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.
Fruensgaard K. Neurotic excoriations: a controlled psychiatric examination. Acta Psychiatr Scand 1984; 312Suppl. 69: 1–52Google Scholar
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
Arnold LM, McElroy SL, Mutasim DF, et al. Characteristics of 34 adults with psychogenic excoriation. J Clin Psychiatry 1998; 59: 509–14PubMedCrossRefGoogle Scholar
Wilhelm S, Keuthen NJ, Deckersbach T, et al. Self-injurious skin picking: clinical characteristics and comorbidity. J Clin Psychiatry 1999; 60: 454–9PubMedCrossRefGoogle Scholar
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
Koblenzer CS. Psychocutaneous disease. New York (NY): Grune & Stratton, 1987Google Scholar
Stein DJ, Hollander E. Dermatology and conditions related to obsessive-compulsive disorder. J Am Acad Dermatol 1992; 26: 237–42PubMedCrossRefGoogle Scholar
Phillips KA, Taub SL. Skin picking as a symptom of body dysmorphic disorder. Psychopharmacol Bull 1995; 31: 279–88PubMedGoogle Scholar
Stein DJ, Mullen L, Islam MN, et al. Compulsive and impulsive symptomatology in trichotillomania. Psychopathology 1995; 28: 208–13PubMedCrossRefGoogle Scholar
American Psychiatric Association. Diagnostic and statistical manual of mental disorders. 4th ed. Washington, DC: American Psychiatric Association, 1994Google Scholar
Arnold LM, McElroy SL. The nosology of compulsive skin picking [reply letter]. J Clin Psychiatry 1999; 60: 618–9CrossRefGoogle Scholar
Greisemer RD. Emotionally triggered disease in a psychiatric practice. Psychiatr Ann 1978; 8: 407–12Google Scholar
Gupta MA, Gupta AK, Haberman HF. Neurotic excoriations: a review and some new perspectives. Compr Psychiatry 1986; 27: 381–6PubMedCrossRefGoogle Scholar
McElroy SL, Phillips KA, Keck PE, et al. Obsessive compulsive spectrum disorder. J Clin Psychiatry 1994; 55(10 Suppl.): 33–53PubMedGoogle Scholar
Oldham JM, Hollander E, Skodol AE. Impulsivity and compulsivity. Washington, DC: American Psychiatric Press, 1996Google Scholar
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
Stout RJ. Fluoxetine for the treatment of compulsive facial picking [letter]. Am J Psychiatry 1990; 147: 370PubMedGoogle Scholar
Gupta MA, Gupta AK. Fluoxetine is an effective treatment for neurotic excoriations: case report. Cutis 1993; 51: 386–7PubMedGoogle Scholar
Stein DJ, Hutt CS, Spitz JL, et al. Compulsive picking and obsessive-compulsive disorder. Psychosomatics 1993; 34: 177–81PubMedCrossRefGoogle Scholar