Excoriation disorder

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] Associate Editor(s)-in-Chief: Kiran Singh, M.D. [2] Yashasvi Aryaputra[3]

Synonyms and keywords: Compulsive skin picking; CSP; dermatillomania; neurotic excoriation; psychogenic excoriation

Overview

Excoriation disorder (also known as dermatillomania, compulsive skin picking, neurotic excoriation, psychogenic excoriation, or CSP) is an impulse control disorder and form of self-injury characterized by the repeated urge to pick at one's own skin, often to the extent that damage is caused. Excoriation disorder may be related to body dysmorphic disorder (BDD).

Compulsive picking of the knuckles (via mouth) illustrating disfiguration of the distal and proximal joints of the middle and little fingers.

Sufferers of dermatillomania find skin picking to be stress relieving or gratifying, though it can still be as physically painful as it would be for a non-skin picker.

Classification

The inability to control the urge to pick is similar to trichotillomania. Recent research suggests that, like trichotillomania, dermatillomania may be an impulse control disorder. This is part of the obsessive compulsive disorder spectrum.

In some animal models, it has been shown that animals that who excessively pull their hairs have more endorphin receptors in their brain than animals who do not. Endorphin receptors enable endorphins to have an effect on the brain. If this is true for humans, people who are particularly compulsive about their repetitive habits may have more endorphin receptors in their brain as well. This may explain why sufferers get more enjoyment out of picking their scabs than others.

Pathophysiology

• Episodes of skin picking are often preceded or accompanied by tension, anxiety, stress, or paranoia. During these moments, there is commonly a compulsive urge to pick, bite, or scratch at a surface or region of the body, often at the location of a perceived skin defect. Sufferers may experience relief from upsetting emotions by engaging in skin picking.

• 

  Skin Picking results on arms, shoulders and chest are visible. While this look can be a social disturbance, it is also a time-consuming habit.

• The regions most commonly affected by this are the face, back, scalp, stomach, chest, and extremities such as the hands, feet, and arms. Physical indicators of dermatillomania most commonly expressed in these areas are swelling, scarring, and callusing due to damage to the affected region's epidermis.

• Aware of the damage they are inflicting, many sufferers feel and recognize a need to stop the behavior but are physically and mentally unable to do so without aid. Additionally, the behavior's addict-like characteristics are very similar to the expression of trichotillomania, or the compulsive pulling of hair from the body.

• Many dermatillomania sufferers find that the disorder interferes with daily life. Plagued by shame, embarrassment, and humiliation, they may take measures to hide their disorder by not leaving the home, wearing long sleeves and pants in summer, or covering visible damage to skin with cosmetics and/or bandages. The disorder is typically found among females more than males.

Differential Diagnosis

Excoriation disorder must be differentiated from:

• Neurodevelopmental disorders

• Prader-Willi syndrome
• Tourette's disorder

• Other obsessive-compulsive and related disorders

• Body dysmorphic disorder

• Other disorders
• Other medical conditions

• Acne
• Scabies

• Psychotic disorder

• Delusion
• Tactile hallucination

• Somatic symptom and related disorders

• Factitious disorder

• Substance/medication-induced disorders

• Cocaine

Epidemiology and Demographics

Prevalence

The prevalence of excoriation (skin-picking) disorder is 1,400 per 100,000 (1.4%) of the overall population.

Risk Factors

• Genetic predisposition
• Obsessive-compulsive disorder(OCD)

Diagnostic Criteria

DSM-V Diagnostic Criteria for Excoriation (Skin-Picking) Disorder

“

A. Recurrent skin picking resulting in skin lesions. AND B. Repeated attempts to decrease or stop skin picking. AND C. The skin picking causes clinically significant distress or impairment in social, occupational, or other important areas of functioning. AND D. The skin picking is not attributable to the physiological effects of a substance (e.g.,cocaine) or another medical condition (e.g., scabies). AND E. The skin picking is not better explained by symptoms of another mental disorder (e.g., delusions or tactile hallucinations in a psychotic disorder, attempts to improve a perceived defect or flaw in appearance in body dysmorphic disorder, stereotypies in stereotypic movement disorder, or intention to harm oneself in non suicidal self-injury).

”

Laboratory Findings

• There is no information regarding laboratory studies for excoriation disorder.

Other Imaging Studies

• There are no other imaging findings associated with excoriation disorder.

Other Diagnostic Studies

There are no other diagnostic studies associated with excoriation disorder.

Medical Therapy

Few mental health practitioners have studied the disease, as many of these cases go unreported, but some individuals have found relief through cognitive-behavioral therapy. Hypnosis, self-hypnosis and meditation have also been useful for some patients. They are also sometimes prescribed medications, such as those prescribed for obsessive compulsive disorder. For example, artificial fingernails (acrylic or gel) have been found to be useful to some in stopping the picking behavior.

Psychotherapy

• Habit reversal training, acceptance and commitment therapy, acceptance-enhanced behavioral therapy, and cognitive behavioral therapy were all used to help treat excoriation disorder.

• These strategies help reduce skin picking behavior in individuals with excoriation disorder, but no psychological issues.

Brain Stimulation Therapy

• There is no brain stimulation therapy associated with excoriation disorder.

References

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