Excoriation Disorder

Excoriation (skin picking) disorder is recurrent picking of skin resulting in lesions with repeated attempts to stop.

• Prevalence 1.4 to 5%; women 75%; onset in adolescence.
• Triggers: tension, boredom, perceived imperfections; may be automatic or focused.
• Comorbid OCD, BDD, trichotillomania, depression, anxiety.
• Complications: scarring, infection (cellulitis, abscess), disfigurement, rarely sepsis.

• Picking at face, arms, hands, torso; scabs, ulcers, scars; repeated time spent picking, camouflaging with clothing and makeup.
• Distress, shame, impaired function.
• Lesions with angular shapes of different ages.

• Clinical, using the Skin Picking Scale; examine the skin, document lesions and infection.
• Exclude scabies, dermatitis herpetiformis, acne, prurigo nodularis, delusional infestation, substance induced picking (stimulants), medical pruritus (renal, hepatic, thyroid, iron deficiency, lymphoma).
• Screen for depression, OCD and BDD.

• Habit reversal training and acceptance based behavioural therapy (decoupling, stimulus control) first line.
• Medication: N-acetylcysteine 1200 to 3000 mg daily (response in 50 to 60%), SSRIs (fluoxetine 40 to 80 mg, sertraline 100 to 200 mg), lamotrigine 100 to 200 mg, olanzapine 5 to 10 mg, naltrexone 50 to 100 mg.
• Wound care, topical antibiotics (mupirocin), oral antibiotics (cefalexin 500 mg four times daily) for infection, covering skin lesions, keeping nails short, hydrocolloid dressings.
• Treat comorbid depression and anxiety; dermatology liaison.