CNS Drugs

, Volume 15, Issue 5, pp 351–359 | Cite as

Psychogenic Excoriation

Clinical Features, Proposed Diagnostic Criteria, Epidemiology and Approaches to Treatment
  • Lesley M. Arnold
  • Megan B. Auchenbach
  • Susan L. McElroy
Therapy in Practice


Psychogenic excoriation (also called neurotic excoriation, acne excoriée, pathological or compulsive skin picking, and dermatotillomania) is characterised by excessive scratching or picking of normal skin or skin with minor surface irregularities. It is estimated to occur in 2% of dermatology clinic patients and is associated with functional impairment, medical complications (e.g. infection) or substantial distress.

Psychogenic excoriation is not yet recognised in the DSM. We propose preliminary operational criteria for its diagnosis that take into account the heterogeneity of behaviour associated with psychogenic excoriation and allow for subtyping along a compulsivity-impulsivity spectrum.

Psychiatric comorbidity in patients with psychogenic excoriation, particularly mood and anxiety disorders, is common. Patients with psychogenic excoriation frequently have comorbid disorders in the compulsivity-impulsivity spectrum, including obsessive-compulsive disorder, body dysmorphic disorder, substance use disorders, eating disorders, trichotillomania, kleptomania, compulsive buying, obsessive-compulsive personality disorder, and borderline personality disorder.

There are few studies of the pharmacological treatment of patients with psychogenic excoriation. Case studies, open trials and small double-blind studies have demonstrated the efficacy of selective serotonin (5-hydroxytryptamine; 5-HT) reuptake inhibitors in psychogenic excoriation. Other pharmacological treatments that have been successful in case reports include doxepin, clomipramine, naltrexone, pimozide and olanzapine.

There are no controlled trials of behavioural or psychotherapeutic treatment for psychogenic excoriation. Treatments found to be effective in case reports include a behavioural technique called ‘habit reversal’ a multicomponent programme consisting of self-monitoring, recording of episodes of scratching, and procedures that produce alternative responses to scratching; and an ‘eclectic’ psychotherapy programme with insight-oriented and behavioural components.


Olanzapine Naltrexone Borderline Personality Disorder Body Dysmorphic Disorder Impulse Control Disorder 
These keywords were added by machine and not by the authors. This process is experimental and the keywords may be updated as the learning algorithm improves.


  1. 1.
    Fruensgaard K. Neurotic excoriations: a controlled psychiatric examination. Acta Psychiatr Scand 1984; 312Suppl. 69: 1–52Google Scholar
  2. 2.
    Simeon D, Stein DJ, Gross S, et al. A double-blind trial of fluoxetine in pathologic skin picking. J Clin Psychiatry 1997; 58: 341–7PubMedCrossRefGoogle Scholar
  3. 3.
    Arnold LM, McElroy SL, Mutasim DF, et al. Characteristics of 34 adults with psychogenic excoriation. J Clin Psychiatry 1998; 59: 509–14PubMedCrossRefGoogle Scholar
  4. 4.
    Wilhelm S, Keuthen NJ, Deckersbach T, et al. Self-injurious skin picking: clinical characteristics and comorbidity. J Clin Psychiatry 1999; 60: 454–9PubMedCrossRefGoogle Scholar
  5. 5.
    Keuthen NJ, Deckersbach T, Wilhelm S, et al. Repetitive skin-picking in a student population and comparison with a sample of self-injurious skin-pickers. Psychosomatics 2000; 41: 210–5PubMedCrossRefGoogle Scholar
  6. 6.
    Koblenzer CS. Psychocutaneous disease. New York (NY): Grune & Stratton, 1987Google Scholar
  7. 7.
    Stein DJ, Hollander E. Dermatology and conditions related to obsessive-compulsive disorder. J Am Acad Dermatol 1992; 26: 237–42PubMedCrossRefGoogle Scholar
  8. 8.
    Phillips KA, Taub SL. Skin picking as a symptom of body dysmorphic disorder. Psychopharmacol Bull 1995; 31: 279–88PubMedGoogle Scholar
  9. 9.
    Stein DJ, Mullen L, Islam MN, et al. Compulsive and impulsive symptomatology in trichotillomania. Psychopathology 1995; 28: 208–13PubMedCrossRefGoogle Scholar
  10. 10.
    American Psychiatric Association. Diagnostic and statistical manual of mental disorders. 4th ed. Washington, DC: American Psychiatric Association, 1994Google Scholar
  11. 11.
    Arnold LM, McElroy SL. The nosology of compulsive skin picking [reply letter]. J Clin Psychiatry 1999; 60: 618–9CrossRefGoogle Scholar
  12. 12.
    Greisemer RD. Emotionally triggered disease in a psychiatric practice. Psychiatr Ann 1978; 8: 407–12Google Scholar
  13. 13.
    Gupta MA, Gupta AK, Haberman HF. Neurotic excoriations: a review and some new perspectives. Compr Psychiatry 1986; 27: 381–6PubMedCrossRefGoogle Scholar
  14. 14.
    McElroy SL, Phillips KA, Keck PE, et al. Obsessive compulsive spectrum disorder. J Clin Psychiatry 1994; 55(10 Suppl.): 33–53PubMedGoogle Scholar
  15. 15.
    Oldham JM, Hollander E, Skodol AE. Impulsivity and compulsivity. Washington, DC: American Psychiatric Press, 1996Google Scholar
  16. 16.
    Bloch MR, Elliott MA, Thompson H, et al. Fluoxetine for skin picking. Abstracts of the New Clinical Drug Evaluation Unit Annual Meeting. Boca Raton, Florida, May 30–June 2, 2000Google Scholar
  17. 17.
    Stout RJ. Fluoxetine for the treatment of compulsive facial picking [letter]. Am J Psychiatry 1990; 147: 370PubMedGoogle Scholar
  18. 18.
    Gupta MA, Gupta AK. Fluoxetine is an effective treatment for neurotic excoriations: case report. Cutis 1993; 51: 386–7PubMedGoogle Scholar
  19. 19.
    Stein DJ, Hutt CS, Spitz JL, et al. Compulsive picking and obsessive-compulsive disorder. Psychosomatics 1993; 34: 177–81PubMedCrossRefGoogle Scholar
  20. 20.
    Vittorio CC, Phillips KA. Treatment of habit-tic deformity with fluoxetine. Arch Dermatol 1997; 133: 1203–4PubMedCrossRefGoogle Scholar
  21. 21.
    Kalivas J, Kalivas L, Gilman D, et al. Sertraline in the treatment of neurotic excoriations and related disorders. Arch Dermatol 1996; 132: 589–90PubMedCrossRefGoogle Scholar
  22. 22.
    Arnold LM, Mutasim DF, Dwight MM, et al. An open clinical trial of fluvoxamine treatment of psychogenic excoriation. J Clin Psychopharmacol 1999; 19: 15–8PubMedCrossRefGoogle Scholar
  23. 23.
    O’Sullivan RL, Phillips KA, Keuthen NJ, et al. Near-fatal skin picking from delusional body dysmorphic disorder responsive to fluvoxamine. Psychosomatics 1999; 40: 79–81PubMedCrossRefGoogle Scholar
  24. 24.
    Biondi M, Arcangeli T, Petrucci RM. Paroxetine in a case of psychogenic pruritus and neurotic excoriations. Psychother Psychosom 2000; 69: 165–6PubMedCrossRefGoogle Scholar
  25. 25.
    Ravindran AV, Lapierre YD, Anisman H. Obsessive-compulsive spectrum disorders: effective treatment with paroxetine. Can J Psychiatry 1999; 44: 805–7PubMedGoogle Scholar
  26. 26.
    Harris BA, Sherertz EF, Flowers FP. Improvement of chronic neurotic excoriations with oral doxepin therapy. Int J Dermatol 1987; 26: 541–3PubMedCrossRefGoogle Scholar
  27. 27.
    Lienemann J, Walker FD. Reversal of self-abusive behavior with naltrexone [letter]. J Clin Psychopharmacol 1989; 9: 448–9PubMedCrossRefGoogle Scholar
  28. 28.
    Duke EE. Clinical experience with pimozide: emphasis on its use in postherpetic neuralgia. J Am Acad Dermatol 1983; 8: 845–50PubMedCrossRefGoogle Scholar
  29. 29.
    Garnis-Jones S, Collins S, Rosenthal D. Treatment of self-mutilation with olanzapine. J Cutan Med Surg 2000; 4: 161–3PubMedGoogle Scholar
  30. 30.
    Gupta MA, Gupta AK. Olanzapine is effective in the management of some self-induced dermatoses: three case reports. Cutis 2000; 66: 143–6PubMedGoogle Scholar
  31. 31.
    Fruensgaard K. Psychotherapeutic strategy and neurotic excoriations. Int J Dermatol 1991; 30: 198–203PubMedCrossRefGoogle Scholar
  32. 32.
    Rosenbaum MS, Ayllon T. The behavioral treatment of neuro-dermatitis through habit-reversal. Behav Res Ther 1981; 19:313–8PubMedCrossRefGoogle Scholar
  33. 33.
    Kent A, Drummond LM. Acne excoriée — a case report of treatment using habit reversal. Clin Exp Dermatol 1989; 14: 163–4PubMedCrossRefGoogle Scholar
  34. 34.
    Welkowitz LA, Held JL, Held AL. Management of neurotic scratching with behavioral therapy. J Am Acad Dermatol 1989; 21: 802–4PubMedCrossRefGoogle Scholar
  35. 35.
    Fruensgaard K. Psychotherapy and neurotic excoriations. Int J Dermatol 1991; 30: 262–5PubMedCrossRefGoogle Scholar
  36. 36.
    Fried RG. Evaluation and treatment of ‘psychogenic’ pruritus and self-excoriation. J Am Acad Dermatol 1994; 30: 993–9PubMedCrossRefGoogle Scholar

Copyright information

© Adis International Limited 2001

Authors and Affiliations

  • Lesley M. Arnold
    • 1
  • Megan B. Auchenbach
    • 1
  • Susan L. McElroy
    • 2
  1. 1.Women’s Health Research ProgramUniversity of Cincinnati College of MedicineCincinnatiUSA
  2. 2.Biological Psychiatry Program, Department of PsychiatryUniversity of Cincinnati College of MedicineCincinnatiUSA

Personalised recommendations