Background

• Excoriation Disorder, or Dermatillomania or Skin Picking Disorder, is a mental health condition that shows repetitive and compulsive picking of one’s skin to the extent that it causes noticeable damage.
• This disorder falls under Obsessive-Compulsive and Related Disorders in the Fifth Edition (DSM-5) of the Diagnostic and Statistical Manual of Mental Disorders. 

Epidemiology

• Prevalence: Excoriation Disorder is considered a relatively common condition, but it often goes undiagnosed due to the secretive nature of the behavior and its associated stigma. Prevalence rates can vary depending on the population studied and the diagnostic criteria used, but estimates suggest that around 1% to 5% of the general population may be affected by Excoriation Disorder. 
• Demographics: Excoriation Disorder can affect individuals of all ages, genders, and backgrounds. However, it appears to be more common in females than in males. The disorder often begins in adolescence or early adulthood, though cases have also been reported in children and older adults. 
• Comorbidity: Excoriation Disorder frequently occurs alongside other mental health conditions, particularly those within the anxiety and obsessive-compulsive spectrum. Common comorbidities include: 
• Obsessive-Compulsive Disorder  
• Body Dysmorphic Disorder (BDD 
• Anxiety Disorders 
• Depressive Disorders 
• Impact 
• Treatment Seeking 

Anatomy

Pathophysiology

Neurobiological Factors: 

• Dopaminergic System: Some research suggests that there may be alterations in the brain’s dopamine pathways in individuals with Excoriation Disorder. Dopamine is a neurotransmitter associated with reward and pleasure, and dysregulation in its function might play a role in the repetitive and compulsive behaviors characteristic of the disorder. 
• Serotonergic System: Serotonin is another neurotransmitter often implicated in mood regulation and impulse control. Disruptions in serotonin signaling could contribute to the urges and lack of control associated with skin picking. 

Genetics: 

• There appears to be a genetic component to Excoriation Disorder, as it tends to run in families. Studies have suggested that certain genetic variations might increase the susceptibility to developing the disorder. However, the specific genes involved and their mechanisms are still being investigated. 
• Psychological Factors: 
• Coping Mechanisms: Skin-picking behavior may develop as a maladaptive coping mechanism for stress, anxiety, boredom, or other negative emotions. Picking can provide temporary relief or a sense of control, reinforcing the behavior over time. 
• Body-Focused Repetitive Behaviors (BFRBs):  

Excoriation Disorder is considered a type of Body-Focused Repetitive Behavior, including conditions like trichotillomania (hair pulling). These behaviors are often associated with a need for sensory stimulation or a way to regulate emotional distress. 

• Cognitive Factors: 

Individuals with Excoriation Disorder may have distorted perceptions of their skin imperfections, leading them to believe that they need to engage in picking behaviors to correct these perceived flaws. This cognitive distortion can contribute to the compulsive nature of the behavior. 

• Environmental and Social Factors: 

Exposure to stressful or traumatic events, childhood adversity, and environmental triggers could contribute to the development of Excoriation Disorder. Social and cultural factors and learned behaviors from family or peers could also play a role. 

• Neurocognitive Factors: 

Some studies suggest that individuals with Excoriation Disorder might exhibit differences in certain neurocognitive functions, such as inhibitory control and attentional biases. These differences could contribute to difficulty resisting the urge to pick at the skin. 

Etiology

The etiology of Excoriation Disorder involves a complex interplay of genetic, neurobiological, psychological, and environmental factors. The following factors are believed to contribute to the development of the disorder: 

• Neurocognitive Factors: Differences in neurocognitive functions, such as inhibitory control and attentional biases, might play a role in the inability to resist the urge to pick at the skin. 
• Brain Circuitry: Neuroimaging studies have indicated potential differences in brain circuitry associated with reward and impulse control in individuals with Excoriation Disorder, further suggesting a neurobiological basis for the disorder. 
• Cognitive Factors: 

Perception of Imperfections: Individuals with Excoriation Disorder often have distorted perceptions of their skin’s imperfections, leading them to believe that they need to engage in picking to correct these perceived flaws. 

Attentional Bias: There may be an attentional bias towards skin imperfections, causing affected individuals to focus excessively on minor irregularities. 

Genetics

Prognostic Factors

The prognosis of Excoriation Disorder (Dermatillomania) can vary widely from person to person. It depends on several factors, including the severity of the disorder, the presence of coexisting conditions, the individual’s willingness to engage in treatment, and the effectiveness of the interventions used. Here are some critical prognostic factors to consider: 

• Severity of Symptoms: 

Individuals with milder Excoriation Disorder may have a better prognosis, as they may be more responsive to treatment and experience less impairment in daily functioning. 

• Treatment Engagement: 

A willingness to engage in treatment is a favorable prognostic factor. Individuals actively participating in therapy and adhering to treatment recommendations are more likely to experience positive outcomes. 

• Treatment Approach: 

Different treatment approaches, like cognitive-behavioral therapy (CBT), medications, and mindfulness-based interventions, can yield varying results for different individuals. The appropriateness and effectiveness of the chosen treatment method can impact prognosis. 

• Presence of Comorbid Conditions: 

Coexisting mental conditions, like anxiety disorders or depression, can complicate the prognosis. Addressing and effectively treating these conditions can lead to better outcomes for Excoriation Disorder as well. 

• Social Support: 

Strong social support from family, friends, or support groups can positively impact prognosis by providing encouragement and reinforcement for treatment efforts. 

• Duration and Chronicity: 

The longer the disorder persists without intervention, the more challenging it might be to address. Chronic cases might require more intensive and prolonged treatment. 

• Cognitive Insight: 

An individual’s insight into their condition and willingness to recognize and challenge cognitive distortions related to skin picking can affect the prognosis. 

• Response to Treatment: 

Early positive responses to treatment, such as reducing skin-picking behavior and improving quality of life, can predict a better long-term outcome. 

• Relapse Prevention: 

Developing effective strategies for relapse prevention is essential. Individuals who learn to manage triggers and maintain progress over time are likelier to have a favorable prognosis. 

Clinical History

Non-specific signs & symptoms 

• Visible skin damage 
• Compulsive behavior 
• Preoccupation 
• Time consumption 
• Physical consequences 
• Social isolation 
• Impact on self-esteem 
• Attempts to stop 
• Secondary consequences 
• Signs of OCD/anxiety 

    Systemic signs & symptoms 

• Skin infection 
• Scarring 
• Hyperpigmentation 
• Open sores 
• Skin sensitivity 
• Psychological stress 

Age Group:  

• Children 

• Adults 
• Elderly 
• Elderly adults 

Physical Examination

A physical examination in the context of Excoriation Disorder, also known as Dermatillomania or Skin Picking Disorder, primarily focuses on assessing the skin damage caused by the picking behavior.  

• Visual Inspection: A visual skin inspection is a fundamental examination part. The examiner will look for evidence of skin damage, wounds, sores, scabs, and scars caused by repetitive picking. The examination might involve assessing various body parts, depending on where the individual engages in skin-picking behavior. 
• Skin Condition: The examiner will evaluate the overall condition of the skin, including signs of inflammation, infection, redness, and changes in pigmentation. They will look for signs of healing wounds and any secondary complications that might have arisen due to the skin picking. 
• Distribution and Pattern: The examiner will assess the distribution and pattern of skin damage. This can help determine whether the behavior is localized to specific areas or more widespread. Understanding the pattern can provide insights into potential triggers or stressors. 
• Infections and Complications: If signs of infection, such as redness, swelling, warmth, or discharge, the examiner might consider whether medical treatment is necessary. In some cases, skin picking can lead to bacterial or fungal infections. 
• Scarring and Healing: Scarring and areas of healed skin damage can indicate the chronic nature of the behavior. The examiner might assess the extent of scarring and inquire about any discomfort or pain associated with scar tissue. 
• Observation of Behavior: While not a traditional part of a physical examination, observing the individual’s behavior during the examination can provide insights into the urge to pick, any visible signs of discomfort, and potential avoidance behaviors. 
• Communication: The examiner will likely converse with the individual to gather information about their skin-picking behavior, triggers, frequency, duration, and any attempts to control or stop the behavior. 

Age group

Associated comorbidity

The acuity of presentation refers to how rapidly and intensely a condition or disorder becomes noticeable and clinically significant. In the context of Excoriation Disorder (Dermatillomania or Skin Picking Disorder), the acuity of presentation can vary from person to person. Here are a few different scenarios that describe the acuity of the presentation: 

1. Sudden Onset:

In some cases, Excoriation Disorder can have a sudden onset. An individual who has not previously engaged in significant skin picking might suddenly start engaging in the behavior due to increased stress, a triggering event, or other factors. The skin damage and picking behavior might become noticeable relatively quickly, leading to concern and the need for intervention. 

2. Gradual Development:

For many individuals, the development of Excoriation Disorder is more gradual. They might start with occasional skin picking that gradually increases in frequency and intensity over time. This slow progression can make it less noticeable to the individual and those around them until it becomes a more significant concern. 

3. Childhood Onset:

In some cases, Excoriation Disorder can begin in childhood. Children might pick up skin due to stress, boredom, or curiosity. Parents or caregivers might initially consider it normal behavior, but the need for intervention becomes evident as the skin damage becomes more pronounced and consistent. 

4. Subtle Signs:

In certain situations, Excoriation Disorder can present with subtle signs that might not be immediately recognized. For example, an individual might pick at their skin in private, making the behavior less evident to others. Over time, however, the behavior can become more apparent due to visible skin damage or changes in behavior. 

5. Chronic Pattern:

In individuals with a chronic pattern of Excoriation Disorder, the acuity might involve periods of exacerbation and remission. They might have experienced skin picking for years, with fluctuations in intensity based on factors such as stress levels, emotional triggers, or life events. 

Associated activity

Acuity of presentation

Differential Diagnoses

• Other Body-Focused Repetitive Behaviors (BFRBs): 

Trichotillomania (Hair Pulling Disorder): This involves compulsive hair pulling, which, like Excoriation Disorder, is a BFRB. Both disorders involve repetitive behaviors targeting the body. 

Onychophagia (Nail Biting): Nail biting can resemble skin picking in terms of repetitive behavior directed at the body. 

• Obsessive-Compulsive Disorder (OCD): 

Obsessive-Compulsive Disorder involves intrusive, distressing thoughts (obsessions) and repetitive behaviors or mental acts (compulsions) aimed at reducing the anxiety caused by the obsessions. Skin picking might be a compulsion in the context of OCD. 

• Body Dysmorphic Disorder (BDD): 

This involves a preoccupation with perceived flaws or defects in physical appearance, often leading to compulsive behaviors such as mirror checking, comparing, and seeking reassurance. Skin picking could be driven by concerns related to BDD. 

• Dermatological Conditions: 

Certain dermatological conditions, such as chronic itching, dermatitis, or psoriasis, could cause individuals to scratch or pick at their skin due to discomfort or itching. 

• Impulse Control Disorders: 

Conditions such as Pathological Gambling, Compulsive Buying Disorder, and Trichotillomania fall under Impulse Control Disorders and may share similarities in compulsive behaviors with Excoriation Disorder. 

• Substance Abuse or Withdrawal: 

Substance abuse or withdrawal from drugs might lead to behaviors like skin picking, often due to anxiety, restlessness, or nervousness. 

• Stereotypic Movement Disorder: 

Stereotypic Movement Disorder involves repetitive, purposeless movements that might include picking at the skin, particularly in individuals with intellectual disabilities. 

• Pruritus Disorder: 

Pruritus disorder involves chronic itching that might lead to skin scratching or picking as a response to the itch. This condition is primarily driven by itching rather than psychological factors. 

• Attention-Deficit/Hyperactivity Disorder (ADHD): 

Individuals with ADHD might use impulsive behaviors, including picking at the skin, to manage restlessness or sensory seeking. 

• Medical Conditions: 

Certain medical conditions, such as neurodevelopmental disorders or neurological conditions, might lead to repetitive behaviors that could overlap with skin picking. 

Laboratory Studies

Imaging Studies

Procedures

Histologic Findings

Staging

Treatment Paradigm

• The treatment of Excoriation Disorder typically involves a combination of therapeutic approaches that address the underlying psychological factors contributing to excoriation behaviors. 

by Stage

by Modality

Chemotherapy

Radiation Therapy

Surgical Interventions

Hormone Therapy

Immunotherapy

Hyperthermia

Photodynamic Therapy

Stem Cell Transplant

Targeted Therapy

Palliative Care

providing-environmental-and-psychological-alliance-to-manage-excoriation-disorder-specialty-psychology-psychiatry-counseling-therapy-clinical-social-work-occupational-therapy-dermatology-pri

• Modifying the environment can be an effective strategy to help individuals manage and reduce the symptoms of Excoriation Disorder (Dermatillomania or Skin Picking Disorder). Environmental modifications aim to create a supportive and conducive setting that minimizes triggers for skin-picking behaviors. Here are some strategies to consider: 
• Identify Triggers: 
• Work with a mental health professional to identify triggers that lead to skin-picking episodes. Triggers can be emotional, situational, or environmental factors that prompt the behavior. 
• Create a Skin-Friendly Environment: 
• Short nails can reduce the physical damage caused by skin picking. 
• Use Fidget Toys: Provide sensory alternatives such as stress balls, fidget spinners, or textured items that individuals can manipulate instead of picking their skin. 
• Increase Awareness: 
• Mirrors: Limit or cover mirrors to reduce the opportunity for scrutinizing the skin. 
• Dim Lighting: Dim or soft lighting can make imperfections less noticeable. 
• Distraction Techniques: Engage in Hobbies: Encourage engaging activities such as art, crafting, reading, or puzzles that keep the hands and mind busy. Keep Hands Occupied: Provide objects like worry stones, beads, or handheld puzzles to keep the hands occupied. 
• Barrier Methods: 
• Bandages or Dressings: Applying a bandage or dressing to areas prone to picking can act as a physical barrier. 
• Wearing Gloves: Wearing gloves can prevent direct contact with the skin and serve as a reminder to avoid picking. 
• Social Support: 
• Accountability Buddy: Having a supportive friend, family member, or therapist who can provide encouragement and redirection when the urge to pick arises can be helpful. 
• Regular Check-Ins: Schedule regular check-ins with a trusted person to discuss progress and challenges. 
• Behavior Tracking: 
• Encourage individuals to keep a journal to track triggers, emotions, and instances of skin picking. This can help identify patterns and develop strategies to manage them.  

providing-emotional-validation-and-non-judgemental-support

• Validating the patient’s emotions and experiences, even distressing, can help address underlying psychological needs and reduce the drive to feign symptoms for attention. 
• Creating a supportive environment where patients feel understood can encourage them to discuss their motivations and psychological distress. 

Selective Serotonin Reuptake Inhibitors (SSRIs) to treat excoriation disorder

• Fluoxetine  

Fluoxetine is a selective serotonin reuptake inhibitor (SSRI) medication often used to treat various mental health conditions, including depression, anxiety disorders, and certain impulse control disorders like Excoriation Disorder (Dermatillomania or Skin Picking Disorder). 

• Sertraline  

Sertraline, like other SSRIs, works by increasing the levels of serotonin in the brain. Serotonin is a neurotransmitter that plays a role in regulating mood, emotions, and behaviors. By increasing serotonin levels, sertraline can help reduce the urge to engage in compulsive behaviors like skin picking. 

• Fluvoxamine  

Fluvoxamine works by increasing the levels of serotonin in the brain. Serotonin is a neurotransmitter that plays a role in regulating mood, emotions, and behaviors. By enhancing serotonin levels, fluvoxamine can help reduce the urge to engage in compulsive behaviors like skin picking. 

• Paroxetine 

Paroxetine increases the levels of serotonin in the brain. By enhancing serotonin levels, paroxetine can help reduce the tendency to engage in compulsive behaviors like skin picking 

• Citalopram  

Citalopram works by increasing the levels of serotonin in the brain. Serotonin is a neurotransmitter that plays a role in regulating mood, emotions, and behaviors. By boosting serotonin levels, citalopram can help decrease the urge to engage in compulsive behaviors like skin picking. 

Benzodiazepines to treat excoriation disorder

Benzodiazepines are a class of medications primarily used to manage anxiety and related conditions. While they are not typically considered a first-line treatment for Excoriation Disorder (Dermatillomania or Skin Picking Disorder). 

• Alprazolam: 

Alprazolam, commonly known by its brand name Xanax, is a benzodiazepine medication often prescribed for the short-term management of anxiety disorders and panic disorders. While it’s not typically considered a first-line treatment for Excoriation Disorder (Dermatillomania or Skin Picking Disorder), it might be used in some instances to address symptoms of anxiety, agitation, or restlessness that could contribute to skin-picking behaviors.  

• Clonazepam: 

Clonazepam might be used in some cases to address symptoms of anxiety, agitation, or restlessness that could contribute to skin-picking behaviors. 

use-of-intervention-with-a-procedure-in-treating-excoriation-disorder

• Habit Reversal Training (HRT): Habit Reversal Training is a behavioral therapy technique commonly used to treat repetitive behaviors like skin picking. It involves identifying the triggers for skin picking and developing alternative behaviors incompatible with picking, such as clenching fists or keeping the hands occupied. The individual learns to recognize the urge to pick and replaces it with a competing response. HRT also includes raising awareness of the behavior through self-monitoring and regularly practicing these techniques. 
• Stimulus Control: Stimulus control involves modifying the environment to reduce the likelihood of engaging in skin-picking behaviors. This can include keeping the skin well-moisturized, wearing gloves or bandages, using fidget toys or stress balls to keep the hands busy, and implementing other strategies that make skin picking less accessible. 
• Cognitive-Behavioral Therapy (CBT): CBT is a well-established therapeutic approach to treat various mental health conditions, including Excoriation Disorder. In skin picking the therapist works with the individual to develop healthier coping strategies and ways to manage triggers and urges to pick. 
• Comprehensive Skin Care Routine: Establishing a thorough and gentle skincare routine can help improve the skin’s overall condition and reduce the urge to pick. Using appropriate skincare products, keeping the skin clean, and avoiding harsh treatments can help minimize the physical effects of skin picking and promote healing. 
• Dermatological Treatments: In cases where skin picking has led to skin damage, infection, or scarring, dermatological treatments may be necessary to address these physical concerns. This can include wound care, antibiotics to prevent or treat infection, and procedures to improve the appearance of scars. 
• Psychodermatology: Psychodermatology is a field that focuses on the interaction between the mind and the skin. Dermatologists and mental health professionals work together to address skin conditions influenced by psychological factors. In the context of Excoriation Disorder, psych dermatology can involve a combination of dermatological treatments and psychological interventions. 

use-of-phases-in-managing-the-excoriation-disorder

Managing excoriation disorder involves several phases: assessment, intervention, and follow-up. It’s essential to approach the management of excoriation with a comprehensive and individualized plan that addresses the underlying motivations and psychological factors contributing to the behavior.  

• Assessment and Diagnosis: 

The first phase involves a thorough assessment conducted by a mental health professional, such as a psychiatrist or psychologist. The purpose is to determine if the individual meets the criteria for Excoriation Disorder and to understand the severity of the condition, triggers, and underlying psychological factors. 

• Treatment Planning: 

Based on the assessment, a personalized treatment plan is developed. This plan considers the individual’s needs, preferences, and coexisting conditions. It might include a combination of psychotherapy, medication (if appropriate), and behavioral interventions. 

• Psychotherapy: 

Psychotherapy, particularly cognitive-behavioral therapy (CBT), is a critical component of treatment. During this phase, the individual learns to identify triggers for skin picking, challenge distorted thoughts and beliefs, develop healthier coping strategies, and practice techniques to manage the urge to pick. 

• Medication (if applicable): 

In some cases, medication might be considered as part of the treatment plan, like the administration of Selective serotonin reuptake inhibitors (SSRIs). 

• Behavioral Interventions: 

Behavioral interventions include Habit Reversal Training (HRT) and stimulus control. These techniques aim to replace skin-picking behaviors with healthier alternatives, raise awareness of triggers, and provide practical tools to manage the urge to pick. 

• Maintenance and Relapse Prevention: 

Once progress is made and skin-picking behaviors are reduced, the focus shifts to maintaining these improvements and preventing relapse. This phase involves continued practice of learned skills, ongoing therapy sessions (if necessary), and strategies to manage stressors that could trigger skin picking. 

• Long-Term Management: 

Excoriation Disorder is a chronic condition, and long-term management is crucial. This phase involves regular follow-up appointments with mental health professionals to monitor progress, address relapses, and adjust the treatment plan. Developing a sustainable self-care routine and ongoing self-awareness is also essential. 

• Support and Education: 

Throughout all phases, support, and education play a vital role. Individuals and their families and loved ones can benefit from learning about the disorder, understanding triggers, and being equipped with tools to provide support and encouragement.

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References

• https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5522672/