Excoriation (Skin-Picking) Disorder

Excoriation, like many psychological disorders, can manifest physically and emotionally. Recognizing the signs and symptoms can be one of the first steps in seeking appropriate help.

Physical signs:

• Visible skin damage. Frequent open sores, scabs, or lesions may appear on the skin, especially on the face, arms, and hands.
• Repeated injuries. Continually picking at the same spot can lead to delayed healing or permanent scars. 
• Infections. There is an increased risk of bacterial infections resulting from open wounds or compromised skin barriers.
• Disguise. Individuals may use makeup, clothing, or accessories to conceal skin damage.

Emotional/behavioral signs:

• Compulsion. Individuals with this disorder may feel an overwhelming urge to pick at the skin, even if there are no blemishes or imperfections on the skin.
• Stress relief. Some individuals find temporary relief from stress, anxiety, or other emotions through skin-picking, but feelings of guilt or shame often follow this relief. 
• Avoidance behavior. Some people avoid social situations or activities due to embarrassment about their skin’s appearance or the fear of being caught picking.

Other signs and symptoms:

• Decreased self-esteem. Some people experience a decline in confidence or self-worth due to the physical aftermath of picking.
• Disruption of daily activities. The compulsion to pick can become so consuming that it interrupts daily routines, work, or school. 
• Isolation. As a means to hide the condition (usually out of shame), some individuals might isolate themselves from friends and family.

While skin-picking can be a common behavior for many, it may indicate a more serious underlying condition when it becomes frequent and results in noticeable skin damage or emotional distress.

Researchers haven’t identified a single cause of excoriation, but it may be related to genetics, other mental health conditions, and changes in brain structure. The following are some potential causal factors. 

Potential causes

• Emotional regulation. For many, skin-picking is a coping mechanism to manage emotions like anxiety, stress, or feelings of emptiness. The act can provide temporary relief, though it’s often followed by guilt and shame.
• Stimulus. Physical sensations like itching or irritation can initiate skin picking. Over time, even minor sensations might trigger an episode.
• Brain structure. Someone with excoriation disorder may have changes in brain structure that affect how they form habits.  

Key risk factors 

• Family history. Individuals with close relatives who exhibit body-focused repetitive behaviors (BFRBs) or obsessive-compulsive disorder might be at a heightened risk for developing a skin-picking disorder.
• Age. While the disorder can begin at any age, the onset is usually observed in adolescence, a period often marked by significant hormonal and emotional changes.
• Coexisting disorders. The presence of other mental health disorders like anxiety, depression, or obsessive-compulsive disorder (OCD) may increase risk of BFRBs.

While the exact cause of excoriation disorder might vary from individual to individual, a combination of emotional, physical, and genetic factors may play a role in its development. Recognizing these may help individuals and professionals address the disorder in a timely manner. 

Excoriation, like many psychological conditions, may improve with a blended treatment approach of therapy and medication. Many individuals find success with therapy. The primary goals of treatment are typically to reduce or eliminate skin-picking behaviors, to alleviate associated emotional distress, and to improve overall quality of life.

Medication

There is not currently a drug specifically intended for excoriation disorder management. However, there are medications that have shown some promise in managing the disorder:

• Selective serotonin reuptake inhibitors (SSRIs). Commonly prescribed for depression and anxiety, SSRIs might also help reduce skin-picking behaviors for some individuals.
• Glutamatergic Agents: In some studies, these medications showed significant improvement in ED symptoms. An example of this medication would be N-acetylcysteine (NAC).
• Anti-anxiety medications. For some individuals whose skin-picking is triggered primarily by anxiety, anti-anxiety medication may offer some relief.
• Inositol. Research suggests inositol may reduce skin picking. 
• Topical Treatments: Topical treatments like antibiotics may be needed to treat skin infections resulting from picking. 

It is recommended that you consult with a psychiatrist or primary care physician before starting any kind of medication. 

Other treatment options

Beyond traditional therapy and medication, some individuals may benefit from alternative treatments:

• Biofeedback and neurofeedback. These techniques may teach individuals to control physiological functions, potentially helping manage the urges associated with skin-picking disorder.
• Acupuncture. Though research is ongoing, some individuals feel relief from the urge to skin-pick after acupuncture treatments.

Self-care

Managing excoriation is an ongoing process, and self-care can play a significant role in supplementing formal treatment:

• Skin care routine. Implementing a gentle skin care routine may aid in healing existing wounds and prevent further damage. 
• Barrier methods. Tools like gloves, bandages, or even acrylic nails can physically hinder the act of picking.
• Mindfulness and meditation. Techniques like deep breathing, guided imagery, or progressive muscle relaxation can divert attention from the urge to pick. 
• Journaling. Keeping a journal or diary may help identify triggers and track progress, offering insights into patterns and potential coping strategies.

Combining treatments tailored to individual needs often yields the best results. Regular consultation with professionals, paired with self-awareness and self-care, may help individuals manage and reduce the impact of excoriation on their lives.

Therapy can be an important step in treating excoriation, offering a space for individuals to explore triggers and develop coping strategies. CBT has been proven particularly effective in treating skin-picking behaviors and often helps individuals identify and replace negative thought patterns. For those seeking a flexible therapeutic solution, BetterHelp offers online CBT via audio, video, or live chat, which may be especially helpful for those whose symptoms make it difficult to leave home.

Some additional resources to aid in understanding and managing excoriation include:

• The TLC Foundation for Body-Focused Repetitive Behaviors. This organization offers an online community, resources, and tools specifically tailored for individuals with body-focused repetitive behaviors (BFRBs), including skin picking. It can also connect individuals and their families to local BFRB support groups in their area.
• The Picking Me Foundation NFP. The Picking Me Foundation NFP offers a number of resources and campaigns to support individuals who experience excoriation disorder.

There is ongoing research for both skin-picking disorders and body-focused repetitive behaviors (BFRBs), including medication and therapy options. 

N-acetylcysteine (NAC) has garnered interest as a promising treatment for body-focused repetitive behavior disorders, including excoriation. One study suggests that NAC, a glutamate modulator, may reduce compulsive behaviors associated with these disorders. In a 12-week study involving adults, significant improvements in skin-picking severity were observed in those treated with NAC compared to a placebo. Similarly, a pilot study in both pediatric and adult patients indicated reduced skin-picking behaviors after NAC treatment, with a majority reporting complete resolution. Despite these positive findings, there is a need for larger, more extensive research to establish NAC’s definitive use in treating BFRBs.

Excoriation disorder can lead to skin damage that is often linked with emotional challenges. In a study comparing two therapies for the disorder, psychodrama group therapy (PGT) and support group therapy (SGT), both methods showed promise in reducing skin-picking behaviors and enhancing social adjustment. The study found no significant difference in effectiveness between the two therapies. While both group therapies demonstrated potential, more extensive research is required to identify the best approach to improve ED patients' emotional regulation and overall well-being.

Excoriation disorder has an estimated prevalence of 1.4%–5.4% in the United States

Thousands of Americans are living with excoriation disorder. According to a study in the Journal of Clinical Medicine, the prevelance of this condition is about 1.4% to 5.4% of the adult US population. ¹

¹Journal of Clinical Medicine

Here are more key statistics on excoriation:

• Mental Health America states that the condition “is experienced by women more often than men.”
• According to the American Journal of Psychiatry, “Other grooming disorders, such as trichotillomania, are common in individuals with skin picking disorder. A study of 60 patients with skin-picking disorder found a lifetime rate of co-occurring trichotillomania of 38.3%.
• Mental Health America also says, “Evidence suggests that both medication and cognitive-behavioral therapy (CBT) may effectively reduce symptoms of excoriation disorder. Specific types of CBT, habit reversal training (HRT), and the comprehensive behavioral model (ComB) may be helpful forms of treatment.”