Excoriation Disorder

Excoriation Disorder is a topic covered in the 5-Minute Pediatric Consult.

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Basics

Description

Excoriation or skin picking disorder (ExD) is recurrent picking at one’s skin to the point of causing skin lesions or recurrent bleeding. Skin picking causes clinically significant distress or functional impairment, is accompanied by repeated efforts to stop or reduce the picking, and is not due to another mental disorder or a general medical or dermatologic condition.

  • Skin picking can occur in any region of the body, but the most common sites are the face, arms, and hands. Many individuals pick at multiple sites, which may also vary over time.
  • Picking can focus on pimples, scabs, insect bites, or other skin irregularities, but individuals also often pick at healthy unblemished skin.
  • Most individuals pick with their fingernails, but instruments such as tweezers, needles, knives, or pins may also be used.
  • Squeezing, rubbing or biting of skin, or lancing of pimples of other lesions is also common.
  • Some patients experience tension immediately before picking or when attempting to resist the behavior, whereas others experience pleasure or relief when they have picked at a blemish or scab.
  • Patients may engage in rituals related to their skin picking, for example, putting the picked scab in the mouth, playing with the extruded material from a pimple.
  • Picking and the associated rituals often consume several hours a day.
  • Picking may be deliberate (and is often done in front of a mirror) or more automatic or habitual in nature, and is typically not associated with pain.
  • Individuals with chronic ExD often attempt to conceal or camouflage the resulting skin lesions with cosmetics, bandages, long sleeves, or other articles of clothing.

Epidemiology

  • Although ExD can occur in children <10 years and in adults, the typical onset is in adolescence between ages 13 and 15 years.
  • 75% or more of individuals with ExD are female.

Risk Factors

ExD is more common in individuals with obsessive-compulsive disorder (OCD) and in their 1st-degree relatives.

Genetics

  • A study of >5400 female twins suggests that the heritability of ExD is ~ 47%, and that it has substantial genetic overlap with trichotillomania (TTM), also known as hair pulling disorder. Approximately 15% of genetic risk for ExD is shared with other obsessive-compulsive and related disorders.
  • No specific genes have been implicated for ExD.

Commonly Associated Conditions

  • Localized infections, abscesses and scarring, in severe cases, septicemia can occur.
  • Psychiatric comorbidity is common (seen in 20–50% of adolescents with ExD) and includes
    • Mood disorders
    • Anxiety disorders
    • Body dysmorphic disorder
    • OCD
    • Substance abuse
  • Skin picking typically begins earlier in childhood than any of the associated psychiatric comorbidities.
  • Patients may also engage in nail-biting, hair pulling, or other pathologic grooming behaviors.

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