Excoriation (Skin-Picking) Disorder is a chronic and distressing psychiatric condition characterized by recurrent skin-picking behaviors aimed at removing real or perceived imperfections in the skin. These behaviors typically include scratching, squeezing, pulling or digging at the skin and often impair daily functioning. The disorder is frequently triggered by emotions such as anxiety, tension or boredom; while it may provide temporary relief, it usually leads to long-term feelings of regret and shame. According to the DSM-5 criteria, it is classified under “Obsessive-Compulsive and Related Disorders.”

DSM-5 Diagnostic Criteria for Excoriation Disorder

The DSM-5 diagnostic criteria for excoriation disorder include:

• Recurrent skin-picking resulting in skin lesions.
• Repeated attempts to decrease or stop the behavior.
• The skin-picking causes clinically significant distress or impairment in social, occupational or other areas of functioning.
• The behavior is not attributable to substance use (for example, cocaine) or another medical condition (for example, dermatological disorders).
• The behavior is not better explained by another psychiatric disorder (for example, delusional parasitosis or autism spectrum disorder).

All of these criteria must be met for diagnosis.

Symptoms of Excoriation Disorder

The disorder predominantly involves accessible areas such as the face, arms, hands and legs. It may present as:

• Picking with fingers, nails or objects such as tweezers, needles or scissors,
• Recurrent removal of scabs,
• Scraping at small irregularities in the skin in an attempt to “fix” them,
• Temporary relief after picking, followed by guilt, shame and anxiety,
• Impairment in social or occupational functioning due to the behavior.

Some individuals pick unconsciously, while others engage deliberately as a means of tension regulation.

Etiology of Excoriation Disorder

The etiology is not fully clarified but is believed to result from the interaction of neurobiological, genetic and psychosocial factors.

1. Neurobiological Hypotheses

Research suggests functional abnormalities in cortico-striato-thalamo-cortical circuits. Increased activity in the orbitofrontal cortex and striatum has been linked to impaired impulse control (Grant & Chamberlain, 2016). Dysregulation of dopaminergic and serotonergic systems is also significant in explaining the repetitive nature of the behavior.

2. Genetic Predisposition

Family studies indicate a genetic component. Individuals with a family history of obsessive-compulsive disorder or trichotillomania have an increased risk.

3. Psychosocial Factors

Childhood trauma, physical or sexual abuse, low self-esteem, family conflict and anxiety disorders play a role. Many patients show high self-criticism, perfectionism and vulnerability under stress.

Risk Factors

Major risk factors include:

• Family history of OCD or trichotillomania,
• Female gender (approximately twice as common in women),
• Adolescent onset of anxiety disorders,
• Traumatic life events,
• Low emotional regulation capacity.

Dermatological conditions such as acne or eczema may also trigger pathological focus on the skin, increasing the likelihood of picking.

Diagnosis

Excoriation disorder is often concealed due to shame, delaying clinical presentation. Diagnosis requires a thorough psychiatric assessment.

Steps in diagnosis include:

• Semi-structured clinical interview based on DSM-5 criteria,
• Dermatological examination of skin lesions,
• Toxicology screening to exclude substance use,
• Evaluation of comorbid conditions such as OCD, depression or anxiety disorders.

Some individuals exhibit low awareness (automatic style), while others engage in conscious, tension-relieving picking (focused style).

Treatment of Excoriation Disorder

Effective treatment requires combined pharmacological and psychotherapeutic approaches, usually long-term.

1. Pharmacotherapy

There are no FDA-approved medications specifically for excoriation disorder, but several have shown benefit:

• SSRIs (for example, fluoxetine, sertraline, paroxetine) are first-line due to similarities with OCD pathophysiology.
• N-acetylcysteine (NAC): Regulates glutamate levels and has been shown to reduce impulsive behaviors (Grant et al., 2009).
• Antipsychotics or antiepileptics: Risperidone and lamotrigine have been used as adjuncts in resistant cases.

Treatment should be individualized and closely monitored by a psychiatrist.

2. Psychotherapy

• Cognitive Behavioral Therapy (CBT): Targets maladaptive thought patterns and develops alternative strategies.
• Habit Reversal Training (HRT): Encourages replacement of picking with alternative motor responses, such as manipulating objects with the hands.
• Mindfulness-Based Interventions: Enhance awareness of automatic behaviors and improve emotion regulation.

3. Family Education and Support

Especially important in adolescents and young adults. Families should:

• Understand the pathophysiology of the disorder,
• Provide nonjudgmental support,
• Reduce family-related stress factors.

Impact on Daily Life

Excoriation disorder has significant physical, psychological and social consequences.

• Physical: Infections, pigmentation changes, scar formation and permanent disfigurement,
• Psychological: Guilt, shame, body image disturbances, social anxiety,
• Social: Social withdrawal, relationship difficulties, academic and occupational impairment.

Therefore, treatment should not only aim to reduce symptoms but also to improve quality of life with a holistic approach.