Diagnostic features

• Recurrent skin picking resulting in lesions, wounds, scabs or tissue damage.
• Repeated attempts to stop or reduce the behaviour.
• Picking causes clinically significant distress or impairment (social, occupational, medical).
• Not better explained by another medical condition (e.g., scabies), another psychiatric disorder (e.g., delusions) or substance effects.

Clinical presentation & patterns

• Common sites: face (acne, blackheads), arms, legs, cuticles, scalp and other accessible skin areas.
• Patterns: automatic (habitual, low awareness) vs focused (triggered by emotions, tension or perceived skin imperfection); many individuals show mixed patterns.
• Severity spectrum: from cosmetic concerns to severe tissue damage, recurrent infection, and medical complications (cellulitis, scarring).

Associated conditions

• Often co‑occurs with trichotillomania (hair pulling), OCD spectrum disorders, depression, anxiety, ADHD and substance misuse.
• Psychosocial consequences include shame, social withdrawal, avoidance of activities and reduced quality of life.

Assessment checklist

1. History: onset, frequency, triggers, awareness level (automatic vs focused), sites picked, and prior treatments or attempts to stop.
2. Examine lesions and rule out primary dermatologic causes or infection — involve dermatology where diagnosis uncertain or wounds severe.
3. Assess comorbid mental health (depression, anxiety, OCD, ADHD), suicidality, and functional impact (work, relationships).
4. Consider using scales (e.g., Skin Picking Scale, NE-YBOCS for BFRBs) to quantify severity and monitor response.

First‑line treatment — behavioural therapies

• Habit Reversal Training (HRT): core intervention — awareness training, competing response (incompatible behaviour), stimulus control and social support.
• Comprehensive Behavioral Intervention for Tics/Body‑Focused Repetitive Behaviors (CBIT/BFRT): expands HRT with functional assessment and tailored strategies.
• Acceptance & Commitment Therapy (ACT) and CBT elements: helpful for emotional regulation, distress tolerance and reducing avoidance.

Medical & adjunctive treatments

• Wound care and dermatology input for infected or complex lesions — cleaning, dressings, topical antibiotics where indicated, and scar management.
• Pharmacologic options: evidence is mixed — N‑acetylcysteine (NAC) has some support; SSRIs, antipsychotics or other agents considered in specialist settings for severe or comorbid presentations.
• Telehealth, group therapy and digital habit‑reversal programs can increase access where therapists are limited.

Practical self‑help & harm‑reduction strategies

1. Identify triggers and implement stimulus control (keep nails short, wear gloves, use fidget objects, cover mirrors) to reduce opportunities to pick.
2. Competing responses: adopt brief behaviours incompatible with picking (clenching fists, squeezing a stress ball) when urge arises.
3. Use a picking diary to increase awareness and schedule ‘skin checks’ rather than continuous picking; reinforce small successes and use contingency plans for relapse.

Key takeaways

• Excoriation Disorder ranges from mild to severe; first‑line treatment is behavioural (HRT/CBIT) combined with dermatologic wound care when needed.
• Identify triggers, use stimulus control and competing responses, and coordinate dermatology and psychiatry for complex cases.
• Escalate urgently for infection, severe scarring, suicidality or major functional decline.