Skin picking—also referred to as dermatillomania or excoriation disorder—has been classified as a distinct disorder under the umbrella term of “body-focused repetitive disorders” (BFRBs), as has trichotillomania (APA, 2013). Literally, dermatillomania means “skin-picking obsession.”
Dermatillomania involves intentional or even automated, repetitive scratching, plucking, and squeezing of skin blemishes (as well as healthy skin), scabs, or insect bites, which can result in noticeable injury (Wilhelm et al., 1999).
Just don’t scratch? Easier said than done. See Helpful Things as well as Self-Help Techniques and Videos for suggestions of techniques for stopping the annoying habit. You are not alone. Advice from professionals as well as success stories and blogs from other affected people can help you reduce symptoms.
If you experience other problems such as feeling down or depressed, you should also try the free COGITO app (for Android and iOS). The app contains numerous tips on how to raise your self-esteem and mood.
Diagnosis
Dermatillomania is recognized as a separate diagnostic entity in the Diagnostic and Statistical Manual of Mental Disorders (DSM-5; APA, 2013).
Current DSM-5 diagnostic criteria for the presence of dermatillomania are:
- Recurrent picking of the skin, resulting in skin lesions
- Repeated attempts to stop the behavior
- Symptoms cause clinically significant distress or impairment
- Symptoms are not caused by a substance or medical or dermatological condition
- Symptoms cannot be better explained by another psychiatric disorder
Age of onset
The disorder can occur at any time, but its onset is particularly common in late childhood (beginning at age 10) through early adolescence (e.g., acne can be a trigger; Ekore & Ekore, 2021; Eskeland et al., 2021; Flessner & Woods, 2006; Ricketts et al., 2018; Wilhelm et al., 1999). The average age of onset is approximately 13 ½ years according to one of our own studies (Moritz et al., 2023).
In addition to those affected since childhood or adolescence, there is a second group in whom skin picking appears between the ages of 30 and 45 (Fricke, 2013; Grant et al., 2012; Ricketts et al., 2018). There are also some cases of dermatillomania below the age of 10 (Torales et al., 2020).
The disorder often occurs during transitional periods, such as during puberty or after a life-changing situation such as a breakup or the death of a loved one (Lin et al., 2023; Wilhelm et al., 1999).
Skin diseases are a risk factor; around one in four people with a skin disease suffer from dermatillomania (Spitzer et al., 2022). In addition, many affected individuals report that they were already prone to skin blemishes and had dry, itchy or irritated skin before they began engaging in dermatillomania (Moritz et al., 2023).
Prevalence
General population
Based on several studies, 2 to 5.4 percent of the population will suffer from dermatillomania at least once in their lifetime (Eskeland et al. 2021; Farhat et al., 2023; Grant & Chamberlain, 2020; Hayes et al., 2009; Keuthen et al., 2000; Machado et al., 2018). However, as with other BFRBs, the number of unreported cases is likely much higher. There is some recent evidence that up to 8.7 percent of the general population is affected by dermatillomania with functional impairment or visible effects (e.g., scars) at least once during their lifetime (Moritz et al., 2024).
Childhood/Adolescence
Approximately 25 percent of children and adolescents aged 4 to 17 are affected by skin picking; 8.3 percent report significant impairment from these behaviors (Selles et al., 2015).
Adulthood
All in all, approximately 2.1 percent of the general population between the ages of 18 to 69 is affected by dermatillomania (Grant & Chamberlain, 2020). For adults aged 18 to 44, the figure is about 5.7 percent (Houghton et al., 2018).
Gender differences
Dermatillomania is thought to affect more females than males (APA, 2013; Farhat et al., 2023; Grant & Chamberlain, 2020; Greenberg et al., 2018; Hayes et al., 2009; Houghton et al., 2018; Odlaug et al., 2013; Wilhelm et al., 1999). However, it is possible that the proportion of affected males is underestimated because they are less likely to seek medical and psychological help for this disorder.
Manifestation
It is not uncommon to occasionally pick, nibble, or scratch some areas of blemished skin. The transition to pathological skin picking is gradual, and the severity is determined by the extent, the degree of the urge, and the associated damage and impairment in normal everyday life.
Individuals who suffer from skin picking engage in significantly more extreme behavior regarding their skin; they pull, squeeze, press, rub, and scratch more frequently over a longer period of time on multiple areas of the body. They may pull off small pieces of skin, manipulating both healthy and previously damaged areas. This behavior may be automated (i.e., unconscious scratching) or ritualized and intentional (e.g., focused behavior after looking in a mirror). Many affected people also report being in a trance-like state during scratching and picking, which often lasts for several minutes (Spitzer et al., 2023).
Individuals use their fingernails, teeth, or instruments (e.g., tweezers) to manipulate body surfaces, most commonly on the face, back, neck, or scalp.
Commonly reported experiences that lead to picking include an urge or physical tension before picking, unpleasant emotions, beliefs about how the skin should look or feel, or an (alleged) flaw in one’s appearance.
Consequences
The feelings associated with skin picking are complex and contradictory: feelings of relief or pleasure but also shame, as well as subsequent emotional states such as anxiety or depression. Furthermore, avoidance behavior (e.g., social withdrawal) and a decrease in productivity due to over-engagement with one’s own body are common.
On a long-term basis, many small to large scars as well as infections and skin lesions can develop. Many of those affected usually pick on their skin when they are alone. The fear of negative responses from others is usually very high; intimacy with nudity is often avoided.
Dermatillomania prevents healing, especially if a skin disease, such as acne, is already present. This complicates the clinical picture.
Literature
American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). https://doi.org/10.1176/appi.books.9780890425596
Ekore, R. I., & Ekore, J. O. (2021). Excoriation (skin-picking) disorder among adolescents and young adults with acne-induced postinflammatory hyperpigmentation and scars. International Journal of Dermatology, 60(12), 1488–1493. https://doi.org/10.1111/ijd.15587
Eskeland, S. O., Moen, E., Meland, K. J., Andersen, A., & Hummelen, B. (2021). Skin picking disorder. Hudplukkingslidelse. Tidsskrift for den Norske laegeforening: Tidsskrift for PraktiskMedicin, ny Raekke, 141(18), 10.4045/tidsskr.21.0128. https://doi.org/10.4045/tidsskr.21.0128
Farhat, L. C., Reid, M., Bloch, M. H. & Olfson, E. (2023). Prevalence and gender distribution of excoriation (skin-picking) disorder: A systematic review and meta-analysis. Journal Of Psychiatric Research, 161, 412–418. https://doi.org/10.1016/j.jpsychires.2023.03.034
Flessner, C. A. & Woods, D. W. (2006). Phenomenological characteristics, social problems, and the economic impact associated with chronic skin picking. Behavior Modification, 30(6), 944–963. https://doi.org/10.1177/0145445506294083
Fricke, S. (2013). Dermatillomanie. Zeitschrift für Psychiatrie, Psychologie und Psychotherapie, 61(3), 175–179. https://doi.org/10.1024/1661-4747/a000156
Grant, J. E., & Chamberlain, S. R. (2020). Prevalence of skin picking (excoriation) disorder. Journal of Psychiatric Research, 130, 57–60. https://doi.org/10.1016/j.jpsychires.2020.06.033
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Hayes, S. L., Storch, E. A., & Berlanga, L. (2009). Skin picking behaviors: An examination of the prevalence and severity in a community sample. Journal of Anxiety Disorders, 23(3), 314–319. https://doi.org/10.1016/j.janxdis.2009.01.008
Keuthen, N. J., Deckersbach, T., Wilhelm, S., Hale, E., Fraim, C., Baer, L., O’Sullivan, R. L., & Jenike, M. A. (2000). Repetitive skin-picking in a student population and comparison with a sample of self-injurious skin-pickers. Psychosomatics, 41(3), 210–215. https://doi.org/10.1176/appi.psy.41.3.210
Lin, A., Farhat, L. C., Flores, J. M., Levine, J. L., Fernandez, T. V., Bloch, M. H. & Olfson, E. (2023). Characteristics of trichotillomania and excoriation disorder across the lifespan. Psychiatry Research, 322, 115120. https://doi.org/10.1016/j.psychres.2023.115120
Machado, M. O., Köhler, C. A., Stubbs, B., Nunes-Neto, P. R., Koyanagi, A., Quevedo, J., Soares, J. C., Hyphantis, T. N., Marazziti, D., Maes, M., Stein, D. J. & Carvalho, A. F. (2018). Skin picking disorder: prevalence, correlates, and associations with quality of life in a large sample. CNS Spectrums, 23(5), 311–320. http://doi.org/10.1017/S1092852918000871
Moritz, S., Penney, D., Mißmann, F., Snorrason, I. & Schmotz, S. (2023). Same but different? Phenomenological differences among various types of body-focused repetitive behaviors. Annals of Clinical Psychiatry, 35(4). https://doi.org/10.12788/acp.0123
Moritz, S., Scheunemann, J., Jelinek, L., Penney, D., Schmotz, S., Hoyer, L., Grudzień, D. & Aleksandrowicz, A. (2024). Prevalence of body-focused repetitive behaviors in a diverse population sample – rates across age, gender, race and education. Psychological Medicine, 54(8), 1552–1558. https://doi.org/10.1017/S0033291723003392
Odlaug, B. L., Lust, K., Schreiber, L. R., Christenson, G., Derbyshire, K. & Grant, J. E. (2013). Skin picking disorder in university students: health correlates and gender differences. General Hospital Psychiatry, 35(2), 168–173. https://doi.org/10.1016/j.genhosppsych.2012.08.006
Ricketts, E. J., Snorrason, Í., Kircanski, K., Alexander, J. R., Thamrin, H., Flessner, C. A., Franklin, M. E., Piacentini, J. & Woods, D. W. (2018). A latent profile analysis of age of onset in pathological skin picking. Comprehensive Psychiatry, 87, 46-52. https://doi.org/10.1016/j.comppsych.2018.08.011
Selles, R. R., Nelson, R., Zepeda, R., Dane, B. F., Wu, M. S., Novoa, J. C., Guttfreund, D. & Storch, E. A. (2015). Body focused repetitive behaviors among Salvadorian youth: Incidence and clinical correlates. Journal of Obsessive-Compulsive and Related Disorders, 5, 49–54. https://doi.org/10.1016/j.jocrd.2015.01.008
Torales, J., Díaz, N. R., Barrios, I., Navarro, R., García, O., O’Higgins, M., Castaldelli-Maia, J. M., Ventriglio, A., & Jafferany, M. (2020). Psychodermatology of skin picking (excoriation disorder): a comprehensive review. Dermatologic Therapy, 33(4), e13661. https://doi.org/10.1111/dth.13661
Spitzer, C., Lübke, L., Lindstädt, T., Gallinat, C., Tietze, J. K., Emmert, S. & Thiem, A. (2022). Prevalence of pathological skin-picking in dermatological patients. Journal Of Psychiatric Research, 147, 232–236. https://doi.org/10.1016/j.jpsychires.2022.01.035
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