OVERVIEW

What kind of disease is excoriation disorder?

Excoriation disorder, also known as skin picking disorder (SPD), is a condition characterized by repeated scratching or picking of the skin, leading to tissue damage.

Patients often experience significant distress and attempt to stop the behavior but struggle with self-control. Many feel ashamed to admit their picking habits and avoid seeking medical help, often visiting dermatologists only for skin lesions.

How common is excoriation disorder?

The prevalence of excoriation disorder is approximately 1.25%–5.4%, with women accounting for about 75% of cases. It can develop at any age, with the peak onset between 12–16 years old, often triggered by skin conditions like acne or pimples.

SYMPTOMS

What are the symptoms and manifestations of excoriation disorder?

The core symptom of excoriation disorder is recurrent skin picking leading to lesions. Common areas include the face, arms, and hands. The picked areas may initially have minor imperfections, but previously picked or even normal skin can also be targeted.

Picking behaviors often occur when alone or only with family members and may be unconscious. Ritualistic actions frequently accompany picking, such as rubbing the removed skin between fingers.

Studies show about 32%–35% of patients ingest the picked skin, while a small portion may pick at others' skin. Episodes typically occur intermittently throughout the day, worsening at night and sometimes even during sleep.

Some patients experience temporary relief from anxiety after picking, followed by shame or embarrassment. Mood disorders, anxiety, eating disorders, and substance use disorders are common comorbidities.

Patients may conceal severely affected areas with makeup or clothing and avoid public settings due to embarrassment, leading to school or work absenteeism. Repeated picking can cause infections or severe skin damage requiring surgical intervention.

If you have excoriation disorder, managing symptoms alongside lifestyle adjustments like meditation or exercise can help. Professional counseling may assist in emotional recovery. If someone you know has this condition, offer them understanding and support.

CAUSES

What is the etiology of excoriation disorder?

The specific pathogenesis and underlying causes of excoriation disorder remain unclear. Current research suggests it may be related to genetic factors, neuroanatomical abnormalities, environmental factors (such as stress and trauma), and other aspects.

DIAGNOSIS

How is excoriation disorder diagnosed?

A clinical diagnosis of excoriation disorder requires meeting the following criteria.

• Recurrent skin picking resulting in skin lesions.

• Repeated attempts to reduce or stop skin picking.

• The condition causes significant distress or impairment in social, occupational, or other important areas of functioning.

• The skin picking cannot be attributed to the physiological effects of a substance, a medical condition, or another mental disorder. Examples include cocaine-induced skin picking, scabies or acne-related scratching, delusions or tactile hallucinations in psychotic disorders, attempts to improve perceived defects in body dysmorphic disorder, or nonsuicidal self-injury.

Is excoriation disorder a type of OCD? What conditions should it be differentiated from, and how?

Excoriation disorder is classified as an obsessive-compulsive and related disorder. It should be differentiated from the following conditions:

• Psychotic disorders: Skin picking may occur in psychotic disorders but is typically a response to delusions or tactile hallucinations, unlike excoriation disorder.
• Other obsessive-compulsive and related disorders: In individuals with OCD, compulsive washing due to contamination obsessions may lead to skin damage. Similarly, those with body dysmorphic disorder may pick their skin due to appearance concerns. These differ from excoriation disorder.
• Neurodevelopmental disorders: Stereotypic movement disorder in neurodevelopmental disorders involves repetitive self-injurious behaviors, including skin picking, but these emerge in early development and align with stereotypic symptoms. Tourette syndrome may also cause self-injury through tics, but excoriation disorder behaviors are not tic-like.
• Other medical conditions: If skin picking is caused by dermatological conditions (e.g., scabies, acne), it is not excoriation disorder.
• Substance/medication-induced disorders: If skin picking results from substance use (e.g., cocaine), it is not excoriation disorder.

TREATMENT

What department should I see for excoriation disorder?

Psychiatry or mental health department.

How is excoriation disorder treated?

• Psychotherapy: Cognitive behavioral therapy (CBT) has shown relatively positive efficacy for excoriation disorder. Intervention strategies mainly include:

  • Education on mental health and disease knowledge;

  • Correcting distorted cognition in patients, such as replacing "I can't resist the urge to scratch" with "I believe the scratching urge will soon disappear," or replacing "I'll just take a look or touch lightly" with "Looking or touching increases the likelihood of scratching";

  • Strengthening self-control, such as using gloves to isolate fingers from the skin, or employing distraction techniques to delay scratching (e.g., cleaning the house, going for a walk, meeting friends);

  • Learning to recognize signs of relapse.

• Medication: SSRIs and lamotrigine may be effective for excoriation disorder, though their efficacy remains uncertain, and current research findings are controversial.

• Symptomatic treatment: For patients with severe itching, potent topical corticosteroids or intralesional triamcinolone therapy is recommended. Patients with excoriated acne should actively treat the underlying acne. Those with skin infections should receive topical and/or systemic antibiotics.

DIET & LIFESTYLE

What should patients with excoriation disorder pay attention to in daily life and diet?

First, maintain personal hygiene. Common physical comorbidities of excoriation disorder include tissue damage, scarring, and infections. Therefore, keeping the skin clean and fingernails short can reduce potential harm caused by skin injuries.

Second, excoriation disorder is often accompanied by certain skin conditions (such as acne), so proper skincare and medical attention for these conditions are essential.

Additionally, excoriation disorder is closely linked to emotional state and stress levels. Thus, maintaining a healthy diet (e.g., eating more vegetables, fruits, and fiber-rich foods while avoiding fast food) and a balanced mindset are crucial.

PREVENTION

How to prevent excoriation disorder?

Master healthy stress-coping methods and maintain emotional well-being.

Apart from genetic factors, scratching behavior is heavily influenced by emotions and stress—it may accompany various emotional states (such as anxiety, boredom, or escalating stress). Meanwhile, some patients feel scratching temporarily relieves stress and physical discomfort.

Thus, through stress management and cultivating a positive mindset, scratching behavior can be alleviated to some extent, helping prevent excoriation disorder.