Skin-Picking Disorder: A Guide to Diagnosis and Management

Abstract

Skin-picking disorder, also known as excoriation disorder or psychogenic skin excoriations, is an obsessive–compulsive and related disorder that is classified with other body-focused repetitive-behavior disorders in the most recent edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5). Skin-picking disorder is associated with significant comorbidity and psychosocial dysfunction. The disorder has a female predominance across studies, and the average age of onset is variable but commonly in adolescence and adulthood. A full clinical and dermatologic examination and multidisciplinary approach is important in the diagnosis of this condition. There is no specific or recommended treatment option, but cognitive–behavioral therapy, particularly habit-reversal therapy and acceptance and commitment therapy have shown promise. Various pharmacological interventions have also been described to treat this condition in case reports and open and controlled trials. Specific classes of agents implemented include selective serotonin reuptake inhibitors (SSRIs), serotonin-norepinephrine reuptake inhibitors, antipsychotics, and glutaminergic-modulating agents. SSRIs and N-acetylcysteine have been shown to be the most effective of the pharmacological interventions.

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References

  1. 1.

    Arnold LM, Auchenbach MB, McElroy SL. Psychogenic excoriation. CNS Drugs. 2001;15(5):351–9.

    CAS  PubMed  Article  Google Scholar 

  2. 2.

    Wilson E. Lectures on dermatology. Delivered in the Royal College of Surgeons of England, 1874–1875. London: J and A Churhil; 1875.

    Google Scholar 

  3. 3.

    Bach M, Bach D. Psychiatric and psychometric issues in acné excoriée. Psychother Psychosom. 1993;60(3–4):207–10.

    CAS  PubMed  Article  Google Scholar 

  4. 4.

    Diagnostic and Statistical Manual of Mental Disorders (DSM-5) Washington DC: American Psychiatric Association. 2013.

  5. 5.

    Misery L, Chastaing M, Touboul S, et al. Psychogenic skin excoriations: diagnostic criteria, semiological analysis and psychiatric profiles. Acta Derm Venereol. 2012;92(4):416–8.

    PubMed  Article  Google Scholar 

  6. 6.

    Koo JYM, Lee CS. General approach to evaluating psychodermatological disorders. In: Koo JYM, Lee CS, editors. Psychocutaneous medicine. New York: Marcel Dekker, Inc.; 2003. p. 1–29.

    Google Scholar 

  7. 7.

    Jafferany M, Franca K. Psychodermatology: basics concepts. Acta Derm Venereol. 2016;96(217):35–7.

    PubMed  Google Scholar 

  8. 8.

    Houghton DC, Alexander JR, Bauer CC, et al. Body-focused repetitive behaviors: more prevalent than once thought? Psychiatry Res. 2018;2(270):389–93.

    Article  Google Scholar 

  9. 9.

    Hayes SL, Storch EA, Berlanga L. Skin picking behaviors: an examination of the prevalence and severity in a community sample. J Anxiety Disord. 2009;23(3):314–9.

    PubMed  Article  Google Scholar 

  10. 10.

    Keuthen NJ, Koran LM, Aboujaoude E, Large MD, Serpe RT. The prevalence of pathologic skin picking in US adults. Compr Psychiatry. 2010;51(2):183–6.

    PubMed  Article  Google Scholar 

  11. 11.

    Machado MO, Köhler CA, Stubbs B, et al. Skin picking disorder: prevalence, correlates, and associations with quality of life in a large sample. CNS Spectr. 2018;23(5):311–20.

    PubMed  Article  Google Scholar 

  12. 12.

    Ricketts EJ, Snorrason Í, Kircanski K, et al. A latent profile analysis of age of onset in pathological skin picking. Compr Psychiatry. 2018;87:46–52.

    PubMed  Article  Google Scholar 

  13. 13.

    Gupta A, Jafferany M. Psychocutaneous disease. In: Sadock BJ, Sadock VA, Ruiz P, editors. Kaplan and Sadock’s comprehensive textbook of psychiatry. 10th ed. Philadelphia: Lippincott William & Wilkins; 2000.

    Google Scholar 

  14. 14.

    Cyr PR, Dreher GK. Neurotic excoriations. Am Fam Physician. 2001;64(12):1981–4.

    CAS  PubMed  Google Scholar 

  15. 15.

    Lochner C, Roos A, Stein DJ. Excoriation (skin-picking) disorder: a systematic review of treatment options. Neuropsychiatr Dis Treat. 2017;14(13):1867–72.

    Article  Google Scholar 

  16. 16.

    Odlaug BL, Grant JE. Pathologic skin picking. In: Grant JE, Stein DJ, Woods DW, Keuthen NJ, editors. Trichotillomania, Skin Picking and Other Body-Focused Repetitive Behaviors. Washington, DC: American Psychiatric Publishing Inc; 2012. p. 21–41.

    Google Scholar 

  17. 17.

    Solley K, Turner C. Prevalence and correlates of clinically significant body-focused repetitive behaviors in a non-clinical sample. Compr Psychiatry. 2018;86:9–18.

    PubMed  Article  Google Scholar 

  18. 18.

    Sampaio DG, Grant JE. Body-focused repetitive behaviors and the dermatology patient. Clin Dermatol. 2018;36(6):723–7.

    PubMed  Article  Google Scholar 

  19. 19.

    Odlaug BL, Kim SW, Grant JE. Quality of life and clinical severity in pathological skin picking and trichotillomania. J Anxiety Disord. 2010;24(8):823–9.

    PubMed  Article  Google Scholar 

  20. 20.

    Snorrason I, Smári J, Olafsson RP. Emotion regulation in pathological skin picking: findings from a non-treatment seeking sample. J Behav Ther Exp Psychiatry. 2010;41(3):238–45.

    PubMed  Article  Google Scholar 

  21. 21.

    Flessner CA, Woods DW. Phenomenological characteristics, social problems, and the economic impact associated with chronic skin picking. Behav Modif. 2006;30(6):944–63.

    PubMed  Article  Google Scholar 

  22. 22.

    Mutasim DF, Adams BB. The psychiatric profile of patients with psychogenic excoriation. J Am Acad Dermatol. 2009;61(4):611–3.

    PubMed  Article  Google Scholar 

  23. 23.

    Gupta M. Body-focused repetitive behaviors (BFRB) (trichotillomania, skin picking, onychophagia) and eating disorders (ED): Preliminary findings in a nondermatologic sample. J Am Acad Dermatol. 2016;74(5):46.

    Google Scholar 

  24. 24.

    Neziroglu F, Rabinowitz D, Breytman A, et al. Skin picking phenomenology and severity comparison. Prim Care Companion J Clin Psychiatry. 2008;10(4):306–12.

    PubMed  PubMed Central  Article  Google Scholar 

  25. 25.

    Tucker BT, Woods DW, Flessner CA, et al. The Skin Picking Impact Project: phenomenology, interference, and treatment utilization of pathological skin picking in a population-based sample. J Anxiety Disord. 2011;25(1):88–95.

    PubMed  Article  Google Scholar 

  26. 26.

    Koblenzer CS, Gupta R. Neurotic excoriations and dermatitis artefacta. Semin Cutan Med Surg. 2013;32(2):95–100.

    PubMed  Article  Google Scholar 

  27. 27.

    Jafferany M, Stoep AV, Dumitrescu A, Hornung RL. Psychocutaneous dis- orders: a survey study of psychiatrists’ awareness and treatment patterns. South Med J. 2010;103:1199–203.

    PubMed  Article  Google Scholar 

  28. 28.

    Jafferany M, Stoep AV, Dumitrescu A, Hornung RL. The knowledge, awareness, and practice patterns of dermatologists toward psychocutaneous dis- orders: results of a survey study. Int J Dermatol. 2010;49:784–9.

    PubMed  Article  Google Scholar 

  29. 29.

    Franklin ME, Tolin DF. In treating trichotillomania: cognitive behavioral therapy for hair pulling and related problems. New York: Springer; 2010. p. 51.

    Google Scholar 

  30. 30.

    Teng EJ, Woods DW, Twohig MP. Habit reversal as a treatment for chronic skin picking: a pilot investigation. Behav Modif. 2006;30(4):411–22.

    PubMed  Article  Google Scholar 

  31. 31.

    Mouton SG, Stanley MA. Habit reversal training for trichotillomania: a group approach. Cogn Behav Pract. 1999;3(1):159–82.

    Article  Google Scholar 

  32. 32.

    Lerner J, Franklin ME, Meadows EA, et al. Effectiveness of a cognitive behavioral treatment program fro trichotillomania: an uncontrolled evaluation. Behav Ther. 1998;29(1):157–71.

    Article  Google Scholar 

  33. 33.

    Van Minnen A, Hoogduin KA, Keijsers GP. Treatment of trichotillomania with behavioral therapy or fluoxetine: a randomized, waiting-list controlled study. Arch Gen Psychiatry. 2003;60(5):517–22.

    PubMed  Article  Google Scholar 

  34. 34.

    Woods DW, Wetterneck CT, Flessner CA. A controlled evaluation of acceptance and commitment therapy plus habit reversal for trichotillomania. Behav Res Ther. 2006;44(5):639–56.

    PubMed  Article  Google Scholar 

  35. 35.

    Keuthen NJ, Rothbaum BO, Falkenstein MJ, et al. DBT-enhanced habit reversal treatment for trichotillomania: 3- and 6-month follow up results. Depress Anxiety. 2011;28(4):310–3.

    PubMed  Article  Google Scholar 

  36. 36.

    Relaxation Shenefelt PD. meditation and hypnosis for skin disorders and procedure. In: de Luca BN, editor. Mind-body and relaxation research focus. Hauppauge: Nova Science Publishers; 2008. p. 45–63.

    Google Scholar 

  37. 37.

    Flessner CA, Busch AM, Heideman PW, et al. Acceptance-enhanced behavior therapy (AEBT) for trichotillomania and chronic skin picking: exploring the effects of component sequencing. Behav Modif. 2008;32:579–94.

    PubMed  Article  Google Scholar 

  38. 38.

    Shedler J. The efficacy of psychodynamic psychotherapy. Am Psychol. 2010;65:98–109.

    PubMed  Article  Google Scholar 

  39. 39.

    Hayes SC. Acceptance and Commitment Therapy and the New Behavior Therapies: Mindfulness, Acceptance, and Relationship. In: Hayes SC, Follette VM, Linehan MM, editors. Mindfulness and acceptance: Expanding the cognitive-behavioral tradition. New York: Guilford Press; 2004. p. 1–29.

    Google Scholar 

  40. 40.

    Fjorback LO. Mindfulness and body distress. Dan Med J. 2012;59:B4547.

    PubMed  Google Scholar 

  41. 41.

    Merakou K, Tsoukas K, Stavrinos G, et al. The effect of progressive muscle relaxation on emotional competence: depression-anxiety-stress-sense of coherence-health related quality of life and well being of unemployed people in Greece: an intervention study. Explore (NY). 2019;15(1):38–46. https://doi.org/10.1016/j.explore.2018.08.001.

    Article  Google Scholar 

  42. 42.

    Schumer MC, Bartley CA, Bloch MH. Systematic review of pharmacological and behavioral treatments of skin picking disorder. J Clin Psychopharmacol. 2016;36(2):147–52.

    CAS  PubMed  PubMed Central  Article  Google Scholar 

  43. 43.

    Gelinas BL, Gagnon MM. Pharmacological and psychological treatments of pathological skin-picking: a preliminary meta-analysis. J Obsessive Compuls Rel Disord. 2013;2(2):167–75.

    Article  Google Scholar 

  44. 44.

    Selles RR, McGuire JF, Small BJ. A systematic review and meta-analysis of psychiatric treatments for excoriation (skin-picking) disorder. Gen Hosp Psychiatry. 2016;41:29–37.

    PubMed  Article  Google Scholar 

  45. 45.

    Simeon D, Stein DJ, Gross S, et al. A double -blind trial of fluoxetine in pathological skin picking. J Clin Psychiatry. 1997;58:341–7.

    CAS  PubMed  Article  Google Scholar 

  46. 46.

    Sharma H. Psychogenic excoriation responding to fluoxetine; A case report. J Indian Med Assoc. 2008;106(4):245–62.

    PubMed  Google Scholar 

  47. 47.

    Bloch MR, Elliott M, Thompson H, et al. Fluoxetine in pathological skin picking: open label and double-blind results. Psychosomatics. 2001;42(4):314–9.

    CAS  PubMed  Article  Google Scholar 

  48. 48.

    Keuthen NJ, Jameson M, Loh R, et al. Open label trial of Escitalopram treatment for pathological skin picking. Int Clin Psychopharmacol. 2007;22(5):268–74.

    PubMed  Article  Google Scholar 

  49. 49.

    Arbabi M, Farnia V, Balighi K, et al. Efficiency of Citalopram in treatment of pathological skin picking: a randomized double-blind placebo controlled trial. Acta Med Iran. 2008;46(5):367–72.

    Google Scholar 

  50. 50.

    Kalivas J, Kalivas L, Gilman D, et al. Sertraline in the treatment of neurotic excoriations and related disorders. Arch Dermatol. 1996;132(5):589–90.

    CAS  PubMed  Article  Google Scholar 

  51. 51.

    Biondi M, Arcangeli T, Petrucci RM. Paroxetine in a case of psychogenic pruritus and neurotic excoriation. Psychother Psychosom. 2000;69:165–6.

    CAS  PubMed  Article  Google Scholar 

  52. 52.

    Ravindran AV, Lapierre YD, Anisman H. Obsessive compulsive spectrum disorders:effective treatment with paroxetine. Can J Psychiatry. 1999;44:805–7.

    CAS  PubMed  Article  Google Scholar 

  53. 53.

    Harris BA, Sherertz EF, Flowers FP. Improvement of chronic neurotic excoriations with oral doxepin therapy. Int J Dermatol. 1978;26:541–3.

    Article  Google Scholar 

  54. 54.

    Arnold LM, Mutasim DF, Dwight MM, et al. An open clinical trial of fluvoxamine treatment of psychogenic excoriation. J Clin Psychopharmacol. 1999;19(1):15–8.

    CAS  PubMed  Article  Google Scholar 

  55. 55.

    Hafeez ZH. Resolution of pathological skinpicking with fluvoxamine in a 74-year-old dementia patient. Prim Care Companion CNS disord. 2016. https://doi.org/10.4088/PCC.15l01844.

    PubMed  PubMed Central  Article  Google Scholar 

  56. 56.

    Roi C, Bazzano A. Improvement in skin excoriation (skin picking) with use of Risperidone in a patient with developmental diability. Pediatr Rep. 2017;9(1):6946.

    PubMed  PubMed Central  Article  Google Scholar 

  57. 57.

    Christensen RC. Olanzapine augmentation of fluoxetine in the treatment of pathological skin picking. Can J Psychiatry. 2004;49(11):788–9.

    PubMed  Article  Google Scholar 

  58. 58.

    Garnis-Jones S, Collins S, Rosenthal D. Treatment of self-mutilation with Olanzapine. J Cut Med Surg. 2000;4(3):161–3.

    CAS  Google Scholar 

  59. 59.

    Spiegel DR, Finklea L. The recognition and treatment of pathological skin picking. A potential neurobiological underpinning of the efficacy of pharmacotherapy in impulse control disorders. Psychiatry. 2009;6(2):38–42.

    PubMed  Google Scholar 

  60. 60.

    Pittenger C, Bloch MH, Williams K. Glutamate abnormalities in obsessive-compulsive disorder: neurobiology, pathophysiology and treatment. Phamacol Ther. 2011;132(3):314–32.

    CAS  Article  Google Scholar 

  61. 61.

    Grados MA, Atkins EB, Kovacikova GI, et al. A selective review of glutamate pharmacological therapy in obsessive compulsive and related disorders. Psychol Res Behav Manag. 2015;8:115–31.

    PubMed  PubMed Central  Article  Google Scholar 

  62. 62.

    Pittenger C. Glutamatergic agents for OCD and related disorders. Curr Treat Options Psychiatry. 2015;2(3):271–83.

    PubMed  PubMed Central  Article  Google Scholar 

  63. 63.

    Asevedo E, Mendes AC, Berk M, et al. Systemic review of N-Acetylcysteine in the treatment of addictions. Rev Bras Psiquiatr. 2014;36(2):168–75.

    PubMed  Article  Google Scholar 

  64. 64.

    Grant JE, Chamberlain SR, Redden SA, et al. N-Acetylcysteine in the treatment of excoriation disorder: a randomized clinical trial. JAMA Psychiatry. 2016;73(5):490–6.

    PubMed  Article  Google Scholar 

  65. 65.

    Silva-Netto R, Jesus G, Nogueora M, et al. N-Acetylcysteine in the treatment of skin picking disorder. Braz J Psychiatr. 2014;36(1):101.

    Article  Google Scholar 

  66. 66.

    Odlaug BL, Grant JE. N-Acetylcysteine in the treatment of grooming disorder. J Clin Psychopharmacol. 2007;27:227–9.

    PubMed  Article  Google Scholar 

  67. 67.

    Grant JE, Odlaug BL, Kim SW. Lamoatrigine treatment of pathologic skin picking: an open label study. J Clin Psychiatry. 2007;68:1384–91.

    CAS  PubMed  Article  Google Scholar 

  68. 68.

    Grant JE, Odlaug BL, Chamberlain SR, et al. A double-blind placebo-controlled trial of Lamotrigine for pathological skin picking: treatment efficacy and neurocognitive predictors of response. J Clin Psychopharmacol. 2010;30:396–403.

    CAS  PubMed  PubMed Central  Article  Google Scholar 

  69. 69.

    Jafferany M, Osuagwu FC. Use of topiramate in skin picking disorder: a pilot study. Prim Care Companion CNS Disord. 2017. https://doi.org/10.4088/pcc.16m01961.

    PubMed  Article  Google Scholar 

  70. 70.

    Bonnot O, Cohen D, Thuilleaux D, et al. Psychotropic treatments in Prader-Willi syndrome: a critical review of published literature. Eur J Periatr. 2016;175(1):9–18.

    CAS  Article  Google Scholar 

  71. 71.

    Jafferany M, Shireen F, Ibrahim A. An open-label trial of topiramate in the treatment of skin picking in pervasive developmental disorder not otherwise specified. Prim Care Companion J Clin Psychiatry. 2010. https://doi.org/10.4088/PCC.09l00829yel.

    PubMed  PubMed Central  Article  Google Scholar 

  72. 72.

    Shapira NA, Lessig MC, Murphey TK, et al. Topiramate attenuate self-injurious behavior in Prader-Willi syndrome. Int J Neuropsychopharmacol. 2002;5(2):141–5.

    CAS  PubMed  Article  Google Scholar 

  73. 73.

    Sasso DA, Kalanithi PS, Trueblood KV, et al. Beneficial effects of the glutamate-modulating agent riluzole on disordered eating and pathological skin-picking behaviors. J Clin Psychopharmacol. 2006;26(2):685–7.

    PubMed  Article  Google Scholar 

  74. 74.

    Banga A, Conner DF. Effectiveness of Naltrexone for treating pathological skin picking behavior in an adolescent with Prader-Willi syndrome. J Child Adolesc Psychopharmacol. 2012;22(5):396–8.

    CAS  PubMed  Article  Google Scholar 

  75. 75.

    Benjamin E, Bout-Smith T. Naltrexone and fluoxetine in Prader-Willi syndrome. J Am Acad Child Adolesc Psychiatry. 1993;32(4):870–3.

    CAS  PubMed  Article  Google Scholar 

  76. 76.

    Seedat S, Stein DJ, Harvey BH. Inositol in the treatment of trichotillomania and compulsive skin picking. J Clin Psychiatry. 2001;62(1):60–1.

    CAS  PubMed  Article  Google Scholar 

  77. 77.

    Jones G, Keuthen N, Greenberg E. Assessment and treatment of trichotillomania (hair pulling disorder) and excoriation (skin picking) disorder. Clin Dermatol. 2018;36:728–36.

    PubMed  Article  Google Scholar 

  78. 78.

    Dunbar AB, Magid M, Reichenberg JS. Habit Reversal training for body focused repetitive behaviors. G Ital Dermatol Venereol. 2018;153(4):557–66.

    PubMed  Google Scholar 

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Correspondence to Mohammad Jafferany.

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Dr. Jafferany has received payment for service on a speaker bureau for Allergan Inc. Arsh Patel has no conflicts of interest that are directly relevant to the content of this article.

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Jafferany, M., Patel, A. Skin-Picking Disorder: A Guide to Diagnosis and Management. CNS Drugs 33, 337–346 (2019). https://doi.org/10.1007/s40263-019-00621-7

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