What is Excoriation (Skin Picking) Disorder?
The most distinguishing symptom of Excoriation (Skin Picking) Disorder (SPD) is the recurrent picking of one’s skin resulting in noticeable skin damage. Individuals pick from a variety of body areas (and often from multiple sites), but the most common are face, arms, and hands. Individuals may pick at healthy skin, minor skin imperfections, lesions, pimples, calluses, or at scabs that have formed from previous picking episodes. While most skin picking is done with the fingers, it not uncommon for individuals to use tools such as tweezers or pins. Individuals with SPD often spend at least 1 hour per day (sometimes several hours) picking their skin, thinking about their skin picking, and resisting the urge to pick. Pickers often report embarrassment or shame due to their picking behaviors and resulting appearance, as well as feeling a loss of control. SPD can also cause significant distress and impairment in various areas of functioning, such as the avoidance of social situations.
The triggers for skin picking can vary considerably between and within individuals. Some individuals with SPD engage in more focused skin picking associated with specific emotional correlates such as boredom or anxiety. Individuals with focused picking may also pick in response to an uncomfortable sensation in their body. Focused pickers often report tension before the picking episode, or when they try to resist the skin picking, and a sense of relief, pleasure or gratification following the episode. For other individuals, the picking may be much more automatic with lowered awareness regarding when they engage in skin picking. Most individuals with SPD experience a mix of both focused and automatic picking.
SPD affects about 1.4% of the general population. Research suggests that SPD has a tri-modal age of onset: before age 10, between ages 15-21, and between ages 30-45. SPD symptoms most commonly emerge during adolescence, and greater than 75% of those diagnosed with the disorder are female. While it is likely true that SPD affects more women than men, reported gender ratios may be artificially inflated by several factors, including different attitudes regarding appearance for males and females and a greater likelihood that women seek treatment than men.
SPD shares many features with other body-focused repetitive behaviors, such as trichotillomania (hair pulling disorder) or pathological nail biting. Additionally, there are many similarities between SPD and other obsessive compulsive spectrum disorders (i.e., Obsessive-Compulsive Disorder, Body Dysmorphic Disorder, and Tourette Syndrome).
Treatment for Excoriation Disorder
Current consensus suggests that CBT is the best treatment intervention for Excoriation (Skin-Picking) Disorder. A form of CBT called Habit Reversal Training (HRT) is considered to be the core approach. This treatment package includes:
- Habit Awareness Training to bring greater attention to picking behaviors
- Competing Motor Responses to engage in actions incompatible with skin picking (i.e., fist-clenching) when the urge to pick is present
- Relaxation Techniques to reduce stress and potential triggering of the behavior
- Social Support to provide positive feedback, encouragement, and reminders to practice coping skills
Stimulus control is another intervention used in the treatment of excoriation. Stimulus control is used to modify the environment to eliminate sensory input that would lead to skin picking or make it more difficult to engage in picking behavior. For example, if an individual tends to pick when they are alone, they may be encouraged to change their circumstances so that they spend more time around other people. Clinicians may also use other treatment approaches to augment HRT and stimulus control. One such approach is Acceptance and Commitment Therapy (ACT). The goal of ACT is to teach skin pickers that when one is feeling the urge to pick or experiences a negative emotion associated with picking, one can accept the urge or emotion without having to respond to it. Dialectic Behavior Therapy (DBT) is also often used to supplement CBT. DBT teaches pickers emotion regulation strategies, as well as methods to tolerate uncomfortable emotions and urges.
Research exploring the efficacy of psychopharmacological interventions in the treatment of skin picking disorder is limited and few randomized control trials exist. The serotonin reuptake inhibitors (SRIs), widely used in the treatment of depression, anxiety, and obsessive-compulsive disorder, may be effective in the treatment of skin picking. Specific medications which have been studied include fluoxetine (Prozac), citalopram (Celexa), escitalopram (Lexapro), fluvoxamine (Luvox), and sertraline (Zoloft). While the mechanism of action in skin picking is not well understood, it has been postulated that the SSRIs may reduce skin picking by targeting triggers like anxiety or depression.
N-acetylcysteine (NAC), naltrexone, olanzapine (Zyprexa), aripiprazole (Abilify), milk thistle and lithium are some of the less well-studied medications used to treat skin picking. Despite having limited research support, NAC and naltrexone are commonly used; these medications are also used to treat hair-pulling disorder, a condition with similar body-focused repetitive behavior.
For more general information regarding treatment, please read our Treatment Approaches page on our website.
How our program can help:
Our program specializes in evidence-based treatment for Excoriation (Skin Picking) Disorder with cognitive behavioral therapy (CBT) and medication. For more information, please contact our intake coordinator at 617-726-6766.
Excoriation Clinic and Research Unit
Nancy Keuthen, Ph.D., is the Director of the Massachusetts General Hospital Excoriation Clinic and Research Unit. Dr. Keuthen has extensive research experience studying skin picking. She developed several self-report scales to assess picking severity and impact, studied the efficacy of medication treatment for skin picking and documented prevalence rates for this disorder. She is currently a site PI for the TLC Foundation for Body Focused Repetitive Behavior Precision Medicine Initiative. The aim of this project is to identify potential subtypes of body-focused repetitive behaviors to enhance treatment outcomes. She has authored numerous journal articles and chapters on skin picking. Dr. Keuthen is an editor of the text Trichotillomania, Skin Picking and Other Body-Focused Repetitive Behaviors. Additionally, Dr. Keuthen serves as the Vice-Chair (formerly the Chair) of the Scientific Advisory Board of the TLC Foundation for BFRBs and is a member of the Scientific Advisory Board of the International OCD Foundation.
Lisa Zakhary, M.D., Ph.D., serves as the Director of Psychopharmacology in the Excoriation Clinic and Research Unit, and is an attending psychiatrist within the OCD and Related Disorders Program. As a psychiatry resident, Dr. Zakhary co-founded the MGH Comprehensive Skin Management Clinic, a combined psychiatry and dermatology clinic offering multidisciplinary treatment for skin picking and other psychodermatologic disorders. She has published research examining dermatologists’ practices when treating obsessive-compulsive related disorders including skin picking and was awarded the TLC Foundation for Body-Focused Repetitive Behaviors Resident Scholarship. In addition, she is an active educator and speaks internationally on the treatment of obsessive-compulsive and related disorders to audiences ranging from medical providers to the community.
Our mission involves the provision of state-of-the-art, empirically-based treatments for skin picking symptoms and the alleviation of suffering. Our clinic is committed to advancing the current treatments for Excoriation (Skin Picking) Disorder through our program of research. For more information, please read our Treatment Approaches page on our website or contact our intake coordinator at 617-726-6766.