*Excoriation (skin picking) disorder*

Dear Colleague,

Did you know that Excoriation (skin picking) disorder is a new, separate, formal diagnosis in DSM-5?

It is included in the chapter on Obsessive-Compulsive and Related Disorders.

Its ICD-10 code is F42.4.

*Why is it important for mental health professionals to know about?*

1. Personal and social impairment can be significant in these persons.

2. Persons with skin picking disorder often use alcohol or other substances to cope with the skin picking.

3. Comorbid depression and anxiety are extremely common.

4. Comorbid OCD, trichotillomania, etc are also common.

*Diagnostic criteria*

The behavior of skin picking is quite common. As with many symptoms, it can range from mild to severe and at some point is called a “disorder.”

The DSM-5 diagnostic criteria for Excoriation (skin picking) disorder are relatively straightforward but let’s review them quickly. Here they are (reworded by me):

1. The person repeatedly engages in skin picking

2. The skin picking is bad enough to cause skin lesions

3. The person repeatedly tries to decrease or stop skin picking.

4. The skin picking causes the person significant distress or impairment in some way.

For example, skin picking behavior can take up several hours per day and the person’s work, school, and social life may suffer.

5. The skin picking is not due to substance use (e.g., cocaine) or another medical condition like scabies.

6. The skin picking is not better explained by symptoms of another mental disorder, e.g.,

– either delusions or tactile hallucinations

– attempts to improve a perceived defect or flaw in appearance by a person with body dysmorphic disorder

– stereotypies in stereotypic movement disorder, or

– intention to harm oneself (nonsuicidal self-injury).

*Excoriation (skin picking) disorder*

Dear Colleague,

Did you know that Excoriation (skin picking) disorder is a new, separate, formal diagnosis in DSM-5?

It is included in the chapter on Obsessive-Compulsive and Related Disorders.

Its ICD-10 code is F42.4.

*Why is it important for mental health professionals to know about?*

1. Personal and social impairment can be significant in these persons.

2. Persons with skin picking disorder often use alcohol or other substances to cope with the skin picking.

3. Comorbid depression and anxiety are extremely common.

4. Comorbid OCD, trichotillomania, etc are also common.

*Diagnostic criteria*

The behavior of skin picking is quite common. As with many symptoms, it can range from mild to severe and at some point is called a “disorder.”

The DSM-5 diagnostic criteria for Excoriation (skin picking) disorder are relatively straightforward but let’s review them quickly. Here they are (reworded by me):

1. The person repeatedly engages in skin picking

2. The skin picking is bad enough to cause skin lesions

3. The person repeatedly tries to decrease or stop skin picking.

4. The skin picking causes the person significant distress or impairment in some way.

For example, skin picking behavior can take up several hours per day and the person’s work, school, and social life may suffer.

5. The skin picking is not due to substance use (e.g., cocaine) or another medical condition like scabies.

6. The skin picking is not better explained by symptoms of another mental disorder, e.g.,

– either delusions or tactile hallucinations

– attempts to improve a perceived defect or flaw in appearance by a person with body dysmorphic disorder

– stereotypies in stereotypic movement disorder, or

– intention to harm oneself (nonsuicidal self-injury).

*Key clinical features of Excoriation (skin picking) disorder*

Here is a quick synopsis of its key clinical features:

About 75% or more of the patients with this disorder are female.

Often the skin picking starts with picking at acne or some other skin lesion, but the continues even when the original lesion is gone.

Initially, the skin picking tends to be unconscious but tends to become conscious later on.

Different persons have different triggers and it is usual to have multiple triggers. Triggers for skin picking may include stress, anxiety, not being occupied, being bored, tired, or angry, feeling a bump or blemish in the skin, etc.

The most common site of picking is the face, but many different parts of the body are commonly involved.

The patient may use makeup, bandages, etc. to conceal the self-inflicted skin lesions.

Many patients report feeling increasingly tense either immediately before picking at the skin or when trying to resist the urge to pick. Then, after picking the skin, they may feel relieved or even experience pleasure.

Excoriation (skin picking) disorder is often comorbid with OCD, body dysmorphic disorder, and trichotillomania. It can be a manifestation of OCD or body dysmorphic disorder, in which case it would not be separately diagnosed. But, it is important to realize that Excoriation (skin picking) disorder can also be a distinct disorder that requires separate assessment and treatment.

*How to treat excoriation (skin picking) disorder: Part one*

Before we can discuss the treatment of Excoriation disorder, we must note that in the short-term at least, this disorder tends to fluctuate over time and is subject to a considerable placebo effect. Inactive, control treatments lead to improvement in a significant proportion of patients. This means that we should completely ignore the numerous published clinical trials that did not have a placebo control group. It also means that if one of us has found a particular treatment to work for several patients, it does not mean anything. It may have been a placebo effect.

There are no FDA-approved medications for the treatment of Excoriation (skin picking) disorder. But have any medications been shown in randomized, placebo-controlled clinical trials to be efficacious for this disorder?

1. N-acetylcysteine, which improves extracellular glutamate concentration in the nucleus accumbens and is also an antioxidant, was shown in one placebo-controlled study to be efficacious . About half the patients showed clinically significant improvement on N-acetylcysteine; they were considered “much improved” or “very much improved” by clinicians. That’s pretty good for a disorder that does not respond well to medications. The N-acetylcysteine was started at 1200 mg/day and increased, if tolerated, to 3600 mg/day. Of course, we will have more confidence in the utility of this treatment when there is replication in at least one more placebo-controlled study.

*How to treat excoriation (skin picking) disorder: Part two*

What else can be tried?

2. Some support has been found for the efficacy of fluoxetine. While SSRIs do not seem to be great treatments for Excoriation disorder, they can be tried.

3. Lamotrigine was not found to be efficacious in the one and only randomized, controlled trial that has been conducted as of May 2017. However, I still mention it here because of the following. Given that lamotrigine needs to be titrated up and that some patients received low doses (as little as 12.5 mg/day), I think that this study does not rule out the potential efficacy of lamotrigine, which has been found to be efficacious in a previous open-label study.

What about non-pharmacological treatments? Two psychological treatments have been claimed to be efficacious for Excoriation disorder:

1. Cognitive-Behavior Therapy (CBT)

2. Habit Reversal Therapy (HRT)

These can be used but I want to make a methodological point. The clinical trials for these two treatments used wait-list controls, which I do not think is an adequate “placebo” control group. If some patients are monitored while they are waiting to start a treatment, this takes into account spontaneous fluctuation in the illness. But how is this a “placebo” in the sense that psychopharmacologists think of it, i.e., with positive suggestion and an expectation of improvement?