Anyone who has survived adolescence knows the feeling of seeing an ugly head of pus on the face and having the urge to press it out. Despite many commonly known warnings about the evils that befall those that pop pimples (the pimples will spread, grow infected and/or scar), few resist.
However, there are cases in which this behavior can become extreme. Such behavior becomes a condition called excoriation disorder (also known as dermatillomania, acne excoriée, neurotic excoriation, or psychogenic excoriation) when it is repetitive and intentionally self-harming.
Characteristics of excoriation disorder
Skin-picking is quite common and may occur at any age. It typically begins in adolescence as it coincides with the onset of puberty. Patients suffering from acne or eczema are more likely to pick their skin.
What distinguishes excoriation disorder from normal skin picking is that this behavior is self-injurious and involves repetitive scratching or picking at healthy skin, minor skin irregularities or general skin-picking automatically without realizing it. The behavior also results in tissue damage.
Sufferers of this disorder may skin-pick any area of the body and usually do so in multiple places. The most common areas are the face, followed by the hands, fingers, arms or legs. Acne, papules, scabs, scars, calluses and insect bites are also sometimes excoriation sites.
While potential skin-picking triggers may vary across individuals, common ones include emotions such as stress, anger, and anxiety. Skin-picking is often common during sedentary activities as well such as watching television and reading, boredom and feeling tired.
Excessive picking can result in tissue damage and lead to medical complications such as localized infections. Such behavior often begins with the onset of a dermatological condition like acne, and often worsens conditions by preventing wounds from healing properly.
Psychological aspect of the disorder
The behavior associated with skin picking shares similar symptoms with obsessive-compulsive disorder (OCD) and impulse control disorder. Features that resemble OCD include obsessions about an irregularity on the skin or preoccupation with having smooth skin and excoriating in response to the thoughts. Individuals who pick their skin may also experience mild to moderate levels of depression and/or anxiety.
Through the experience of picking, sufferers may feel tension prior to excoriating and relief or pleasure during or afterwards. However, any positive feelings are unfortunately transient and give way to the urge to pick again.
Individuals who skin pick rarely seek dermatological or psychiatric treatment for their condition; they are either embarrassed or believe that the condition is untreatable.
Instead, some patients may avoid social activities as it may expose their scars or injuries. Others resort to cosmetics, clothing and/or bandages to camouflage their scars.
However, there are other ways out. For excoriation disorder, both pharmacological and nonpharmacological treatments can help.
Cognitive-behavioral therapy and habit reversal therapy can be powerful interventions for excoriation disorder sufferers. Cognitive-behavioral therapy involves psychoeducation, cognitive restructuring and an emphasis on relapse prevention.
Habit reversal therapy involves self-monitoring and substituting skin-picking with an incompatible action. For examples, patients can be advised to clench their fists whenever they feel the urge to skin pick. Another example is to introduce a new behavioural sequence that ends with a harmless action: the hand approaches the face to pick the skin but then consciously deviates to a different location such as the ear.
Research on the use of medications for excoriation disorder is currently limited. Individuals who suffer from skin picking should receive a thorough physical examination before going on any medication.
Having said that, many individuals can benefit from drug interventions. Pharmacological agents used to treat excoriation disorder include:
Selective serotonin reuptake inhibitors
It is widely believed that imbalanced or low serotonin levels contribute to depression, anxiety disorders and some personality disorders. Better regulating serotonin is believed to help improve the brain function and thereby reduce the urge to skin-pick. Common drugs that increase levels of serotonin to the brain include clomipramine, fluoxetine and sertraline.
Like serotonin, people with low dopamine may exhibit more depression, anxiety, poor outlook, addiction and self-harming behavior. Opioid antagonists (naltrexone, nalmefene) increase the dopamine levels in our body and help diminish the urge to pick.
Examples include N-acetyl cysteine (NAC) and riluzole. Skin picking, along with other compulsive and habitual disorders, is said to arise from defective signalling of a substance called glutamate. With glutamatergic agents such as NAC, it helps to increase levels of glutamate in the brain, ensuring signalling functions normally again, reducing the urge to pick on skin.
When to visit a dermatologist
When picking on acne becomes serious, such as causing frequent infections or severe scarring, patients should seek help and visit a dermatologist. While skin picking is rather common, patients should take note if the intensity and frequency of such behaviour increases over time. Skin picking can inflict severe tissue damage, and may require a long period of time for scars to heal. A dermatologist will be able to provide professional treatment and advice before the condition worsens.