Shawn Faust, DNP, PMHNP-BC
Published on 6/22/2026
What Is Excoriation Disorder?
Excoriation Disorder — also known as Skin Picking Disorder or dermatillomania — is a type of obsessive-compulsive related disorder characterized by recurrent, compulsive picking at one’s own skin, leading to tissue damage.¹ It is classified alongside conditions like Trichotillomania (Hair Pulling Disorder) and Obsessive-Compulsive Disorder (OCD).¹
Excoriation Disorder affects an estimated 2–3% of the general population, with a lifetime prevalence of approximately 3%.¹˒²˒³ It is more common in women, with three-quarters or more of affected individuals being female.¹ It can begin at any age but most commonly starts in adolescence or early adulthood, often triggered by a dermatological condition such as acne.⁴ Despite being relatively common, it is underrecognized and undertreated — many people suffer in silence for years, feeling ashamed of their behavior and its visible consequences. Effective treatments, including behavioral therapy and certain medications, are available.⁴˒⁵
What Excoriation Disorder Feels Like
Skin picking often begins almost automatically — sometimes without the person fully realizing they are doing it. They may be watching television, reading, or lying in bed when their fingers find a bump, a scab, or an area of rough skin. What starts as a brief touch becomes focused picking that can last minutes or hours. There may be a sense of tension or an urge beforehand, and a brief feeling of relief or satisfaction during the picking — followed by guilt, shame, and frustration when the damage becomes apparent.
For others, the picking is more deliberate — driven by a need to “fix” a perceived imperfection in the skin, to make it smooth or “right.” Hours may be spent in front of a mirror, examining and picking at skin that others would consider normal. The result is often the opposite of what was intended: wounds, scars, infections, and skin damage that is far more noticeable than the original imperfection.
The emotional aftermath is often the most painful part. Many people with Excoriation Disorder feel deep shame about their skin and go to great lengths to conceal the damage — wearing long sleeves in summer, avoiding swimming or intimacy, applying heavy makeup. The behavior feels impossible to control despite repeated attempts to stop, which can lead to feelings of helplessness and self-blame.
Signs and Symptoms of Excoriation Disorder
Excoriation Disorder involves compulsive skin picking that causes tissue damage.
DSM-5 Diagnostic Criteria
To be diagnosed with Excoriation Disorder, a person must meet the following criteria:¹
- Recurrent skin picking resulting in skin lesions
- Repeated attempts to decrease or stop the picking
- The picking causes clinically significant distress or impairment in social, occupational, or other important areas of functioning
- The skin picking is not attributable to the physiological effects of a substance or another medical condition (e.g., scabies)
- The skin picking is not better explained by symptoms of another mental disorder
Picking sites most commonly include the face, arms, hands, and legs, but any body area can be affected. Picking may target real skin irregularities (pimples, scabs, calluses) or healthy skin. Tools such as tweezers, pins, or fingernails may be used.¹˒⁴
Two styles of picking are recognized:¹˒⁴
- Automatic (unfocused): Picking occurs outside of awareness, often during sedentary activities
- Focused: Picking is deliberate, often in response to an urge, tension, or desire to “fix” the skin
Many people experience a mix of both styles.
Additional & Associated Features
Beyond the formal diagnostic criteria, many people with Excoriation Disorder also experience:¹˒⁴
- Skin damage including wounds, scarring, and infections
- Significant time spent picking (often more than one hour per day)
- Avoidance of social situations due to visible skin damage
- Emotional distress including shame, embarrassment, and frustration
- Co-occurring anxiety, depression, OCD, and other body-focused repetitive behaviors³˒⁶
How Excoriation Disorder Affects Daily Life
Excoriation Disorder can significantly affect physical health, emotional well-being, and social functioning. The skin damage itself can lead to scarring, infections, and in severe cases, the need for medical or surgical treatment. Significant time is lost to picking episodes and to the rituals of concealing the damage.
Social life often suffers. Many people avoid activities that would expose their skin — swimming, intimacy, wearing certain clothing — and may withdraw from social situations altogether. Work and school performance can be affected by the time consumed by picking and by the distress and self-consciousness that follow.
The shame associated with Excoriation Disorder can be profound. Many people feel that they “should” be able to stop and blame themselves for their inability to do so, which can contribute to depression and further isolation.
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Common Causes and Risk Factors for Excoriation Disorder
The exact causes of Excoriation Disorder are not fully understood, but several factors are implicated.
Genetics: Excoriation Disorder is more common in people with first-degree relatives who have OCD or other body-focused repetitive behaviors, suggesting a genetic component.¹˒⁴
Brain biology: Research has implicated dysfunction in the glutamate system and in brain circuits involved in habit formation and impulse control — particularly the cortico-striatal pathways. These findings parallel those seen in Trichotillomania and have informed targeted pharmacological treatments.⁵˒⁷
Temperament and emotional regulation: Perfectionism, difficulty tolerating imperfection, and high levels of negative emotionality are associated with Excoriation Disorder. Emotional states — including anxiety, boredom, tension, and frustration — are common triggers for picking episodes.¹˒⁴
Life experiences: Skin picking often begins in the context of a dermatological condition (such as acne) or during a period of stress. Stressful life events can trigger the onset or worsening of picking behavior.⁴
Other factors: Excoriation Disorder frequently co-occurs with depression, anxiety disorders, OCD, Trichotillomania, and Body Dysmorphic Disorder (BDD).³˒⁶
How Excoriation Disorder Is Diagnosed
Excoriation Disorder is diagnosed through a clinical interview with a mental health professional — not through lab work or imaging. The clinician will ask about the frequency and duration of skin picking, the resulting tissue damage, attempts to stop, and the impact on daily functioning and emotional well-being. Because many people feel ashamed of their skin picking, direct and nonjudgmental questioning is important — many people will not volunteer information about picking unless specifically asked.
To meet diagnostic criteria, there must be recurrent skin picking resulting in skin lesions, repeated attempts to decrease or stop, and clinically significant distress or impairment. The picking must not be attributable to a substance or medical condition, and must not be better explained by another mental disorder.¹
The clinician will also consider whether symptoms are better explained by another condition. BDD may involve skin picking performed specifically to “fix” a perceived flaw in appearance — in Excoriation Disorder, the picking may be driven by urges, tension, or habit rather than appearance concerns.¹ Nonsuicidal self-injury involves intentional self-harm to regulate emotions, whereas in Excoriation Disorder the damage is an unwanted consequence.¹ A dermatological examination may be helpful to assess the extent of skin damage and to rule out primary skin conditions such as eczema, psoriasis, or scabies.
The evaluation is straightforward and conversational — the goal is to understand your experience so the right treatment can begin.
Treatment for Excoriation Disorder
Excoriation Disorder responds well to treatment, even in severe cases. The two main evidence-based approaches are behavioral therapy and medication, and they can be used alone or in combination. There are no FDA-approved treatments specifically for Excoriation Disorder, but several approaches have shown benefit in clinical trials.⁴˒⁵
Behavioral therapy: Habit Reversal Training (HRT) is the most established behavioral treatment.⁴˒⁸ HRT involves three core components: awareness training (learning to recognize the urge and situations that trigger picking), competing response training (substituting a different behavior when the urge arises), and social support. Comprehensive Behavioral Treatment (ComB) expands on HRT by incorporating additional strategies such as stimulus control (modifying the environment to reduce picking opportunities) and cognitive techniques. Acceptance and Commitment Therapy (ACT) may also be incorporated to help manage the emotional distress that drives picking behavior.⁸
Medication: Glutamatergic medications have targeted evidence for reducing picking behavior:
- N-acetylcysteine (NAC) — demonstrated significant benefit in a randomized controlled trial (1200–3000 mg/day), with 47% of participants rated “much or very much improved” compared to 19% on placebo⁵
- Memantine (Namenda) — demonstrated significant benefit in a double-blind placebo-controlled trial (10–20 mg/day) for both skin picking and hair pulling⁷
Serotonergic medications may also be considered:
- Clomipramine (Anafranil) — a tricyclic antidepressant with strong serotonin reuptake inhibitor properties
- SSRIs such as sertraline (Zoloft), fluoxetine (Prozac), and escitalopram (Lexapro) — with some evidence of benefit for reducing picking severity⁹
SSRIs are particularly useful when co-occurring depression, anxiety, or OCD is present — conditions that, when untreated, can exacerbate picking symptoms.⁴˒⁹
Combination treatment: Combining medication with behavioral therapy is often more effective than either alone. Medication can reduce urge intensity, making it easier to engage in and benefit from behavioral therapy — while HRT/ComB builds lasting awareness and competing response skills.
Treatment duration: Long-term or maintenance treatment is often necessary, as skin picking symptoms frequently recur when treatment is discontinued. Ongoing use of behavioral strategies — and in many cases continued medication — helps maintain improvement.
When to Seek Professional Help for Excoriation Disorder
Consider reaching out to a mental health professional if:
- Skin picking is causing noticeable tissue damage, scarring, or infections
- Repeated attempts to stop have been unsuccessful
- Picking is consuming significant time or causing emotional distress
- Social activities, relationships, or work are being affected by the behavior or its consequences
- Sleep is being regularly disrupted by picking urges or distress about the behavior
- There is reliance on alcohol or other substances to manage distress
Seek immediate help if experiencing thoughts of self-harm or suicide. Contact the 988 Suicide and Crisis Lifeline by calling or texting 988, available 24/7.
Conditions That Can Look Similar to Excoriation Disorder
Obsessive-Compulsive Disorder (OCD): Some people with OCD pick at skin as part of a compulsion driven by an obsession (e.g., picking to remove perceived contamination). In Excoriation Disorder, the picking is driven by urges, tension, or habit rather than obsessive thoughts.¹
Body Dysmorphic Disorder (BDD): In BDD, skin picking is performed specifically to “fix” a perceived flaw in appearance. In Excoriation Disorder, the picking may be driven by urges, tension, or habit rather than appearance concerns.¹
Trichotillomania: A closely related condition involving compulsive hair pulling rather than skin picking. The two conditions frequently co-occur and share similar treatment approaches.¹
Frequently Asked Questions About Excoriation Disorder
Is skin picking just a bad habit?
No. Excoriation Disorder goes beyond a simple habit. It involves a compulsive urge that is difficult to resist, causes significant tissue damage, and leads to distress and impairment. It is a recognized psychiatric condition that responds to treatment.¹
Can skin picking cause permanent damage?
Yes. Chronic skin picking can lead to scarring, skin discoloration, and in severe cases, infections that require medical treatment. Early intervention can help prevent long-term damage.
Why can’t I just stop picking?
Excoriation Disorder involves disruptions in brain circuits related to habit formation and impulse control. The inability to stop is not a matter of willpower — it is a feature of the condition. Behavioral therapy can help develop strategies to manage the urges.
Is N-acetylcysteine (NAC) effective for skin picking?
Yes. NAC has shown benefit in clinical trials for reducing skin picking, with a favorable side effect profile. It is available over the counter as a supplement but should be used under the guidance of a mental health professional, ideally as part of a comprehensive treatment plan.⁵
Why don’t SSRIs work as well for Excoriation Disorder as they do for OCD?
Despite being classified alongside OCD, Excoriation Disorder appears to involve different neurobiological mechanisms — particularly the glutamate system rather than the serotonin system. This is why glutamatergic medications such as NAC and memantine (Namenda) have shown more promise than SSRIs for directly reducing picking behavior.⁵˒⁷
References
- American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, Text Revision (DSM-5-TR). American Psychiatric Publishing; 2022.
- Grant JE, Dougherty DD, Chamberlain SR. Prevalence, Gender Correlates, and Co-Morbidity of Trichotillomania. Psychiatry Res. 2020;288:112948.
- Lin A, Farhat LC, Flores JM, et al. Characteristics of Trichotillomania and Excoriation Disorder Across the Lifespan. Psychiatry Res. 2023;322:115121.
- Grant JE. Obsessive-Compulsive Disorder. N Engl J Med. 2014;371(7):646-653.
- Grant JE, Chamberlain SR, Redden SA, Leppink EW, Odlaug BL, Kim SW. N-Acetylcysteine in the Treatment of Excoriation Disorder: A Randomized Clinical Trial. JAMA Psychiatry. 2016;73(5):490-496.
- Lochner C, Roos A, Stein DJ. Excoriation (Skin-Picking) Disorder: A Systematic Review of Treatment Options. Neuropsychiatr Dis Treat. 2017;13:1867-1872.
- Grant JE, Chesivoir E, Valle S, Ehsan D, Chamberlain SR. Double-Blind Placebo-Controlled Study of Memantine in Trichotillomania and Skin-Picking Disorder. Am J Psychiatry. 2023;180(5):348-356.
- Schuck K, Keijsers GPJ, Rinck M. The Effects of Brief Cognitive-Behaviour Therapy for Pathological Skin Picking: A Randomized Comparison to Wait-List Control. Behav Res Ther. 2011;49(1):11-17.
- Lochner C, Roos A, Stein DJ. Excoriation (Skin-Picking) Disorder: A Systematic Review of Treatment Options. Neuropsychiatr Dis Treat. 2017;13:1867-1872.
6/22/2026