What Is Excoriation, or Skin-Picking?

We’ve all heard suspenseful movies referred to as “nail-biters” and nearly all of us — kids, teens and adults — occasionally pick at a ragged hangnail or poke at a blemish too aggressively. Almost always, we end up regretting what we’ve done. But for some of us, picking at skin or cuticles becomes more than an occasional thing, and it can be very hard to stop, even when it becomes embarrassing. Clinicians call it a body-focused repetitive behavior or BFRB.

Skin picking, formally known as excoriation disorder, is the repetitive, habitual picking of skin anywhere on the body (though the most common areas are the face, hands, arms or legs). Excoriation disorder is not just a bad habit. This behavior is a compulsion — something we feel driven to do even when it has a negative impact on our lives — and is related to obsessive-compulsive disorder. It is common in people who have anxiety disorders.

Skin picking is a “cousin” of trichotillomania, or hair pulling, which is another BFRB and which is also related to both OCD and anxiety. Both disorders can be thought of as unhealthy ways of coping with anxiety or other negative feelings, and the incidents of skin picking and hair pulling are often triggered by stressful situations. Excoriation can be challenging to treat because the child often relies on the picking to self-soothe or diffuse negative emotions. This repetitive habit is, however, embarrassing and disfiguring, and can lead to avoidance of social situations, which only leads to further distress and sometimes depression.

According to Jerry Bubrick, PhD, a clinical psychologist at the Child Mind Institute, skin picking is considered a disorder when:

• Recurrent skin picking results in scarring or other permanent damage
• The individual has made and failed at repeated attempts to stop the behavior
• The picking causes significant distress or impairment in the individual’s daily life
• Symptoms are not caused by medication or another medical condition

Skin picking tends to emerge at puberty and often parents see skin picking as just a bad habit — as if the adolescent could stop if she tried hard enough. “That’s a lot like telling someone with cancer to just ‘get better’ or someone with depression to just ‘cheer up,’ ” says Dr. Bubrick. “There’s tremendous shame associated with skin picking because it results in scarring or other kinds of visible damage to the skin (particularly the face) that make the teen extremely self-conscious.”

Though all skin picking results in visible damage and distress for the child who struggles with it, the picking itself can serve different purposes and it can be helpful to know why someone engages in the behavior in order to better treat it.

In what Dr. Bubrick calls “functional” skin picking, the behavior is a sort of compulsive perfectionism. The child perceives an imperfection in a particular area — a callus, rough cuticle, pimple, etc., and picks or scratches or squeezes it to get rid of it. The “functional” thinking, explains Dr. Bubrick, goes something like this: “My skin is smooth, but as I’m feeling my arm, I feel like I have this bump or this mosquito bite. So, I’m going to keep scratching at that, because I want that off. I want my skin to be smooth again. I’ll look at my fingernails, and I’ll see, oh, on the top of my pointer finger the cuticle is off. So, I’m going to pick at that and bite at that until it looks better.”

But with skin picking disorder, it never does get better. In fact, the individual is likely to pick until the area is worn away and bleeding. Even that doesn’t always stop the behavior. The child continues to pick because it just doesn’t feel right and stops only when it hurts so much that they can’t continue.

 Compulsive skin picking is done to self-soothe or deal with anxiety or other negative emotions. This behavior is very much like a kind of hair pulling. “It’s a way to tune out the world. It’s almost like a drug,” explains Dr. Bubrick. The same feeling might be dealt with by drinking or smoking. Like those behaviors, the skin picking is a bad coping strategy for dealing with stressors.

Some teens who struggle with skin picking engage in the functional type or the compulsive type, but they may also do both. Sometimes they are not even aware they are doing it and then find they’ve spent an hour in a kind of picking trance.

 Identifying the signs of skin picking can be challenging for a number of reasons. For starters, most teens feel so much shame about the visible results of the behavior that they will try to hide them either by wearing band-aids or long sleeves or make-up. Also, teens rarely come into a psychiatrist’s office seeking help for skin picking alone. “A lot of times,” says Dr. Bubrick, “they’re here for anxiety or OCD, and that gets better and they’re like, ‘oh, can we also work on my skin picking, because it’s really bothering me.’”

But in most cases, kids don’t like to talk about skin picking, so unless the clinician asks about it directly, they won’t bring it up. Sometimes kids just don’t see the problem as a big deal. Or it serves as a coping mechanism on which they are so dependent that they won’t want to draw attention to it.

 Success in treating skin picking depends largely on the teen’s desire to change and readiness to make a commitment to work on the problem. “If a kid comes in kicking and screaming, saying, ‘I’m fine. My parents just don’t like it that I bite my nails or I bite my cuticles,’ ” Dr. Bubrick says, “then treatment is going to be tough. But if a kid is coming in and saying, ‘It’s really causing me so much distress, I can’t wear short sleeves or I can’t wear shorts because of my scars or my fingers are bleeding all the time, or I feel self-conscious on a date because my fingers are down to a nub.’ Then treatment’s easier.”

Insight, motivation and readiness for change are key variables clinicians look for when starting to treat the disorder.  Treatment can consist of a number of different approaches, or combinations of approaches:

• Putting a barrier in place: Even something simple like a band-aid can be a starting point to deter picking. Or kids might paint on Liquid Bandage so that they have something to peel off without the behavior causing damage. This approach is what is referred to in OCD terminology as “response prevention.” Response prevention gives the child something else to focus on — the band-aid — when they are tempted to pick. “It gives them a little extra moment to think before they act,” says Dr. Bubrick. It may help, but Dr. Bubrick says this approach is usually not enough eliminate the behavior.
• Cognitive behavior therapy, or CBT: CBT is the most successful treatment for skin picking. CBT covers a broad range of modalities, but it mostly comes down to teaching the child more effective ways of dealing with the stress or anxiety that is triggering the picking instead of biting — finding similar behaviors to replace the damaging ones. For example, Dr. Bubrick says he might say to a patient, “Well, biting is one way of dealing with a stressor. Let’s think about two others, that maybe are less damaging to your body, but still allow you to deal with the stressor.”
• NAC (N-acytel-cystine): Nac is an over-the-counter supplement which has shown variable results in the treatment of skin picking and other body focused repetitive behaviors. Some people do well on it, while others have minimal response. The upside is that there is no harm in trying it and it has no side effects.
• Antidepressants: The class of antidepressants called SSRIs (selective serotonin reuptake inhibitors) can be effective in treating related anxiety or depression, which may be triggering or exacerbating the skin picking behaviors. So decreasing that anxiety or depression may indirectly have a positive effect on the picking.
• Acceptance and Commitment Therapy (ACT): ACT combines techniques from CBT and mindfulness as a way of accepting emotion instead of attempting to get rid of it through coping mechanisms like skin picking. It focuses on the idea that difficult things are going to happen to which the child is going to have a negative response. The child is asked to commit to feeling those things without doing something to hurt themselves, such as skin picking. The goal is to learn “that I can feel negative emotions, and I don’t have to injure myself because I feel them. I can just feel them.” It’s a matter of becoming more at peace with the thoughts and the feelings, rather than feeling desperate to get rid of them.

Dr Bubrick says that treatment for excoriation can be tricky, but if the child is truly committed to changing their behavior, the dysfunctional coping can be overcome. “Typically, they come in ashamed and embarrassed about the picking,” he says, “but the ones who engage the treatment and follow recommendations, even if they think it won’t work in the beginning, tend to do really well over time.”