All About Dermatillomania (Excoriation or Skin Picking Disorder)

Dermatillomania is characterized by repetitive skin picking that results in soft tissue damage.

Skin picking is considered a body-focused repetitive behavior (BFRB), along with other similar behaviors such as compulsive hair pulling, nail biting, and cheek biting.

In the Diagnostic and Statistical Manual of Mental Disorder, 5th edition (DSM-5), dermatillomania is listed under the category of obsessive compulsive and related disorders. It overlaps with trichotillomania, also known as hair pulling disorder.

Skin picking often starts off as an unconscious act, but over time it becomes more deliberate. These skin-picking episodes can last from a few minutes to most of the day.

Many people with dermatillomania say they have a strong craving, urge, or sensation before a skin picking episode. Some report:

• itching
• warmth
• pain
• burning
• a feeling of dryness

Research from 2015 shows that many people with dermatillomania experience a feeling of gratification during picking, which keeps the behavior going. However, this is often accompanied or followed by feelings of shame or distress.

Skin picking can occur on any part of the body, and people with dermatillomania may have several spots they pick at. The most common areas are the:

• face
• hands
• fingers
• arms
• legs

Sometimes people with skin-picking disorder focus on bumps, pimples, or other skin irregularities. Many pick at unblemished skin as well.

People with dermatillomania typically report using their fingernails to pick, though they may also use tweezers, razors, pins, or other sharp objects.

Once the skin is removed, they may:

• discard it
• save it
• consume it

Common behaviors of people with dermatillomania include:

• They can’t stop picking at skin.
• The picking causes bleeding, bruising, or a wound.
• They pick at moles, freckles, bumps, or scars in an attempt to “smooth” them out.
• The picking may be done unconsciously or out of habit.
• Picking may occur more often when they’re feeling anxious, stressed, or bored

Excessive skin picking can result in soft tissue damage as well as significant mental distress.

Over time, dermatillomania can lead to skin lesions in various stages of healing, along with scarring and hyperpigmentation. Skin lesions typically occur in areas that are easy to reach, such as the face, hands, or arms.

When the wounds are severe, you can get an infection or even life threatening complications, such as:

• sepsis (blood poisoning caused by bacteria)
• blood loss (if picking occurs near a major blood vessel)
• brain infection (if picking occurs in the facial area and an intracranial infection develops)

Many people with dermatillomania are unable to stop picking, despite repeated attempts to stop. This can lead to significant anxiety, shame, and depression.

People with dermatillomania tend to spend a lot of time picking their skin, as well as hiding their picking and lesions. This may lead to being late for school, work, or social events.

Skin picking disorder may also result in social embarrassment and avoidance of situations or activities where lesions might be seen.

The exact cause of dermatillomania is unknown.

The disorder may be linked to genetics, since it tends to run in families. A 2012 study found that of 60 people with skin picking disorder, 28.3% of their close family members also had the disorder.

Research from 2017 suggests that dermatillomania has significant comorbidity with other BFRB disorders. The most common of these is trichotillomania (hair pulling disorder).

Obsessive-compulsive disorder (OCD) and body dysmorphic disorder (BDD) are also more common in people with dermatillomania than in the general population. In fact, research suggests that 28% of those with BDD have dermatillomania.

Overall, several mental health disorders and syndromes have been linked to skin picking:

• trichotillomania
• OCD
• obsessive-compulsive personality disorder
• Tourette syndrome
• BDD
• anxiety disorder
• alcohol dependence
• mood disorder
• borderline personality disorder
• autism spectrum disorder
• Prader-Willi syndrome
• Lesch-Nyhan syndrome
• Smith-Magenis syndrome

Triggers vary among individuals, but may include:

• stress
• anxiety
• anger
• boredom
• tiredness
• engaging in sedentary activities like TV watching or reading
• skin conditions, such as acne or eczema

Research from 2021 suggests that the age of onset may be during childhood, adolescence, or adulthood. However, skin picking tends to begin between 13 and 15 years old. There’s also a higher prevalence of dermatillomania among college students (3.8%).

According to the DSM-5, dermatillomania is classified under “obsessive compulsive and related disorders.”

The criteria for the disorder per DSM-5 are:

• repetitive skin picking that results in skin wounds
• repeated attempts to cut back or quit skin picking
• skin picking that leads to significant distress or impairment at work or other important areas of functioning
• skin picking that is not attributable to the physiological effects of a substance or another medical condition
• skin picking that is not better explained by symptoms of another mental health condition

Many people with dermatillomania may be reluctant to seek treatment. Research suggests that fewer than 20% of people with skin-picking disorder seek treatment. Reasons may include embarrassment or the belief that it’s untreatable or just a “bad habit.”

A large majority — 75 to 90% — of those who seek treatment for skin-picking disorder are female.

Those who do seek treatment often see a general practitioner or a dermatologist before seeing a psychologist.

Treatment for dermatillomania should address the underlying mental health condition and any skin conditions (such as eczema or dry and itchy skin). This includes topical treatment for lesions.

Research from 2021 suggests that selective serotonin reuptake inhibitors (SSRIs) are effective in treating the psychiatric aspect of dermatillomania and may be particularly effective in people who also have OCD. N-acetyl cysteine (NAC) and opioid antagonists may also offer potential benefits.

Habit reversal training (HRT), a type of cognitive-behavioral intervention, is considered the first-line treatment to address BFRBs. HRT involves awareness training (self-monitoring), and it teaches a person to substitute skin picking with an incompatible action, such as fist clenching.

Acceptance and commitment therapy (ACT) is another type of CBT for BFRBs.

ACT involves the acceptance of negative thoughts and feelings as part of the human experience. You’re encouraged to think of ways to respond to negative thoughts that go hand in hand with your personal values and goals.

One small 2017 study found that combining HRT and ACT significantly reduced hair pulling and skin picking among all participants.

If your child has skin picking disorder, there are several things you can try:

• Talk with your child openly about their skin picking. Let them know you’re a safe person to confide in. Listen carefully to why they do it and ask how you can help.
• Be careful not to get demanding or yank their hand away. This can make some children feel resentful and hide their behavior even more.
• Maximize the environment for success. Help your child replace the behavior with a fidget toy, a ring or bracelet they can twist, or another activity to occupy their hands, such as knitting, drawing, or journaling.
• Set up a mirror in areas they tend to pick, such as near the couch where they watch TV. Many children pick unconsciously, but if they see themselves doing it, it can act as a gentle reminder (without someone else telling them to stop).
• Consider investing in a technological bracelet for BFRBs. These gently alert the person when they start to pick (another way to avoid being told to stop by another person).
• For some children, an incentive might work. Consider taking two photos — one at the beginning and the other at the end of the week. If the skin looks better a week later, the child gets a reward.

If you or your child has dermatillomania, you’re not alone. There are several resources available online, including support groups and self-help videos. In this video, a therapist talks directly to kids who pick at their skin.

If you feel you can’t stop on your own, you may want to reach out to a healthcare professional. Dermatillomania is highly treatable and many people have been able to stop picking with therapy, medication, or both.