The essential feature of excoriation (skin-picking) disorder is recurrent picking at one’s own skin (Criterion A). The most commonly picked sites are the face, arms, and hands, but many individuals pick from multiple body sites. Individuals may pick at healthy skin, at minor skin irregularities, at lesions such as pimples or calluses, or at scabs from previous picking. Most individuals pick with their fingernails, although many use tweezers, pins, or other objects. In addition to skin picking, there may be skin rubbing, squeezing, lancing, and biting. Individuals with excoriation disorder often spend significant amounts of time on their picking behavior, sometimes several hours per day, and such skin picking may endure for months or years. Criterion A requires that skin picking lead to skin lesions, al- though individuals with this disorder often attempt to conceal or camouﬂage such lesions (e.g., with makeup or clothing). Individuals with excoriation disorder have made repeated attempts to decrease or stop skin picking (Criterion B).
ment in social, occupational, or other important areas of functioning. The term distress in- cludes negative affects that may be experienced by individuals with skin picking, such as feeling a loss of control, embarrassment, and shame. Significant impairment may occur in several different areas of functioning (e.g., social, occupational, academic, and leisure), in part because of avoidance of social situations.
Skin picking may be accompanied by a range of behaviors or rituals involving skin or scabs.
Thus, individuals may search for a particular kind of scab to pull, and they may examine, play with, or mouth or swallow the skin after it has been pulled. Skin picking may also be pre- ceded or accompanied by various emotional states. Skin picking may be triggered by feelings of anxiety or boredom, may be preceded by an increasing sense of tension (either immedi- ately before picking the skin or when attempting to resist the urge to pick), and may lead to gratification, pleasure, or a sense of relief when the skin or scab has been picked. Some indi- viduals report picking in response to a minor skin irregularity or to relieve an uncomfortable bodily sensation. Pain is not routinely reported to accompany skin picking. Some individuals engage in skin picking that is more focused (i.e., with preceding tension and subsequent re- lief), whereas others engage in more automatic picking (i.e., when skin picking occurs with- out preceding tension and without full awareness), and many have a mix of both behavioral styles. Skin picking does not usually occur in the presence of other individuals, except im- mediate family members. Some individuals report picking the skin of others.
In the general population, the lifetime prevalence for excoriation disorder in adults is 1.4% or somewhat higher. Three-quarters or more of individuals with the disorder are female.
This likely reﬂects the true gender ratio of the condition, although it may also reﬂect dif- ferential treatment seeking based on gender or cultural attitudes regarding appearance.
Although individuals with excoriation disorder may present at various ages, the skin pick- ing most often has onset during adolescence, commonly coinciding with or following the onset of puberty. The disorder frequently begins with a dermatological condition, such as acne. Sites of skin picking may vary over time. The usual course is chronic, with some waxing and waning if untreated. For some individuals, the disorder may come and go for weeks, months, or years at a time.
Genetic and physiological. Excoriation disorder is more common in individuals with general population.
Most individuals with excoriation disorder admit to skin picking; therefore, dermato- pathological diagnosis is rarely required. However, the disorder may have characteristic features on histopathology.