Dermatillomania Therapy: Skin Picking Disorder Treatment 2023

Everyone has their own little quirks – odd behaviors that become habits over time. For some, it’s nail-biting while, for others, it might be hair chewing or leg shaking. These habits are generally pretty harmless but compulsive behaviors like skin picking have the potential to do damage. 

Dermatillomania, also known as excoriation disorder or skin-picking disorder, is a psychological condition related to Obsessive-Compulsive Disorder (OCD). This condition affects between 1.4% and 5.4%^[1] of the American population and can occur at any age, though its onset typically coincides with puberty. If you’re struggling with skin picking, dermatillomania therapy may help you learn to control your impulses and overcome this compulsive behavior.

What Is Dermatillomania?

Also known as excoriation disorder, dermatillomania is a chronic skin picking disorder. Affected individuals find themselves repetitively picking at their skin, often leading to soft tissue damage. This condition can affect individuals at any age, though it commonly manifests in childhood or early adolescence between the ages of 13 and 15^[4]. 

Here are the DSM-5 criteria^[5] for the diagnosis of dermatillomania:

• Recurrent picking at the skin resulting in skin lesions
• Repeated attempts to decrease or stop skin picking
• Clinically significant distress or impairment due to skin picking
• Skin picking is not attributable to physiological effects of substances or underlying medical conditions
• Skin picking is not explained by symptoms of another mental disorder

Dermatillomania can range in severity from causing minor skin irregularities to severe tissue damage. Individuals with this condition often experience shame, anxiety, or depression related to their skin picking behaviors which can lead to a reluctance to seek treatment. 

Symptoms & Causes Of Skin Picking Disorder

The primary symptom of dermatillomania is, of course, repetitive skin picking. In many cases, this behavior leads to skin lesions which may range in severity from minor irregularities to severe tissue damage. In addition to physical symptoms, this chronic condition often leads to psychological distress and repeated attempts to stop or reduce skin picking. 

As is true for many mental disorders, the exact cause for dermatillomania is unknown. That being said, there may be a genetic component given that many people with this skin condition have an inherited predisposition to body-focused repetitive behaviors (BFRBs^[6]). It is fairly common for individuals with skin picking disorder to exhibit other BFRBs like hair pulling and cheek biting – they also exhibit a higher-than-average risk for anxiety and other mood disorders in their first-degree relatives. 

On top of genetics, people who exhibit skin picking behavior may also have concurrent medical complications or dermatological conditions like acne. People with this condition can also be perfectionists, prone to overgrooming. 

Complications Of Dermatillomania

Compulsive skin picking can affect the individual’s life in a number of significant ways. Depending on the severity of the skin picking, there is a risk for infections. Medical complications of skin picking may include scabbing, open wounds, scarring, or disfigurement. Individuals may try to cover or camouflage their damaged skin and the condition can affect their relationships with family and friends as well. 

According to the TLC foundation, repetitive picking can also lead to psychological complications^[7] related to shame and embarrassment. Many people with this disorder exhibit clinically significant distress, avoidance of certain activities and social situations, and even medical treatment. Negative emotions associated with the condition may lead to the development of psychiatric disorders such as mood or anxiety disorders. 

Dermatillomania Cures and Treatments

Treatment for skin picking disorder can be divided into two categories: pharmacotherapy and nonpharmacological treatment. Generally speaking, the most effective course of treatment is a combination of these two options. 

Non Pharmacological Treatment

Two common nonpharmacological treatments for excoriation disorder are cognitive behavioral therapy (CBT) and habit reversal therapy (HRT). Cognitive behavioral therapy is typically a multi-pronged treatment involving psychoeducation, cognitive restructuring, and relapse prevention. It may also incorporate elements of habit reversal training. 

Cognitive-behavioral therapy for a person with excoriation disorder tends to be most helpful when they are presented in a self-help format. In one study^[8], 151 patients with excoriation disorder experienced a significant reduction in symptom severity after completing a 3-month Internet-based self-help treatment program. 

In a second randomized controlled study^[9], habit reversal training was compared with decoupling. Decoupling is a treatment in which a person is taught to “unlearn” skin picking by replacing it with a harmless behavior that mimics the core movement. For example, if skin picking typically occurs on the face, the patient might redirect the impulsive movement to a nearby area where skin picking doesn’t usually occur, such as the ear.

Another non pharmacological treatment option for excoriation disorder is acceptance and commitment therapy (ACT). This mental health treatment involves acceptance and mindfulness techniques designed to help the individual deal with unhelpful thoughts and negative emotions. In a limited study^[10] of 5 patients, a combination of ACT and HRT greatly reduced hair pulling and skin picking behaviors for all participants. 

Pharmacotherapy For Skin Picking 

While no medications have been approved as first-line treatments for excoriation disorder, there are a number of limited studies showing the potential benefits of certain drugs for this chronic condition. Selective serotonin reuptake inhibitors (SSRIs) and nutraceuticals have been studied, along with drugs like lamotrigine and opioid antagonists. 

Selective serotonin reuptake inhibitors have demonstrated a clinically significant amount of improvement in skin picking. One drug trial^[11] using fluoxetine improved symptoms more than placebo at an average dosage of 55 mg/day. Another 6-week study^[12], fluoxetine supports these results. Individuals who were on the placebo continued to exhibit skin picking. Citilopram is another drug with some scientific evidence behind it for the treatment of excoriation disorder. In fact, it was the drug used in the largest double-blind study^[13] of SSRIs for skin picking.

Lamotrigine, an anti-epileptic agent, has some scientific support, though the results are inconsistent. The two main trials involving lamotrigine for skin picking used a flexible dosing schedule over the course of 12 weeks of treatment. The first^[14] yielded a 67% response rate but the second^[15] only yielded a 43.8% response rate, lower than the placebo group. 

Glutamatergic agents like N-acetyl cysteine (NAC) are of growing interest in the treatment of obsessive-compulsive and related disorders. N-acetyl cysteine, for example, helps modulate the glutamatergic and neuroinflammatory systems in the body which may help reduce skin picking symptoms. In a recent study^[16], NAC significantly reduced symptoms in nearly half of participants compared to just 19% in the placebo group. 

Finally, opioid antagonists like naltrexone have shown some benefit in dermatological conditions. It is important to note, however, that most studies have involved animals – the efficacy of this treatment in humans is only supported by case reports^[17]. 

Alternative Therapies

While psychotherapy and pharmacological therapies are the most common treatments for skin picking, there are a few alternative therapies^[18] which may help as well. Yoga, hypnosis, and meditation can help and some people find aerobic exercise to be distracting as well. These alternative therapies may help improve mood and relieve anxiety, two factors which can make skin picking worse. 

Tips For Reducing Skin Picking Behavior

Getting the symptoms of excoriation disorder under control can be a slow process. For most people, it requires a combination of cognitive behavioral therapy and prescription medications to learn how to control the impulse. While undergoing treatment, there are a few things you can try to help mitigate skin damage to prevent scars. 

Here are some tips for reducing skin picking:

• Try to keep your hands busy – squeezing a stress ball or using a fidget spinner can help.
• Cover your hands and fingers – wearing gloves can help prevent picking.
• Substitute picking for a beneficial behavior like applying moisturizer to the skin.
• Keep your skin clean to reduce the risk of infections. 
• Don’t let your nails grow long – keep them trimmed short.  

Though excoriation disorder can be difficult to treat, there’s no reason you can’t succeed in reducing your symptoms and regaining healthy skin. Talk to your doctor or dermatologist about treatment options and consider putting some of the tips above to work in the meantime. 

Frequently Asked Questions

---