To excoriate means to strip away skin. An estimated 2 to 5% of the population has an excoriation disorder, also known as dermatillomania, neurotic excoriation, or chronic or compulsive skin picking.
Maybe you rip your cuticles until they bleed or peel layers of skin from the soles of your feet until they’re tender. Perhaps you feel compelled to repeatedly rub, scratch, or squeeze bumps and blemishes on your face, arms, legs, scalp, or back. A mere mosquito bite can linger as an open wound because you won’t let it heal.
“People think they’re the only one, or they think it’s unusual or that they’re weird,” says Suzanne Mouton-Odum, PhD, a private-practice psychologist in Houston and a member of the scientific advisory board of the TLC Foundation for Body-Focused Repetitive Behaviors.
In truth, it’s a treatable condition.
Excoriation disorder is related to hair pulling (trichotillomania) and nail biting (onychophagia). All three are known as body-focused repetitive behaviors (BFRBs), which are repetitive “self-grooming” behaviors that result in injury, impairment, or distress.
But the latest edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-V) classifies excoriation disorder among “obsessive-compulsive and related disorders.” This category includes hoarding, body dysmorphic disorder, and obsessive-compulsive disorder (OCD), among other conditions.
Having a skin-picking disorder does not mean you have OCD. “It’s more like a distant cousin,” Mouton-Odum says.
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Who gets excoriation disorder?
Women are more likely to report dermatillomania than men, but anyone can get it.
Professional counselor Twisa Desai, who treats BFRBs at the Bucks County Anxiety Center in Newtown, Pennsylvania, suspects “the stigma and shame” around BFRBs—needing to have perfect skin and hair—may start much earlier for women.
Research shows you’re more likely to pick if you have a first-degree relative with a grooming disorder, like hair pulling or compulsive nail biting. People who pick often have one of these other disorders, too.
Obsessive skin picking can be a chronic condition, one that comes and goes over time. It often strikes in adolescence, but it can begin at any age, even in very young children and in adulthood (usually between ages 30 and 45).
Adults with excoriation disorder sometimes have depression or anxiety. Whether these mental health conditions are the cause, or a consequence, of picking remains unclear.
Little kids who pick their skin typically enjoy doing it and don’t see it as a problem, Mouton-Odum observes. “They just know that it really upsets mommy or daddy,” she says.
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Excoriation symptoms
When does skin picking cross the line from annoying habit to mental health condition? Based on DSM-V criteria, you might be diagnosed with excoriation disorder if:
- Your recurrent picking leaves skin lesions.
- You’ve repeatedly tried to stop.
- Your symptoms are causing significant distress or impairment.
- It’s not drug-induced or caused by some other physical condition.
- It’s not due to some other mental disorder.
Signs and symptoms may vary from one person to the next. Excoriated skin can leave sore or bloody patches. Some people’s excoriation exposes them to skin infections. Others have lasting spots and scars covering their bodies.
It can stymie people’s social life, too. You might avoid public places, like the pool or gym, because you’re embarrassed by your picked-over appearance.
And when others say, “Why don’t you just stop?” you may feel ashamed. People don’t want to pick, but “the urge is very strong,” says Desai.
Picking can also make daily activities more difficult. Some people’s private pick sessions make them late for school or work because they spend so much time doing it.
If you’re someone who always wears long sleeves to cover lesions on your arms, that may be a sign of excoriation disorder. On the other hand, if you’re scratching and bleeding because you have an itchy skin condition like eczema (atopic dermatitis), that’s dermatologic, not psychiatric, so you’ll need to be evaluated by your physician.
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Causes of skin picking
So why do people pick their skin? There’s no simple answer. Studies show picking runs in families, so there may be a genetic component. But even if you inherit a tendency to pick, other triggering factors are thought to play a role.
You might be stressed or bored or bothered by the look or feel of your skin. Picking at a bump to smooth away the imperfection may set off a vicious cycle of repeated picking.
It might be a mindless activity you do while watching television or reading.
Some people identify a “trance-like state, where they don’t feel like they’re in control,” says Desai.
Other people squeeze pimples and blackheads because they like to see what comes out of their body, Mouton-Odum explains. And some are interested in the taste. (Yes, there are people who eat the skin they pick.)
One way or another, it’s “gratifying some need,” Mouton-Odum says. Her job is to figure out what that need is to help people meet it in a different, non-injurious way.
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How to stop skin picking
Treatment for excoriation disorder and other BFRBs typically consists of talk therapy (also known as psychotherapy)—with or without medication.
If you want to stop picking, the first step is to find a therapist trained to provide cognitive behavioral therapy (CBT) for BFRBs. The TLC Foundation can help you find a mental health provider familiar with treating excoriation disorder and related conditions.
One type of CBT, called habit reversal training, teaches people to recognize when, why, and how they’re likely to pick and what to do instead to break the cycle. Clenching your fists at your sides for 60 seconds is a classic strategy, Desai says.
You’ll also learn where to turn for support (say, finding a hairdresser or skincare professional who will provide non-judgmental services).
ComB (short for Comprehensive Model for Behavioral Treatment) is another type of CBT that focuses on the needs that skin picking satisfies and the triggers that set off this behavior. If the bathroom mirror and nearby tweezers suck you into a face-picking session, the answer may be to change your environment, Mouton-Odum explains. You might dim the lights or cover the mirror, for example.
While there’s no medication specifically approved by the FDA for the treatment of BFRBs, some evidence suggests the nutritional supplement N-acetylcysteineis effective for excoriation disorder. Sometimes SSRIs (or selective serotonin reuptake inhibitors, which are commonly used as antidepressants) are prescribed.
Skin picking isn’t hopeless. It can be treated, but there’s no magic bullet. “You have to be willing to sit through an urge and not act on it,” Mouton-Odum says.
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