Excoriation disorder, more commonly known as dermatillomania, is a mental disorder on the obsessive–compulsive spectrum that is characterized by the repeated urge or impulse to pick at one's own skin, to the extent that either psychological or physical damage is caused. The exact causes of this disorder are unclear but are believed to involve a combination of genetic, psychological, and environmental factors, including stress and underlying mental health conditions such as anxiety or obsessive-compulsive disorder (OCD). In some cases, following picking, the affected person may feel depressed. Severe cases of excoriation disorder can cause life-threatening injuries. According to one reported case, a woman picked a hole through the bridge of her nose, which required surgery to fix, and a 48-year-old woman picked through the skin on her neck, exposing the carotid artery. Pain in the neck or back can arise due to prolonged bent-over positions while engaging in the behavior. Besides physical injuries, excoriation disorder can cause severe physical scarring and disfigurement.

A common hypothesis is that excoriation disorder is often a coping mechanism to deal with elevated levels of turmoil, boredom, anxiety, or stress within the individual, and that the individual has an impaired stress response.

People who have excoriation disorder along with other diagnosed conditions report differing motivations for their picking. Those with both OCD and excoriation disorder report that they will pick their skin due to perceived contamination of the skin, while those with both BDD and excoriation disorder reportedly pick to fix perceived imperfections in the skin. This observation led researchers to study the effects of the SAPAP3 gene on patients with trichotillomania—a disorder marked by the same behaviors directed at one's own head and body hair. This study revealed a significant link between a single nucleotide polymorphism (SNP) within the SAPAP3 gene and trichotillomania. Two of the main reasons for objecting to the inclusion of excoriation disorder in the DSM-5 are: that excoriation disorder may just be a symptom of a different underlying disorder, e.g. OCD or BDD, and excoriation disorder is merely a bad habit and that by allowing this disorder to obtain its own separate category it would force the DSM to include a wide array of bad habits as separate syndromes, e.g., nail-biting, nose-picking, hair pulling, etc.

  • Excoriation disorder occurs as the primary disorder and not as a subset of a larger disorder.
  • Excoriation disorder has well-defined clinical features.
  • There is gathering data on the clinical features and diagnostic criteria for this condition.
  • There is sufficient data to create this as a separate category for excoriation disorder.
  • The incidence rate for excoriation disorder is high within the population.
  • Diagnostic criteria for the disease have already been proposed.
  • The classification of excoriation disorder as a separate condition would lead to better studies and better treatment outcomes.
  • Classification as a separate condition would lead to more awareness of the disorder and encourage more people to obtain treatment. Initial results from the study (n = 120) participants show clinical confirmation at a satisfactory level with 88% of participants identified through the DISP as meeting DSM-5 criteria. Additionally, researchers conducted a 5-month period of validity to determine consistency with the scale. The data shows clinicians can expect to yield consistent data with administration of the scale ranging from satisfactory to perfect levels of diagnosis.

As of the release of the fifth Diagnostic and Statistical Manual of Mental Disorders (DSM-5) in May 2013, this disorder is classified as its own separate condition under "Obsessive Compulsive and Related Disorders" and is termed "excoriation (skin-picking) disorder". The diagnostic material is as follows:

  1. Repeated picking of the skin, resulting in injuries
  2. Recurring attempts to stop picking while relapses continually occur
  3. Picking causes a substantial amount of distress and substantially impairs everyday functioning
  4. The picking is not caused or cannot be better explained by physiological effects of a substance or a medical disorder
  5. The picking is not more accurately attributed to another mental disorder

Classification

Since the DSM-5 (2013), excoriation disorder is classified as "L98.1 Excoriation (skin-picking) disorder" in ICD-10, and is no longer classified in "Impulse control disorder" (f63).

Excoriation disorder is defined as "repetitive and compulsive picking of skin which results in tissue damage". There is also a high level of comorbidity between those that have trichotillomania and those that have excoriation disorder. One shared behavior is continued picking as an emotional or reward sensation. This involves the picking to resolve negative thoughts or emotions or a developed behavior of automatic picking. This automatic picking becomes habitual and is a comorbidity with ADHD. Participants were screened by clinical staff in clinics supporting patients with Tourette Syndrome. Those patients included then completed self-report questionnaires. Of the total number of TS participants (n = 811), 13% revealed diagnosis of trichotillomania and excoriation.

Reviews of treatment of excoriation disorder have shown that the following medications may be effective in reducing picking behavior: doxepin, clomipramine, naltrexone, pimozide, and olanzapine.

Topiramate, an anti-epileptic drug, has been used to treat excoriation disorder; in a small study of individuals with Prader–Willi syndrome, it was found to reduce skin picking.

Several studies have shown that habit reversal training associated with awareness training reduces skin-picking behavior in those individuals with excoriation disorder that do not have psychological problems. In an absence of longitudinal data which follows patients with psychiatric referrals as a result of ED, little is known for the reasons patients do not follow through with the referral, or what more is needed to ensure access to care. Overall, less than 25% of participants in this study achieved long term results, highlighting the need for a collaborative team approach to treatment across several disciplines to include PCP, dermatology, psychology, and psychiatry as needed.

Developmentally disabled

Several different behavioral interventions have been tested to treat excoriation disorder in those with developmental disabilities.

One method is to have individuals wear a form of protective clothing that limits the ability of the patient to pick at their body, e.g., gloves or face mask.

Prognosis

Typically, individuals with excoriation disorder find that the disorder interferes with daily life. Hindered by shame, embarrassment, and humiliation, they may take measures to hide their disorder by not leaving home, wearing long sleeves and pants even in the heat, or covering visible damage to the skin with cosmetics and/or bandages. When untreated, excoriation disorder can last anywhere from 5 to 21 years. However, many doctors consider this disorder to be a permanent diagnosis. Excoriation has been documented as showing active from an onset in childhood and remaining active through adulthood.

Excoriation disorder has a high rate of comorbidity with other psychiatric conditions, especially with mood and anxiety disorders.

In a 2020 Study of Excoriation to identify the variable's such as: demographics, SES, marital status, and gender, more than 75% of participants were identified as female, more than 45% of all participants were unemployed, and more than 60% had marital status which ranged from being single to divorced or widowed. The first known mention of excoriation disorder in print can be found in 1898 by the French dermatologist Louis-Anne-Jean Brocq, describing an adolescent female patient who had uncontrolled picking of acne. Although the condition was first identified in the 19th century, it remains poorly understood. Much of the existing knowledge about the disorder comes from online surveys rather than in-person clinical evaluations.

Society and culture

Excoriation disorder has been the subject of several episodes of Obsessed, a television documentary series that focuses on the treatment of anxiety disorders.

Excoriation disorder is shown as a symptom of Nina Sayers' anxiety and OCD in the movie Black Swan.

During the 2021 Miss America competition, Miss Alaska 2021 Emma Broyles highlighted her vulnerability and openness on social media about having attention deficit hyperactivity disorder and dermatillomania, as well as her history with volunteering for the Special Olympics. She was crowned Miss America 2022.

See also

  • Dermatophagia
  • Morgellons
  • Trichotillomania, a similar compulsive behaviour, characterized by pulling out hair or eyelashes
  • Impulse-control disorder
  • Body-focused repetitive behavior

References

Further reading