Skin-picking disorder

Skin-picking disorder (excoriation disorder or dermatillomania) is a body-focused repetitive behavior (BFRB) where an individual compulsively picks at their skin, causing tissue damage and significant distress. Treatment often involves a combination of therapy, medication, and self-help strategies. 

Symptoms

The primary symptom is recurrent, compulsive picking of the skin, including healthy skin, blemishes, or scabs, often using fingernails, but sometimes tools like tweezers. This leads to: 

• Visible skin lesions, open wounds, bleeding, and bruising.

• Scarring, permanent skin damage, and, in severe cases, dangerous infections like sepsis that may require surgery or skin grafts.

• Feelings of shame, embarrassment, and guilt, leading to social isolation or avoidance of certain activities (e.g., swimming, dating).

• Repeated unsuccessful attempts to stop the behavior. 

Causes

The exact cause is unknown, but contributing factors may include:

• Genetics A family history of TTM or excoriation disorder is a risk factor.

• Brain function Differences in brain areas related to habit formation and motor control have been noted.

• Coping mechanism Picking can be a response to stress, anxiety, boredom, or negative emotions, providing a temporary sense of relief or gratification.

• Co-occurring conditions The disorder is often linked with anxiety, depression, or obsessive-compulsive disorder (OCD). 

Treatments

The most effective approach often involves both behavioral therapy and medical interventions. 

• Habit Reversal Training (HRT): This specialized CBT technique is considered the "gold standard" for BFRBs. It involves:

  • Awareness training Identifying triggers and early warning signs of picking urges.

  • Competing response training Learning alternative, less harmful behaviors to perform when the urge arises (e.g., clenching fists, using a stress ball, or engaging in a craft like knitting).

  • Stimulus control Modifying the environment to make picking more difficult, such as wearing gloves, keeping nails short, or covering frequently picked areas with bandages or hydrocolloid dressings.

• Other Therapies:

  • Cognitive Behavioral Therapy (CBT) Addresses underlying unhelpful thoughts and beliefs related to skin picking and develops healthy coping strategies.

  • Acceptance and Commitment Therapy (ACT) Teaches mindfulness strategies and acceptance of uncomfortable thoughts and feelings without engaging in the picking behavior.

  • Support Groups Connecting with others who have the condition can reduce feelings of isolation and provide valuable advice and encouragement. The TLC Foundation for BFRBs offers resources and support.

• Medication: There are currently no FDA-approved medications specifically for excoriation disorder, but certain medications can help manage symptoms or co-occurring conditions.

  • Selective Serotonin Reuptake Inhibitors (SSRIs) Antidepressants like fluoxetine, sertraline, or citalopram are commonly used and can reduce the severity and frequency of picking symptoms.

  • N-acetylcysteine (NAC) This over-the-counter amino acid supplement modulates brain chemistry and has shown significant promise in clinical studies for reducing picking urges.

  • Other options Anti-epileptic medications (lamotrigine, topiramate) or opioid antagonists (naltrexone) have also been explored with varying success. 

If the condition is causing physical harm, it is also important to see a dermatologist or primary care provider to treat any skin injuries or infections with antibiotics or other topical agents.