Skin picking disorder (SPD) is a psychocutaneous syndrome characterized by recurrent and deliberate manipulation of the skin resulting in tissue damage. Many terms are used to characterize this disorder and include but are not limited to dermatillomania, neurodermatitis, psychogenic excoriation, lichen simplex chronicus, acne excoriée, and neurotic excoriation. In the Diagnostic and Statistical Manual of Mental Disorders, fifth edition (DSM-5), SPD is included as a separate diagnosis in the group of the obsessive-compulsive and related disorders, along with trichotillomania and body dysmorphic disorder.
Hallmarks of SPD clinical manifestations are polymorphic lesions at various stages of healing and severity. Distribution includes extensor surfaces of the upper arms and forearms, face, upper back, scalp, and buttocks. Acutely induced lesions are often angular in shape with serosanguinous crust.
Older lesions may be crusted or appear as hypertrophic nodules or atrophic scars at all stages of evolution with a background of postinflammatory hypo- or hyperpigmentation.
Neurotic Excoriations. Middle-aged female with depression and facial neurotic excoriations. (Image appears with permission from VisualDx [www.visualdx.com].)
Neurotic Excoriations-Legs. Excoriations of the lower leg at various stages of development and healing. (Image appears with permission from VisualDx [www.visualdx.com].)
Neurotic Excoriations—Acute on Chronic Findings. Acute neurotic excoriations over extensor surfaces of the forearm. Lesion size ranges from a few millimeters to centimeters in size. (Image appears with permission from VisualDx [www.visualdx.com].)
Management and Disposition
Management of SPD is notoriously difficult, and evaluation must include a thorough medical and psychiatric history with particular focus on elicitation of underlying psychiatric illness while not excluding consideration of a primary underlying dermatologic etiology. Special attention should be placed on addressing secondary infections and/or skin disfigurement requiring surgical intervention. In some cases, semiocclusive dressings may be helpful in preventing further skin damage and promoting healing. Topical glucocorticoids such as triamcinolone acetonide may be helpful in relieving pruritis, although no clinical trials have been performed to date to determine efficacy. Cognitive-behavioral therapy has shown some promise in promoting discontinuation of skin picking behaviors. Psychiatric referral should be considered when an underlying organic cause has been excluded.
Complications of SPD such as skin infection should be addressed prior to psychiatric evaluation.
Careful consideration of primary or chronic skin conditions should be carefully considered at the time of evaluation.
Successful management of SPD should include psychiatric referral, although many patients may be reticent to accept such a recommendation.