Excoriation disorder, also called skin-picking disorder or dermatillomania, is recurrent skin-picking causing skin lesions, with repeated attempts to decrease or stop, and clinically significant distress or impairment. Like trichotillomania, it is a body-focused repetitive behavior — soothing or grooming-related rather than intrusive-thought-driven.
The pattern: picking at perceived skin imperfections (acne, scabs, dry patches, ingrown hairs) that elaborates into wounds. Sites: face, arms, legs, scalp, hands. Often hidden by clothing. Many patients pick during transition activities (in front of mirrors, before bed, during phone calls) or as a self-regulating response to stress, boredom, or fatigue.
Prevalence is 1-5% lifetime, with substantial female predominance. Onset often in adolescence around acne emergence; the behavior frequently persists long after the original trigger resolves. Substantial shame and concealment — patients often present to dermatology rather than psychiatry, and dermatologic treatment alone rarely addresses the underlying behavior.
Medical and psychiatric comorbidities are common. Secondary skin infection, scarring, occasionally severe infections requiring hospitalization. Psychiatric comorbidity: anxiety, depression, OCD, BDD, trichotillomania (often co-occurs in the same patient). The pattern of body-focused repetitive behaviors often clusters.
Treatment: Habit Reversal Training remains the cornerstone — same protocol as for trichotillomania, adapted to picking-specific triggers and behaviors. Awareness training, competing response (often clenching fists or holding an object), social support and reinforcement.
Pharmacotherapy: N-acetylcysteine 1200-2400 mg/day has the best evidence — modest effect size but worth trying in moderate-severe cases. SSRIs help when superimposed depression, anxiety, or OCD are present but don't substitute for behavioral intervention. Topical or systemic acne treatment may be appropriate alongside behavioral work — reducing triggers (visible imperfections) can help, but does not address the underlying behavior.
Coordinated care: dermatology for wound care, scarring, secondary infection. Psychiatry/therapy for the underlying behavioral pattern. These are not competing approaches — both matter. Without psychiatric intervention, dermatologic treatment alone rarely produces sustained change.
When you encounter a patient with skin lesions in patterns suggestive of picking, ask directly. The shame keeps many patients from volunteering the information. Treatment is effective when the patient engages with HRT — and most patients are relieved to learn this is a recognized, treatable disorder rather than a personal flaw.