Excoriation disorder is associated with distress as well as with social and occupational im- pairment. The majority of individuals with this condition spend at least 1 hour per day picking, thinking about picking, and resisting urges to pick. Many individuals report avoiding social or entertainment events as well as going out in public. A majority of indi- viduals with the disorder also report experiencing work interference from skin picking on at least a daily or weekly basis. A significant proportion of students with excoriation disor- der report having missed school, having experienced difficulties managing responsibilities at school, or having had difficulties studying because of skin picking. Medical complica- tions of skin picking include tissue damage, scarring, and infection and can be life-threaten- ing. Rarely, synovitis of the wrists due to chronic picking has been reported. Skin picking often results in significant tissue damage and scarring. It frequently requires antibiotic treat- ment for infection, and on occasion it may require surgery.
Psychotic disorder. Skin picking may occur in response to a delusion (i.e., parasitosis) or tactile hallucination (i.e., formication) in a psychotic disorder. In such cases, excoriation disorder should not be diagnosed.
Other obsessive-compulsive and related disorders. Excessive washing compulsions in response to contamination obsessions in individuals with 0CD may lead to skin lesions, and skin picking may occur in individuals with body dysmorphic disorder who pick their skin solely because of appearance concerns; in such cases, excoriation disorder should not be diagnosed. The description of body-focused repetitive behavior disorder in other spec- meet diagnostic criteria for excoriation disorder.
Neurodevelopmental disorders. While stereotypic movement disorder may be charac- terized by repetitive self—injurious behavior, onset is in the early developmental period.
For example, individuals with the neurogenetic condition Prader-Willi syndrome may have early onset of skin picking, and their symptoms may meet criteria for stereotypic movement disorder. While tics in individuals with Tourette’s disorder may lead to self- injury, the behavior is not tic-like in excoriation disorder.
Somatic symptom and related disorders. Excoriation disorder is not diagnosed if the skin lesion is primarily attributable to deceptive behaviors in factitious disorder.
Other disorders. Excoriation disorder is not diagnosed if the skin picking is primarily attributable to the intention to harm oneself that is characteristic of nonsuicidal self-injury.
Other medical conditions. Excoriation disorder is not diagnosed if the skin picking is primarily attributable to another medical condition. For example, scabies is a dermatolog- ical condition invariably associated with severe itching and scratching. However, excori- condition. For example, acne may lead to some scratching and picking, which may also be associated with comorbid excoriation disorder. The differentiation between these two clinical situations (acne with some scratching and picking vs. acne with comorbid excori- ation disorder) requires an assessment of the extent to which the individual’s skin picking has become independent of the underlying dermatological condition.
Substance/medication-induced disorders. Skin-picking symptoms may also be induced by certain substances (e.g., cocaine), in which case excoriation disorder should not be di- agnosed. If such skin picking is clinically significant, then a diagnosis of substance/med- ication-induced obsessive-compulsive and related disorder should be considered.
Excoriation disorder is often accompanied by other mental disorders. Such disorders in- clude OCD and trichotillomania (hair-pulling disorder), as well as major depressive dis- order. Repetitive body-focused symptoms other than skin picking and hair pulling (e.g., nail biting) occur in many individuals with excoriation disorder and may deserve an ad- ditional diagnosis of other specified obsessive-compulsive and related disorder (i.e., body-focused repetitive behavior disorder).