at their skin in a trance-like state, often to the point of injury. An excoriation episode can last anywhere from a few minutes to several hours. Most people pick with their fingers, though some may use tweezers, needles, or other tools.

Other Effects

Because a person with excoriation is regularly picking at their skin, they can develop infections very easily. Beyond these physical complications, excoriation disorder causes many psychological issues. Many people have feelings of helplessness, as well as guilt, shame, and embarrassment. These can all lead to self-isolation and greatly increase the risk of self-harm. Around 12% of people with the condition have attempted suicide. Psychiatric hospitalization is also common.

Affected Regions

Excoriation disorder usually causes people to focus on picking a single part of their body. Though picking at the face is most common, some people also pick at their arms, legs, gums, neck, shoulders, scalp, or chest. Some people pick at their fingernails, toenails, or cuticles. Once an area experiences significant damage from the picking, the person will often shift to another area while the initial one heals.

Complications

Over time, severe excoriation disorder can have several serious complications. Because it increases the likelihood of developing infections, it may also lead to tissue damage and sepsis. Records exist of cases so severe that the affected individuals require skin grafts. In some instances, excoriation disorder can become life-threatening. For example, a 48-year-old woman picked through the skin of her neck, exposing her carotid artery. Many people who have this disorder develop severe scars and other blemishes. Excoriation disorder may also cause significant back and neck pain due to the positions a person must take to satisfy specific picking impulses.

Neurological Causes

Doctors and researchers are not sure what causes excoriation disorder, though there are many theories. Interestingly, when the condition occurs alongside other disorders, motivations for picking change. For example, an excoriation disorder that accompanies obsessive-compulsive disorder often causes a perception of contamination on the skin. Alternatively, when it exists alongside body dysmorphic disorder, it can cause a person to pick at perceived imperfections. Dopamine levels and excoriation appear to have some link between them, leading researchers to believe the disorder could result from reward function issues.

Behavioral Concerns

In addition to neurological causes, many psychologists and researchers believe that excoriation stems from the stress response. Specifically, skin picking may be a coping mechanism to help a person manage high levels of stress, arousal, or sadness. A 2010 review from the journal Research in Developmental Disabilities supports this idea. Some experts believe that excoriation disorder has roots in repressed rage, particularly feelings due to overbearing or authoritarian guardians. Many clinical studies cite strong links between traumatic childhood events and excoriation disorder.

Diagnosis

Within the medical community, there is some controversy surrounding the diagnosis of excoriation disorder. Because there isn’t a known cause, many health care providers are unsure of how to classify the condition. Currently, most physicians categorize excoriation disorder along with other body-focused repetitive behaviors, such as picking, pulling, or scraping at hair, skin, and nails. When performing a physical exam to look for signs of skin picking, a doctor will ask a patient about their feelings around the action. If a physician suspects excoriation disorder, they will typically refer the patient to a mental health professional after treating any physical effects.

Medications

Some people find that antidepressants and mood stabilizers help ease self-picking behaviors. The most common medications for excoriation disorder are selective serotonin reuptake inhibitors, a type of antidepressant. Mental health professionals may use medications that normally treat other conditions to help manage certain aspects of excoriation disorder. This is known as “off-label” use.

Therapies

Counseling and behavior therapy are among the most effective treatment options available. Usually, a counselor will help identify the reasons that a person picks their skin and any possible triggers. Once they’ve established these causes, they help the patient develop alternatives to the behavior. When a person wants to pick their skin, their therapist might recommend focusing on a different task, such as squeezing stress balls, painting, or otherwise occupying the hands. Wearing gloves or bandages can also help reduce picking behaviors.

Outlook

Excoriation disorder doesn’t have a specific cure. Most people with the condition continue to feel its effects for their entire lives. However, by learning alternative methods to handle the picking impulses, they may avoid the compulsion entirely. Additionally, managing triggers can limit the number of episodes. While there may be periods where a person relapses, it is important to remember that the treatment process is largely trial and error, and there are many other options available if the first does not work.