Official reprint from UpToDate®
www.uptodate.com ©2017 UpToDate, Inc. and/or its affiliates. All Rights Reserved.

Skin picking (excoriation) disorder and related disorders

Kelly KyungHwa Park, MD
John Koo, MD
Section Editor
Erik Stratman, MD
Deputy Editor
Rosamaria Corona, MD, DSc


Skin picking disorder (SPD) is characterized by deliberate and repetitive manipulation of the skin, causing tissue damage. Excoriation disorder, psychogenic excoriation, lichen simplex chronicus, neurodermatitis, neurotic excoriation, acne excoriée, and dermatillomania (dermatotillomania) are synonyms of SPD.

This topic will discuss the clinical manifestations, diagnosis, and treatment of SPD and related conditions. Obsessive-compulsive disorder and body dysmorphic disorder are discussed separately. (See "Obsessive-compulsive disorder in adults: Epidemiology, pathogenesis, clinical manifestations, course, and diagnosis" and "Body dysmorphic disorder: Epidemiology, pathogenesis, and clinical features" and "Obsessive-compulsive disorder in children and adolescents: Epidemiology, pathogenesis, clinical manifestations, course, assessment, and diagnosis".)


Skin picking disorder (SPD) is defined as the repetitive picking, scratching, rubbing, digging, or squeezing of skin, resulting in visible tissue damage and impairment in social functioning [1]. In the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5), SPD is included as a separate diagnosis in the group of the obsessive-compulsive and related disorders, along with trichotillomania and body dysmorphic disorder [2].


The prevalence of SPD in the general population is unknown; it accounts for approximately 2 percent of all visits to the dermatology clinic [3,4]. In a telephone survey, 1.6 percent of a random sample of 2511 adults residing in the United States reported skin picking with noticeable skin damage [5]. These individuals also reported distress and psychosocial impact associated with skin picking. In another United States population-based study, 5.4 percent of 354 participants reported SPD and associated impairment in daily functioning [6].

In three samples of college students, the rates of severe, self-injurious skin picking ranged from 3.8 to 4.6 percent [7-9]. SPD was associated with high lifetime rates of affective disorders, anxiety disorders, eating disorders, substance abuse, and impulse control disorders and was usually triggered by cutaneous stimuli or specific emotional situations.

To continue reading this article, you must log in with your personal, hospital, or group practice subscription. For more information on subscription options, click below on the option that best describes you:

Subscribers log in here

Literature review current through: Nov 2017. | This topic last updated: Nov 01, 2017.
The content on the UpToDate website is not intended nor recommended as a substitute for medical advice, diagnosis, or treatment. Always seek the advice of your own physician or other qualified health care professional regarding any medical questions or conditions. The use of this website is governed by the UpToDate Terms of Use ©2017 UpToDate, Inc.
  1. Arnold LM, Auchenbach MB, McElroy SL. Psychogenic excoriation. Clinical features, proposed diagnostic criteria, epidemiology and approaches to treatment. CNS Drugs 2001; 15:351.
  2. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5), American Psychiatric Association, Arlington 2013.
  3. Griesemer RD. Emotionally triggered disease in a dermatologic practice. Psychiatr Ann 1978; 8:407.
  4. Gupta MA, Gupta AK, Haberman HF. The self-inflicted dermatoses: a critical review. Gen Hosp Psychiatry 1987; 9:45.
  5. Keuthen NJ, Koran LM, Aboujaoude E, et al. The prevalence of pathologic skin picking in US adults. Compr Psychiatry 2010; 51:183.
  6. Hayes SL, Storch EA, Berlanga L. Skin picking behaviors: An examination of the prevalence and severity in a community sample. J Anxiety Disord 2009; 23:314.
  7. 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.
  8. Bohne A, Wilhelm S, Keuthen NJ, et al. Skin picking in German students. Prevalence, phenomenology, and associated characteristics. Behav Modif 2002; 26:320.
  9. Odlaug BL, Lust K, Schreiber LR, et al. Skin picking disorder in university students: health correlates and gender differences. Gen Hosp Psychiatry 2013; 35:168.
  10. Odlaug BL, Grant JE. Clinical characteristics and medical complications of pathologic skin picking. Gen Hosp Psychiatry 2008; 30:61.
  11. Arnold LM, McElroy SL, Mutasim DF, et al. Characteristics of 34 adults with psychogenic excoriation. J Clin Psychiatry 1998; 59:509.
  12. Odlaug BL, Grant JE. Childhood-onset pathologic skin picking: clinical characteristics and psychiatric comorbidity. Compr Psychiatry 2007; 48:388.
  13. Odlaug BL, Hampshire A, Chamberlain SR, Grant JE. Abnormal brain activation in excoriation (skin-picking) disorder: evidence from an executive planning fMRI study. Br J Psychiatry 2016; 208:168.
  14. Grant JE, Odlaug BL, Hampshire A, et al. White matter abnormalities in skin picking disorder: a diffusion tensor imaging study. Neuropsychopharmacology 2013; 38:763.
  15. Neziroglu F, Rabinowitz D, Breytman A, Jacofsky M. Skin picking phenomenology and severity comparison. Prim Care Companion J Clin Psychiatry 2008; 10:306.
  16. Wilhelm S, Keuthen NJ, Deckersbach T, et al. Self-injurious skin picking: clinical characteristics and comorbidity. J Clin Psychiatry 1999; 60:454.
  17. Mutasim DF, Adams BB. The psychiatric profile of patients with psychogenic excoriation. J Am Acad Dermatol 2009; 61:611.
  18. Obermeyer ME. Psychocutaneous Medicine, Charles C Thomas, Springfield, IL 1995.
  19. Parent DJ, Krafft T, Noel JC, et al. Cutaneous Münchausen syndrome with presentation simulating pyoderma gangrenosum. J Am Acad Dermatol 1994; 31:1072.
  20. Koblenzer CS. Psychocutaneous Disease, Grune and Stratton, New York 1987.
  21. Mackee GM. Neurotic excoriations. Arch Dermatol Syphilol 1920; 1:256.
  22. Panconesi E. Dermatologically expressed psychiatric syndromes. Clin Dermatol 1984; 2:205.
  23. Koblenzer CS. Psychotropic drugs in dermatology. Curr Opinion Dermatol 1996; 3:214.
  24. Phillips KA, Taub SL. Skin picking as a symptom of body dysmorphic disorder. Psychopharmacol Bull 1995; 31:279.
  25. Jafferany M. Psychodermatology: a guide to understanding common psychocutaneous disorders. Prim Care Companion J Clin Psychiatry 2007; 9:203.
  26. Koo JY, Lee CS. General approach to evaluating psychodermatological disorders. In: Psychocutaneous Medicine, Koo JY, Lee CS (Eds), Dekker, New York 2003. p.1.
  27. Schmidt E, Zillikens D. Pemphigoid diseases. Lancet 2013; 381:320.
  28. Graves MW. Pruritus. In: Rook's Textbook of Dermatology, 8th Edition, Burns T, Breathnach S, Cox N., Griffiths C (Eds), Wiley-Blackwell, Oxford, UK 2010. Vol 1.
  29. Hurwitz Clinical Pediatric Dermatology, 3rd Ed, Paller AS, Mancini AJ (Eds), Elsevier Inc., Philadelphia, PA 2006. p.678.
  30. Millard LG, Millard J. Psychocutaneous disorders. In: Rook's Textbook of Dermatology, 8th Ed, Burns T, Breathnach S, Cox N, Griffiths C (Eds), Wiley-Blackwell, Hoboken, NJ 2010. Vol 4.
  31. Phillips KA, Dufresne RG. Body dysmorphic disorder. A guide for dermatologists and cosmetic surgeons. Am J Clin Dermatol 2000; 1:235.
  32. Chamberlain SR, Lochner C, Stein DJ, et al. Behavioural addiction-A rising tide? Eur Neuropsychopharmacol 2016; 26:841.
  33. McGough J, McCracken J, Swanson J, et al. Pharmacogenetics of methylphenidate response in preschoolers with ADHD. J Am Acad Child Adolesc Psychiatry 2006; 45:1314.
  34. Selles RR, McGuire JF, Small BJ, Storch EA. A systematic review and meta-analysis of psychiatric treatments for excoriation (skin-picking) disorder. Gen Hosp Psychiatry 2016; 41:29.
  35. Koo JY, Ng TC. Psychotropic and neurotropic agents in dermatology: unapproved uses, dosages, or indications. Clin Dermatol 2002; 20:582.
  36. Bowes LE, Alster TS. Treatment of facial scarring and ulceration resulting from acne excoriée with 585-nm pulsed dye laser irradiation and cognitive psychotherapy. Dermatol Surg 2004; 30:934.
  37. Ozden MG, Aydin F, Sentürk N, et al. Narrow-band ultraviolet B as a potential alternative treatment for resistant psychogenic excoriation: an open-label study. Photodermatol Photoimmunol Photomed 2010; 26:162.
  38. Soomro GM, Altman D, Rajagopal S, Oakley-Browne M. Selective serotonin re-uptake inhibitors (SSRIs) versus placebo for obsessive compulsive disorder (OCD). Cochrane Database Syst Rev 2008; :CD001765.
  39. Simeon D, Stein DJ, Gross S, et al. A double-blind trial of fluoxetine in pathologic skin picking. J Clin Psychiatry 1997; 58:341.
  40. Bloch MR, Elliott M, Thompson H, Koran LM. Fluoxetine in pathologic skin-picking: open-label and double-blind results. Psychosomatics 2001; 42:314.
  41. Arbabi M, Farnia V, Balighi K, et al. Efficacy of citalopram in treatment of pathological skin picking, a randomized double blind placebo controlled trial. Acta Medica Iranica 2008; 46:367.
  42. Keuthen NJ, Jameson M, Loh R, et al. Open-label escitalopram treatment for pathological skin picking. Int Clin Psychopharmacol 2007; 22:268.
  43. Kalivas J, Kalivas L, Gilman D, Hayden CT. Sertraline in the treatment of neurotic excoriations and related disorders. Arch Dermatol 1996; 132:589.
  44. Damiani JT, Flowers FP, Pierce DK. Pimozide in delusions of parasitosis. J Am Acad Dermatol 1990; 22:312.
  45. Meehan WJ, Badreshia S, Mackley CL. Successful treatment of delusions of parasitosis with olanzapine. Arch Dermatol 2006; 142:352.
  46. Wenning MT, Davy LE, Catalano G, Catalano MC. Atypical antipsychotics in the treatment of delusional parasitosis. Ann Clin Psychiatry 2003; 15:233.
  47. Freudenmann RW, Schönfeldt-Lecuona C, Lepping P. Primary delusional parasitosis treated with olanzapine. Int Psychogeriatr 2007; 19:1161.
  48. Gupta MA, Gupta AK. Olanzapine is effective in the management of some self-induced dermatoses: three case reports. Cutis 2000; 66:143.
  49. Christensen RC. Olanzapine augmentation of fluoxetine in the treatment of pathological skin picking. Can J Psychiatry 2004; 49:788.
  50. Spiegel DR, Finklea L. The recognition and treatment of pathological skin picking: a potential neurobiological underpinning of the efficacy of pharmacotherapy in impulse control disorders. Psychiatry (Edgmont) 2009; 6:38.
  51. Oliver G, Dean O, Camfield D, et al. N-acetyl cysteine in the treatment of obsessive compulsive and related disorders: a systematic review. Clin Psychopharmacol Neurosci 2015; 13:12.
  52. Paydary K, Akamaloo A, Ahmadipour A, et al. N-acetylcysteine augmentation therapy for moderate-to-severe obsessive-compulsive disorder: randomized, double-blind, placebo-controlled trial. J Clin Pharm Ther 2016; 41:214.
  53. Deepmala, Slattery J, Kumar N, et al. Clinical trials of N-acetylcysteine in psychiatry and neurology: A systematic review. Neurosci Biobehav Rev 2015; 55:294.
  54. Miller JL, Angulo M. An open-label pilot study of N-acetylcysteine for skin-picking in Prader-Willi syndrome. Am J Med Genet A 2014; 164A:421.
  55. Odlaug BL, Grant JE. N-acetyl cysteine in the treatment of grooming disorders. J Clin Psychopharmacol 2007; 27:227.
  56. Grant JE, Chamberlain SR, Redden SA, et al. N-Acetylcysteine in the Treatment of Excoriation Disorder: A Randomized Clinical Trial. JAMA Psychiatry 2016; 73:490.
  57. Lee CS, Koo JY. Psychotropic agents. In: Comprehensive Dermatologic Drug Therapy, 2nd ed, Wolverton SE (Ed), Elsevier, London 2007. p.402.
  58. Deckersbach T, Wilhelm S, Keuthen NJ, et al. Cognitive-behavior therapy for self-injurious skin picking. A case series. Behav Modif 2002; 26:361.
  59. Teng EJ, Woods DW, Twohig MP. Habit reversal as a treatment for chronic skin picking: a pilot investigation. Behav Modif 2006; 30:411.
  60. Flessner CA, Busch AM, Heideman PW, Woods DW. Acceptance-enhanced behavior therapy (AEBT) for trichotillomania and chronic skin picking: exploring the effects of component sequencing. Behav Modif 2008; 32:579.
  61. Schuck K, Keijsers GP, Rinck M. The effects of brief cognitive-behaviour therapy for pathological skin picking: A randomized comparison to wait-list control. Behav Res Ther 2011; 49:11.
  62. Woods DW, Houghton DC. Diagnosis, evaluation, and management of trichotillomania. Psychiatr Clin North Am 2014; 37:301.
  63. Maraz A, Hende B, Urbán R, Demetrovics Z. Pathological grooming: Evidence for a single factor behind trichotillomania, skin picking and nail biting. PLoS One 2017; 12:e0183806.
  64. Novak CE, Keuthen NJ, Stewart SE, Pauls DL. A twin concordance study of trichotillomania. Am J Med Genet B Neuropsychiatr Genet 2009; 150B:944.
  65. Swedo SE, Rapoport JL, Leonard HL, et al. Regional cerebral glucose metabolism of women with trichotillomania. Arch Gen Psychiatry 1991; 48:828.
  66. Chamberlain SR, Menzies LA, Fineberg NA, et al. Grey matter abnormalities in trichotillomania: morphometric magnetic resonance imaging study. Br J Psychiatry 2008; 193:216.
  67. Roos A, Grant JE, Fouche JP, et al. A comparison of brain volume and cortical thickness in excoriation (skin picking) disorder and trichotillomania (hair pulling disorder) in women. Behav Brain Res 2015; 279:255.
  68. Christenson GA, Pyle RL, Mitchell JE. Estimated lifetime prevalence of trichotillomania in college students. J Clin Psychiatry 1991; 52:415.
  69. King RA, Zohar AH, Ratzoni G, et al. An epidemiological study of trichotillomania in Israeli adolescents. J Am Acad Child Adolesc Psychiatry 1995; 34:1212.
  70. Harrison JP, Franklin ME. Pediatric trichotillomania. Curr Psychiatry Rep 2012; 14:188.
  71. O'Sullivan RL, Keuthen NJ, Hayday CF, et al. The Massachusetts General Hospital (MGH) Hairpulling Scale: 2. reliability and validity. Psychother Psychosom 1995; 64:146.
  72. Stanley MA, Prather RC, Wagner AL, et al. Can the Yale-Brown Obsessive Compulsive Scale be used to assess trichotillomania? A preliminary report. Behav Res Ther 1993; 31:171.
  73. Winchel RM, Jones JS, Molcho A, et al. The Psychiatric Institute Trichotillomania Scale (PITS). Psychopharmacol Bull 1992; 28:463.
  74. Tolin DF, Diefenbach GJ, Flessner CA, et al. The trichotillomania scale for children: development and validation. Child Psychiatry Hum Dev 2008; 39:331.
  75. Flessner CA, Woods DW, Franklin ME, et al. The Milwaukee Inventory for Styles of Trichotillomania-Child Version (MIST-C): initial development and psychometric properties. Behav Modif 2007; 31:896.
  76. Stefanato CM. Histopathology of alopecia: a clinicopathological approach to diagnosis. Histopathology 2010; 56:24.
  77. Tay YK, Levy ML, Metry DW. Trichotillomania in childhood: case series and review. Pediatrics 2004; 113:e494.
  78. Bloch MH, Landeros-Weisenberger A, Dombrowski P, et al. Systematic review: pharmacological and behavioral treatment for trichotillomania. Biol Psychiatry 2007; 62:839.
  79. Rothbart R, Amos T, Siegfried N, et al. Pharmacotherapy for trichotillomania. Cochrane Database Syst Rev 2013; :CD007662.
  80. Ninan PT, Rothbaum BO, Marsteller FA, et al. A placebo-controlled trial of cognitive-behavioral therapy and clomipramine in trichotillomania. J Clin Psychiatry 2000; 61:47.
  81. McGuire JF, Ung D, Selles RR, et al. Treating trichotillomania: a meta-analysis of treatment effects and moderators for behavior therapy and serotonin reuptake inhibitors. J Psychiatr Res 2014; 58:76.
  82. Grant JE, Odlaug BL, Kim SW. N-acetylcysteine, a glutamate modulator, in the treatment of trichotillomania: a double-blind, placebo-controlled study. Arch Gen Psychiatry 2009; 66:756.
  83. Bloch MH, Panza KE, Grant JE, et al. N-Acetylcysteine in the treatment of pediatric trichotillomania: a randomized, double-blind, placebo-controlled add-on trial. J Am Acad Child Adolesc Psychiatry 2013; 52:231.
  84. Pacan P, Grzesiak M, Reich A, et al. Onychophagia and onychotillomania: prevalence, clinical picture and comorbidities. Acta Derm Venereol 2014; 94:67.
  85. Baran R. Nail biting and picking as a possible cause of longitudinal melanonychia. A study of 6 cases. Dermatologica 1990; 181:126.
  86. Reese JM, Hudacek KD, Rubin AI. Onychotillomania: clinicopathologic correlations. J Cutan Pathol 2013; 40:419.
  87. Torres RJ, Puig JG, Jinnah HA. Update on the phenotypic spectrum of Lesch-Nyhan disease and its attenuated variants. Curr Rheumatol Rep 2012; 14:189.
  88. Elsea SH, Girirajan S. Smith-Magenis syndrome. Eur J Hum Genet 2008; 16:412.
  89. Dallos T, Oppl B, Kovács L, Zwerina J. Pachydermodactyly: a review. Curr Rheumatol Rep 2014; 16:442.
  90. Cabanillas M, Monteagudo B, León-Muíños E, Suárez-Amor O. Pachydermodactyly in a young girl: cutaneous manifestation of a psychiatric disorder? Pediatr Dermatol 2010; 27:306.
  91. Beltraminelli H, Itin P. Pachydermodactyly--just a sign of emotional distress. Eur J Dermatol 2009; 19:5.