Dermatillomania (skin picking disorder): what it is, causes and how it is treated in therapy

Irene is 26 and studying for a civil service exam. She studies six hours a day and, while she highlights her notes, her fingers wander to the skin around her nails: she finds a hangnail, pulls it and moves on to the next one without noticing. When she looks up from the page, two fingers are bleeding. At night something else happens. She washes her face, spots a small pimple on her chin and leans in towards the mirror. "Just that one," she thinks. Forty minutes later she leaves the bathroom with a red face, relieved that it is over and deeply ashamed. She has plasters on three fingers, wears make-up to cover the marks and didn't go to the pool with her friends this summer. Her dermatologist has told her that the acne is under control and the wounds come from picking. What she has has a name, dermatillomania, and it can be treated in therapy.

This guide is written for psychologists and therapists who come across dermatillomania in their practice, sometimes as the main complaint and sometimes hidden behind anxiety or referred by a dermatologist, and also for patients and families looking for reliable information. It covers what it is, how to tell it apart from other skin problems and from self-harm, how to assess it and which treatments have evidence behind them.

What is dermatillomania?

Dermatillomania, also called skin picking disorder or excoriation disorder, means picking, scratching or pulling at your skin over and over until it causes wounds. The MSD Manual Professional Edition sums up the DSM-5-TR criteria like this: there are visible skin lesions caused by recurrent picking (although many people hide them with clothes or make-up), the person has tried many times to cut down or stop, it causes distress or gets in the way of daily life, and it is not better explained by a substance, another medical condition or another mental disorder.

Older texts call it neurotic excoriation or psychogenic excoriation. Since DSM-5 it sits in the chapter on obsessive-compulsive and related disorders, alongside OCD, body dysmorphic disorder, hoarding disorder and trichotillomania, with which it has a lot in common. The WHO's ICD-11 lists it, under code 6B25.1, among the body-focused repetitive behaviour disorders.

Almost everyone picks at a spot or a hangnail now and then, and that is not a disorder. The difference lies in what it causes: wounds that never get the chance to heal, long stretches of lost time, shame and the feeling of being unable to stop however hard you try.

Symptoms of dermatillomania

The way people pick varies a lot from one person to the next, and it changes over the years in the same person. These are the features that come up most often.

Where and how people pick their skin

Most people pick in several places. The face is the most common, followed by the hands, fingers, arms and legs. Sometimes the skin is healthy; other times there are small irregularities: spots, scabs, calluses, hangnails or the skin around the nails. People pick with their fingers and nails, with their teeth or with tools such as tweezers, pins or scissors, as the NHS notes on its skin picking disorder page, which adds another sign: picking moles, freckles, spots or scars to try to "smooth" or "perfect" them.

There is often a small ritual. The MSD Manual describes patients who search carefully for a particular type of scab, remove it in a specific way and sometimes bite or swallow it. Talking about this is very embarrassing, so it helps to ask about it matter-of-factly and without looking surprised.

Picking without noticing, or on purpose

Clinicians distinguish two styles, which nearly always live side by side in the same person. In automatic picking, it happens while the person is doing something else, such as studying, reading or watching a series, and they only notice once there is a wound. In focused picking, the person knows what they are doing and is looking for something specific. It usually starts with tension, anxiety or a rising urge, and picking brings relief and even satisfaction. Guilt and shame follow.

Irene, from the opening, has both: the automatic kind with her notes and the focused kind at the mirror. Telling them apart matters because they are not worked on in the same way, as you will see in the treatment section.

Hiding the wounds

Many people cover the marks with make-up, long sleeves or plasters, and avoid situations where they would show: the beach, the gym, a date or a medical check-up. They hardly ever pick in front of anyone, except perhaps family. In severe cases, picking and covering up the marks can take several hours a day, which leads to being late for or missing work, classes or plans with friends.

What causes dermatillomania?

There is no single cause. What you see in practice is a behaviour that does a job for the person and, for that reason, keeps coming back:

• It regulates emotions. Stress, anxiety, anger, boredom and tiredness are common triggers, as are quiet activities such as reading or watching TV. So are guilt and shame, the very feelings that picking leaves behind.
• It brings relief, and what brings relief gets repeated. In the moment, it lowers tension or gives a small sense of satisfaction. In the long run it leaves wounds and shame, but what gets learned is the immediate relief.
• The skin plays a part too. Acne or eczema often trigger the onset, and any blemish the person wants to get rid of, even if nobody else can see it, can be the starting point.
• It rarely comes alone. Its most common companion is trichotillomania, and OCD and body dysmorphic disorder are more common than in the general population. So are depression and anxiety disorders.

That last point means you always need to look at what else is going on. If there is depression, for example, it has to be part of the treatment plan from the start.

How common is dermatillomania, and when does it start?

More common than it seems. According to the MSD Manual, about 2% to 3% of people have it at any given time, and 60% to 75% of them are women. Older estimates ranged from 1.4% to 5.4%.

It usually begins in adolescence, often around puberty and the arrival of acne, although it can start at any age. Without treatment it tends to be chronic, with better and worse periods, and the areas picked can change over time.

Dermatillomania in teenagers

Because it starts so early, it is common to see teenagers who come in with their family. It helps to ask parents not to scold or keep watch over their child's hands: the shame is already great, and the picking easily goes further underground. Their role is a different one: to give a gentle signal when the teenager has asked for it, to notice progress and to help with changes at home. Our article on therapy with teenagers has more on setting up the work with the family.

Not every skin wound is dermatillomania

Before talking about dermatillomania, other explanations need to be ruled out. The criteria themselves require it:

• A skin or physical condition. Scabies, for example, causes itching and scratching, and skin picking also appears in some genetic syndromes, such as Prader-Willi syndrome. That is why the assessment includes a medical review.
• A substance. Cocaine and other stimulants can lead to scratching that is not excoriation disorder.
• A psychotic disorder. If the person is convinced there are bugs or parasites under their skin, or can feel them, this is a different picture.
• Body dysmorphic disorder. If someone picks to fix a flaw that only they can see, you need to consider body dysmorphic disorder.
• Non-suicidal self-injury. In self-injury the aim is to cause harm in order to relieve emotional pain. In dermatillomania the attention is on the skin itself, on the spot or the scab, and the wound is a side effect, not the goal.

There is another difference from OCD: in dermatillomania the picking is not a response to an obsession. Both can happen at the same time, and then both need treatment. Our guide to obsessive-compulsive disorder explains how to assess it.

When the skin needs a doctor

Dermatillomania is not just a psychological problem: wounds get infected. The MSD Manual points out that, in severe cases, it can cause scarring, infections, heavy bleeding and even sepsis. The NHS advises seeing a GP if there are cuts that don't heal within a few days, and referral to a dermatologist when the skin is badly damaged or when acne or eczema is fuelling the picking.

In practice, working alongside the GP or the dermatology team is part of the treatment. The dermatologist looks after the skin and the acne; you work on the behaviour. If the patient agrees, a conversation with their dermatologist helps both messages point in the same direction.

How to assess dermatillomania in your practice

The interview

The first interview is for understanding the behaviour in detail and helping the patient feel comfortable talking about it. These questions usually give you a lot of information:

• When did it start and how? Was there acne or another skin problem?
• Which areas, with what (fingers, nails, teeth, tweezers) and for how long each day?
• In which situations? Do you notice when you start, or only once there's a wound?
• What do you feel before, during and after?
• How do you cover it up, and what have you stopped doing because of the marks?
• What have you tried in order to stop, and what happened?
• Do you take any medication or substances? Do you also pull your hair or bite your nails?

It is worth screening for symptoms of OCD, body dysmorphic disorder, depression and anxiety, and asking tactfully whether they ever hurt themselves on purpose.

The self-monitoring log

Self-monitoring is the foundation of treatment: without knowing when and where the picking happens, there is no way to change it. Ask the patient to record each episode at the time, not at the end of the day, with just a few details: the time, where they were and what they were doing, the area, how they felt beforehand, how many minutes it lasted and how strong the urge was from 0 to 10. If there are many episodes, they can log periods of the day instead of individual episodes.

After two or three weeks of logging, patterns usually emerge: what times, which places and which emotions. That information decides which changes to the surroundings and which alternative response you agree on. Our article on homework in therapy explains how to set up logs so that patients actually fill them in.

Scales to measure dermatillomania

Two English-language instruments are fairly widely used in research and are useful in clinical practice too:

• Skin Picking Scale–Revised (SPS-R). Eight items about the past week. Four measure severity (how often and how strongly the urge comes, time spent picking each day and control) and four measure impairment (emotional distress, interference with daily life, avoidance and skin damage). Each item is scored from 0 to 4, giving a total of 0 to 32.
• Milwaukee Inventory for the Dimensions of Adult Skin Picking (MIDAS). Twelve items that separate focused from automatic picking, six for each. It helps you decide how much weight to give each part of treatment.

The useful thing is to give them at the start and repeat them every few weeks, so you can compare the patient with their own baseline.

Treatment for dermatillomania

The psychological treatment of choice is cognitive behavioural therapy tailored to the symptoms of excoriation disorder, and within it the best-studied approach is habit reversal training. The MSD Manual agrees on this, and so does the systematic review by Lochner, Roos and Stein, which covers studies published between 1996 and 2017.

Habit reversal training

It has three parts:

• Awareness training. Through the log and in session, the patient learns to notice the early signs: the hand moving towards the face, the fingertip searching for an edge, the urge building.
• Competing response. When the sign appears, they do something that can't be done at the same time as picking until the urge eases. The MSD Manual gives clenching the fists, knitting or sitting on the hands as examples.
• Social support. Someone they trust gives a kind signal when they see them picking and acknowledges their progress.

The evidence is modest, but it points the same way. In a four-week randomised trial with 34 patients, habit reversal worked and the effect held at two months. In another small study, with 19 patients, three sessions were enough to reduce picking more than in the waiting-list group.

Stimulus control: changing the surroundings

This means changing situations so that picking becomes harder. Some measures that are often agreed:

• Keeping nails short and not having tweezers or pins within easy reach.
• Wearing thin gloves or plasters on the fingers at high-risk times, such as studying or the evening series.
• Dimming the bathroom light, removing or covering the magnifying mirror and setting a time limit in front of the mirror.
• Keeping moisturiser handy and applying it to the area when the urge comes.
• Keeping the hands busy with a soft ball or another object.

For Irene, the plan was to study with a rubber ball in her left hand, put the magnifying mirror away in a drawer and wash her face with only the small bathroom light on.

Acceptance and emotion regulation

When the picking is mainly focused, working with emotions carries more weight. Acceptance and commitment therapy teaches the patient to notice the urge without acting on it and to steer their behaviour towards what they value. The studies are small. In one with five patients, four stopped picking almost completely, although three of them did not keep all their gains at follow-up. Combining this therapy with habit reversal, known as acceptance-enhanced behaviour therapy, also cut picking sharply in a pilot study, and a meta-analysis supports these interventions. If you want a refresher on the model, see our guide to acceptance and commitment therapy.

Self-help programmes

For people who can't attend therapy, or as support between sessions, there is evidence for self-help. An online programme based on the cognitive behavioural model reduced symptoms in an uncontrolled study with 151 people. Another trial compared habit reversal with decoupling, both delivered as a manual the patient follows on their own, and confirmed that habit reversal works. Decoupling, which involves diverting the hand's movement to another place, such as the ear, came out worse.

What about medication?

Medication is a decision for the doctor or psychiatrist. According to the MSD Manual, N-acetylcysteine and memantine, two glutamate modulators, are increasingly seen as the first-line medication: in small trials they reduced picking more than placebo did. In the N-acetylcysteine trial described in the Lochner review, 47% of patients were much or very much improved, compared with 19% on placebo. SSRI antidepressants help when there is depression or anxiety and, on more limited evidence, may also reduce picking.

Your role here is to stay coordinated: know what the patient is taking, since when and how they are getting on with it, and note it in their record.

Relapses: plan for them

Dermatillomania tends to come and go. An exam, a break-up or an acne flare can bring a long episode after weeks of doing well. That is why treatment includes relapse prevention from the start: identifying high-risk situations, agreeing what to do in each one and making it clear that a bad day doesn't undo the progress made. Our article on relapse prevention shows how to build that plan.

How to stop picking your skin: everyday tips

These tips don't replace treatment, but they help, and many of them match the NHS advice:

• Note down when and where it happens. Knowing is the first step to avoiding it.
• Keep your hands busy at high-risk times: a soft ball, a ring to twist or a pair of gloves.
• Keep your nails short and put the tweezers somewhere out of reach.
• When you feel the urge, try to hold out a little longer than last time and put moisturiser on the area.
• Keep your skin clean to avoid infection and let the wounds heal.
• Tell someone you trust who can help you notice when you're picking.
• If you have an episode, write it down and carry on with the plan. Guilt is a trigger too.

When to seek professional help

It is worth getting help if you can't stop, if the wounds are slow to heal or get infected, or if picking your skin causes you distress or costs you time, plans or peace of mind. A psychologist experienced in body-focused repetitive behaviours can help you with habit reversal; your GP or a dermatologist can look after your skin.

If there is also a low mood that won't lift or thoughts of hurting yourself, seek help as soon as possible: in Spain the 024 line answers free of charge at any hour and, in an emergency, call 112. Elsewhere, use your local crisis line or emergency number.

How to document progress in dermatillomania

With dermatillomania, patients tend to judge their progress by the latest wound. That is why it pays to keep written data you can compare against:

• The SPS-R score (and the MIDAS, if you use it) at the start and at each review, with the date.
• The minutes per day and the high-risk situations taken from the log.
• The competing responses and changes to the surroundings you have agreed, and which ones work.
• The state of the skin described in words: areas that have healed, open wounds, infections.
• Anything discussed with dermatology or their doctor, if the patient has agreed, and the medication they take.
• The relapse plan.

Going over this data with the patient every few weeks shows them progress they can't see when there is a new wound in front of them.

Dermatillomania in your practice with My Psico Agenda

My Psico Agenda doesn't assess or treat anyone: that is your job. What it does is keep everything around a treatment like this in order:

• Notes for every session. In each appointment's "Details / Notes" you record the SPS-R score, what came out of the log and what was agreed for the week, and the patient's "Clinical History" holds the case summary.
• Your own fields in the record. Under "Additional data" you add the fields you need, such as "Baseline SPS-R", "Areas" or "Competing response". If you work in a centre, the centre can also add its own "Centre fields", shared across all its therapists' records.
• The log in the patient's hands. You upload the template to "Patient files". It goes up as "Hidden"; when you switch it to "Visible", the patient finds it in their space under the "Documents" tab, and in the record you see "Seen" with the date they opened it.
• Teenagers and their family. If you tick "Minor patient?", the record belongs to the minor and stores the details of "Guardian 1" and, if there is one, "Guardian 2". The informed consent can be signed by the guardians, each with their own link or on your own device.
• The details, before the first session. With "Send form to the patient" you send them a link so they can fill in their details on their phone and, if you turn it on, sign the consent on that same page.
• A fixed slot every week. With "Recurring therapy" you book their slot, and they get a WhatsApp reminder 24 hours before with buttons to confirm or cancel.
• Consistency, in numbers. In each patient's statistics you see "Total sessions", "Attendance" and "Cadence", useful when you start spacing out sessions.
• Who has stopped coming. "See inactive patients" shows the people who have gone two months without a session and have nothing booked, with a "Contact on WhatsApp" button. With so much shame involved, dropping out without a word deserves a call.

There are plans for therapists from €4.99/month + VAT and for centres from €99.99/month + VAT, and you can try it free for 1 month, no card needed and no lock-in. Our software for psychologists page has everything that's included.