Excoriation disorder is not diagnosed if the skin lesion is primarily attributable to deceptive behaviors in factitious disorder. 

Dermatitis Artefacta as a Differential Diagnosis to Excoriation (Skin-Picking Disorder)

Excoriation disorder is not diagnosed if the skin picking is primarily attributable to another medical condition. For example, scabies is a dermatological condition invariably associated with severe itching and scratching. However, excoriation disorder may be precipitated or exacerbated by an underlying dermatological condition. For example, acne may lead to some scratching and picking, which may also be associated with comorbid excoriation disorder (so-called acne excoriée). The differentiation between these two clinical situations (acne with some scratching and picking vs. acne with comorbid excoriation disorder) requires an assessment of the extent to which the individual’s skin picking has become independent of the underlying dermatological condition.

Other Medical Conditions as Differential Diagnoses to Excoriation (Skin-Picking 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.

Psychotic Disorder as a Differential Diagnosis to Excoriation (Skin-Picking Disorder) 

Excessive washing compulsions in response to contamination obsessions in individuals with OCD 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 specified obsessive-compulsive and related disorder excludes individuals whose symptoms 
meet diagnostic criteria for excoriation disorder.

Other Obsessive-Compulsive and Related Disorders as Differential Diagnoses to Excoriation (Skin-Picking Disorder)

While stereotypic movement disorder may be characterized 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. 

Neurodevelopmental Disorders as Differential Diagnoses to Excoriation (Skin-Picking Disorder)

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 Disorders as Differential Diagnoses to Excoriation (Skin-Picking Disorder)

Skin-picking symptoms may also be induced by certain substances (e.g., cocaine), in which case excoriation disorder should not be diagnosed. If such skin picking is clinically significant, then a diagnosis of substance/medication-induced obsessive-compulsive and related disorder should be considered.

Substance/Medication-Induced Disorders as Differential Diagnoses to Excoriation (Skin-Picking Disorder) 

- Psychotic disorder
- Other obsessive-compulsive and related disorder
- Neurodevelopmental disorders
- Dermatitis artefacta
- Other disorders
- Other medical conditions
- Substance/medication-induced disorders

State University of New York at Buffalo

Excoriation disorder is an obsessive-compulsive disorder, where individuals constantly show skin picking behavior.


Excoriation (Skin-Picking) Disorder

An online survey of more than 10,000 adults, ages 18–69 years, age- and gender-matched to the U.S. population, found that 2.1% identified as having current excoriation disorder and 3.1% reported lifetime excoriation disorder. Three-quarters or more of individuals with the disorder are women in community samples. 

Prevalence of Excoriation (Skin Picking Disorder)

Although individuals with excoriation disorder may present at various ages, the skin picking 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. 

Development and Course of Excoriation (Skin Picking Disorder)

Most individuals with excoriation disorder admit to skin picking; therefore, dermatopathological diagnosis is rarely required. However, the disorder may have characteristic features on histopathology. 

Diagnostic Markers of Excoriation (Skin Picking Disorder)

Risk and prognostic factors that affect the diagnosis of  Excoriation (Skin Picking Disorder) include:

- Genetic and Physiological

Risk and Prognostic Factors of Excoriation (Skin Picking Disorder) 

Differential Diagnosis of Excoriation (Skin-Picking) DIsorder

Clinical case reports suggest that some of individuals with Excoriation  engage in skin picking during sleep. Picking severity, anxiety and depressive symptoms, and sleep disturbance were significantly increased in those who engaged in picking during sleep relative to those who did not endorse this behavior

Excoriation and Sleeping

A. Recurrent skin picking resulting in skin lesions. 

B. Repeated attempts to decrease or stop skin picking. 

C. The skin picking causes clinically significant distress or impairment in social, occupational, or other important areas of functioning. 

D. The skin picking is not attributable to the physiological effects of a substance (e.g., cocaine) or another medical condition (e.g., scabies). 

E. The skin picking is not better explained by symptoms of another mental disorder (e.g., delusions or tactile hallucinations in a psychotic disorder, attempts to improve a perceived defect or flaw in appearance in body dysmorphic disorder, stereotypies in stereotypic movement disorder, or intention to harm oneself in nonsuicidal self-injury). 

[DSM-5-TR] Criteria of Excoriation (Skin Picking Disorder)

Associated features of excoriation may include:
- Skin picking may be accompanied by a range of behaviors or rituals involving skin or scabs. 
- Skin picking may also be preceded or accompanied by various emotional states.
- Some individuals 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 relief), whereas others engage in more automatic picking (i.e., when skin picking occurs without 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 immediate family members. 
- Some individuals report picking the skin of others.

Associated Features of Excoriation (Skin Picking Disorder)

The essential feature 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, although 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). Criterion C indicates that skin picking causes clinically significant distress or impairment in social, occupational, or other important areas of functioning. The term distress includes negative effects 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.


[DSM-5-TR] Diagnostic Features of Excoriation (Skin-Picking Disorder) 

There are limited data on the prevalence and clinical characteristics of excoriation disorder across cultures. However, clinical features appear similar in studies of individuals in the United States and other countries.

Culture-Related Diagnostic Issues of Excoriation (Skin-Picking Disorder) 

There are several suggested treatment for excoriation. 
Nonpharmacological treatment: 
- Cognitive-behavioral therapy 
- Habit reversal therapy

Pharmacotherapy:
- Selective serotonin reuptake inhibitors (SSRIs)
- Lamotrigine
- Glutamatergic agents
- Augmentation strategies 

Treatment of Excoriation 

Excoriation disorder is associated with social and occupational impairment. 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 individuals 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 disorder report having missed school, having experienced difficulties managing responsibilities at school, or having had difficulties studying because of skin picking. Medical complications of skin picking include tissue damage, scarring, and infection and can be life-threatening. Rarely, synovitis of the wrists resulting from chronic picking has been reported. Skin picking often results in significant tissue damage and scarring. It frequently requires antibiotic treatment for infection, and on occasion it may require surgery.

Functional Consequences of Excoriation (Skin-Picking Disorder)

Excoriation disorder is often accompanied by other mental disorders. Such disorders include OCD and trichotillomania (hair-pulling disorder), as well as major depressive disorder. Depression comorbidity seems to be more common in women. 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 additional diagnosis of other specified obsessive compulsive and related disorder (i.e., other body-focused repetitive behavior disorder).

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