Introduction
Skin picking disorder (SPD), also known as excoriation disorder or dermatillomania, is characterized by repetitive skin picking that damages tissue [1]. This disorder falls under the umbrella of obsessive-compulsive disorders in the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) [2]. While figures for the prevalence of SPD differ in the literature, the general range indicates that it affects approximately 1–5% of the general population. Individuals with SPD often experience lowering of social, occupational, and psychological well-being due to the emotional and physical stresses that accompany the disorder [2].
Understanding SPD is crucial due to its debilitating effects on individuals’ quality of life. The repetitive nature of skin picking behaviours often results in extreme damage to tissue, scarring, and in the worst cases, infections, further exacerbating the physical and psychological burden on affected individuals [3]. In terms of the latter, SPD has been strongly associated with mental health conditions, such as anxiety disorders, depression, and body dysmorphic disorder, complicating its diagnosis and treatment [4].
Moreover, the societal impact of SPD should not be overlooked. The disorder can result in significant healthcare costs due to the medical interventions required to address skin damage and its associated complications. Furthermore, the stigma surrounding SPD may prevent individuals from seeking help, leading to underdiagnosis and undertreatment [5].
Given the complex nature of SPD and its multifaceted impact, there is a critical need for a comprehensive review to synthesize existing knowledge, identify gaps in research, and inform clinical practice. By examining the current state of research on SPD, this review aims to shed light on the epidemiology, aetiology, clinical presentation, treatment approaches, and challenges associated with the disorder.
Epidemiology
Prevalence
SPD is not uncommon, though estimates of its prevalence vary across studies and populations. Research suggests that SPD affects approximately 1% to 5% of the general population, making it more prevalent than previously recognized. However, due to its underreporting and misdiagnosis, the true prevalence of SPD may be higher than reported [6–8].
The prevalence of SPD is thought to be consistent across different age groups, with onset typically occurring in adolescence or early adulthood. However, studies have also reported cases of SPD emerging in childhood or later in adulthood. Additionally, there may be gender differences in the prevalence of SPD, with some studies suggesting a higher prevalence among females compared to males. However, further studies are required to determine the exact nature of these gender differences and their underlying mechanisms [6].
Demographic patterns
Several demographic factors are now linked with a higher risk of developing skin picking disorder. While SPD can affect individuals from diverse backgrounds, certain demographic groups may be more vulnerable to the disorder. For example, individuals with a history of psychiatric conditions such as anxiety disorders, depression, or obsessive-compulsive disorder (OCD) may be at higher risk of developing SPD. Similarly, individuals with a history of trauma, abuse, or neglect may also be more susceptible to SPD [7, 8].
Age is another demographic factor that may influence the risk of developing SPD. As noted, while the disorder can manifest at any age, onset typically occurs during adolescence or early adulthood, coinciding with periods of increased stress and hormonal changes. Specific personality traits, such as perfectionism or neuroticism, have also been shown to play a role in increasing the risk of an individual developing SPD [6, 9].
Socioeconomic factors may also contribute to the prevalence of SPD. Individuals from lower socioeconomic backgrounds often face additional stressors, such as financial strain or limited access to mental health resources, which could increase their risk of developing SPD. Furthermore, cultural factors and societal norms surrounding body image and grooming behaviours have been suggested as potential factors in the prevalence of SPD in different populations [7, 9].
Aetiology and pathophysiology
Genetic factors
There are numerous studies that suggest that genetic factors play an important role in the development of skin picking disorder (SPD). For example, research has indicated a familial aggregation of SPD, with higher rates of the disorder observed among first-degree relatives of sufferers in comparison to the general population. Studies of twins have provided further support for a genetic predisposition to SPD, with higher concordance rates observed among monozygotic compared to dizygotic twins [1, 10].
For this reason, certain candidate genes have been implicated in SPD, with a focus on genes involved in neurotransmitter regulation, impulse control, and emotional processing. For example, variations in genes encoding serotonin receptors, such as the serotonin transporter gene (SLC6A4), have been associated with impulsivity and compulsive behaviours, which are core features of SPD. Additionally, genes involved in the dopaminergic system, such as the dopamine D2 receptor gene (DRD2), have been implicated in reward processing and reinforcement, potentially contributing to the compulsive nature of skin picking behaviours [11, 12].
While genetic factors contribute to individual susceptibility to SPD, the relationship between genetic predisposition and the influence of the environment remains crucial. To be more specific, environmental stressors, trauma, and learned behaviours may interact with genetic vulnerabilities to increase the likelihood of SPD developing.
Neurobiological mechanisms
Neurobiological research has provided insights into the underlying neural circuits and neurotransmitter systems implicated in skin picking disorder. Functional neuroimaging studies show changes in brain regions responsible for impulse control, such as the prefrontal cortex and anterior cingulate cortex, among individuals with SPD. Dysfunction in these regions may contribute to difficulties in inhibiting urges to pick at the skin [13].
Moreover, abnormalities in the dopaminergic and opioid systems have been identified in the pathophysiology of SPD. Dysregulation of dopamine signalling, particularly in reward-related brain regions such as the striatum, may contribute to the reinforcing properties of skin picking behaviours. Similarly, alterations in endogenous opioid release and sensitivity may underlie the pleasurable sensations experienced during skin picking, further reinforcing the behaviour [1, 14].
Additionally, alterations in the serotonin system have been witnessed in studies of SPD, given the involvement of serotonin in impulse control, mood regulation, and anxiety. Reduced serotonin levels or dysregulation of serotonin receptors may contribute to the compulsive and repetitive nature of skin picking behaviours [12, 13].
Psychological factors
Psychological theories offer valuable insights into the development and continuation of skin picking disorder, highlighting the role of cognitive, emotional, and behavioural factors. Cognitive-behavioural models propose that maladaptive beliefs and cognitive biases contribute to the initiation and perpetuation of skin picking behaviours. For example, individuals with SPD may hold beliefs about the effectiveness of skin picking in relieving distress or achieving a sense of control, reinforcing the behaviour over time [15, 16].
Emotional factors, such as stress, anxiety, and negative affect, are closely linked to skin picking behaviours. Stressful life events or emotional triggers, for instance, may precede episodes of skin picking, serving as antecedents for the behaviour. Moreover, skin picking may function as a maladaptive coping mechanism for managing negative emotions or intrusive thoughts, providing temporary relief but ultimately perpetuating the cycle of distress [16].
Behavioural theories highlight reinforcement processes in the maintenance of skin picking behaviours. For example, skin picking may be reinforced by the sensory feedback or relief experienced during the behaviour, leading to its repetition over time. Additionally, social reinforcement from peers or family members may inadvertently reinforce skin picking behaviours [15, 17].
Overall, a multifactorial model incorporating genetic, neurobiological, and psychological factors is likely involved in the aetiology and pathophysiology of skin picking disorder. Understanding these underlying mechanisms is essential for the development of effective interventions and treatments that address the complex interplay of factors contributing to SPD [15].
Clinical presentation
Diagnostic criteria
Skin picking disorder (SPD) is classified under Obsessive-Compulsive and Related Disorders in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5). The diagnostic criteria for SPD include the following [18]:
Repeated skin picking that causes skin lesions.
Persistent efforts to lesson or cease skin picking behaviour.
Significant distress and/or lessening social, occupational, or other vital areas of functioning due to skin picking.
Skin picking not attributable to the physiological effects of a substance (e.g., cocaine) or another medical condition (e.g., dermatological condition, pruritus).
The skin picking being unlikely linked to symptoms of other mental disorders (e.g., visual and tactile hallucinations due to psychosis or the desire to correct perceived bodily flaws due to body dysmorphic disorder).
To meet the diagnostic criteria for SPD, the skin picking behaviour must occur for a significant amount of time (i.e., several hours per day) and cause mental anguish or difficulty functioning. The behaviour may involve picking at any area of the body, including the face, arms, legs, and other accessible areas. Additionally, individuals with SPD may engage in rituals or repetitive behaviours before, during, or after skin picking episodes [2, 18].
Symptomatology
The symptoms of skin picking disorder can vary widely among affected individuals, but common behaviours and triggers are observed across cases. As previously noted, skin picking episodes often occur in response to emotional distress, anxiety, boredom, or tension, serving as a maladaptive coping mechanism for managing negative emotions. Additionally, individuals with SPD may engage in skin picking as a form of sensory stimulation or self-soothing behaviour [19].
During skin picking episodes, individuals may exhibit repetitive, ritualistic behaviours such as scanning the skin for imperfections, using specific tools or instruments to extract or manipulate skin and then examine the extracted material. Skin picking may also result in visible skin lesions, including scabs, scars, excoriations, and open wounds, which can become infected if not properly cared for [2, 18].
Triggers for skin picking behaviours can vary widely and may include environmental stressors, interpersonal conflicts, perceived imperfections in the skin, or exposure to triggering stimuli such as mirrors or photographs. Additionally, individuals may experience a sense of tension or urge preceding skin picking episodes, followed by temporary relief or gratification during and immediately after the behaviour [18, 20].
Finally, the severity and rate of incidence of skin picking behaviours can fluctuate over time, with periods of remission alternating with periods of heightened symptomatology. Individuals with SPD may experience significant mental anguish and lesser functioning in various areas of life, including social relationships, work or school performance, and self-esteem [18].
Comorbidities
Skin picking disorder commonly co-occurs with other psychiatric conditions, particularly anxiety and obsessive-compulsive disorder (OCD). Research indicates high rates of comorbidity between SPD and anxiety disorders such as generalized anxiety disorder, social anxiety disorder, and panic disorder. For this reason, individuals with SPD may engage in skin picking as a way to alleviate anxiety or distress, leading to a vicious cycle of symptom exacerbation [21].
Similarly, OCD is closely related to SPD, with overlapping features such as recurring behaviours and invasive thoughts. Some sufferers of SPD may meet criteria for OCD while others may demonstrate obsessive-compulsive tendencies without meeting full diagnostic criteria. The presence of obsessions related to skin imperfections or contamination fears may exacerbate skin picking behaviours in individuals with OCD [21, 22].
Other common comorbidities of SPD include depression, body dysmorphic disorder (BDD), and impulse control disorders. Depression may co-occur with SPD due to the impact of skin picking behaviours on mood and self-esteem. Individuals with BDD have also been shown to exhibit skin picking as a behaviour to address perceived flaws or imperfections in their appearance. Additionally, impulse control disorders such as trichotillomania (hairpulling disorder) or excoriation (skin-picking) disorder may co-occur with SPD, reflecting shared underlying mechanisms of compulsive behaviour [21–23].
Treatment approaches
Psychotherapy
Psychotherapy, particularly cognitive-behavioural therapy (CBT), is considered the first-line treatment for skin picking disorder (SPD). CBT for SPD typically involves a combination of cognitive restructuring, habit reversal training (HRT), and exposure and response prevention (ERP) techniques [5].
Cognitive restructuring aims to uncover and confront maladaptive beliefs and cognitive distortions related to skin picking. Therapists work with individuals to recognize triggers and negative thoughts associated with skin picking behaviours and replace them with more adaptive and realistic beliefs. By addressing underlying cognitive factors, individuals can develop healthier coping strategies and reduce the occurrence and severity of skin picking episodes [11].
Habit reversal training (HRT), for example, is a behavioural intervention that focuses on making a sufferer more aware of their skin picking behaviours to allow competing responses to interrupt the habit cycle. Individuals learn to identify early warning signs or triggers for skin picking and engage in alternative behaviours, such as clenching fists or engaging in relaxation techniques, to prevent or redirect the urge to pick. Through repeated practice and reinforcement, HRT aims to weaken the association between triggers and skin picking behaviours [9, 24].
Exposure and response prevention (ERP) is another intervention that involves gradual exposure to situations or stimuli that trigger skin picking urges while refraining from engaging in the behaviour. Individuals learn to tolerate discomfort and resist the urge to pick, gradually building tolerance to triggers and reducing the intensity of skin picking behaviours over time. ERP also helps individuals develop effective coping strategies and skills for managing anxiety and distress without resorting to skin picking [9, 25].
Several studies have demonstrated that CBT that includes HRT and ERP components is effective in reducing skin picking symptoms and improving overall functioning among individuals with SPD. CBT interventions have been associated with a decrease in skin picking frequency, severity, and impairment, in addition to improvements in mood, quality of life, and psychosocial functioning [26].
Pharmacotherapy
Pharmacotherapy may be considered as an adjunctive treatment for skin picking disorder, particularly in cases where psychotherapy alone is insufficient or when comorbid conditions require pharmacological management. Selective serotonin reuptake inhibitors (SSRIs), such as fluoxetine and sertraline, are the main prescription medicines used to treat SPD due to their efficacy in also treating accompanying conditions such as obsessive-compulsive disorder (OCD) and anxiety disorders [24].
SSRIs are thought to modulate serotonin production, which may lessen symptoms of impulsivity, compulsivity, and anxiety associated with SPD. However, research reveals somewhat contradictory results on the efficacy of SSRIs in treating SPD, with some studies reporting significant reductions in skin picking symptoms with others finding limited or no improvement. Additionally, individual responses to SSRIs may vary, and side effects such as nausea, insomnia, and sexual dysfunction should be carefully monitored [26, 27].
Other medications, such as tricyclic antidepressants (TCAs), naltrexone, and N-acetylcysteine (NAC), have also been investigated for the treatment of SPD. TCAs may be effective in reducing skin picking behaviours due to their effects on the neurotransmitter systems implicated in impulse control and mood regulation. Naltrexone, an opioid antagonist, is thought to lessen the rewarding effects of skin picking behaviours by blocking endogenous opioid receptors. NAC, a precursor to glutathione and a modulator of glutamate neurotransmission, has shown promise in reducing compulsive behaviours and improving symptom severity in SPD [24, 27].
While pharmacotherapy may provide symptom relief for some individuals with SPD, it is important to carefully consider this possible advantage in light of the potential side effects and negative medication interactions. Moreover, pharmacological treatments should be combined with psychotherapy and other non-pharmacological interventions to address the multifaceted nature of SPD and promote long-term recovery [28, 29].
Alternative therapies
In addition to traditional psychotherapy and pharmacotherapy, several alternative and complementary therapies have been explored as potential treatments for skin picking disorder. These alternative approaches may offer additional options for individuals who do not respond to conventional treatments or who prefer nonpharmacological interventions [24, 26, 27].
Mindfulness-based interventions, such as mindfulness meditation and acceptance and commitment therapy (ACT), aim to encourage a person to be present in the moment and therefore be accepting of emotions as they occur, including urges to pick. By developing mindfulness skills, individuals can learn to observe skin picking urges without judgment and choose more adaptive responses in line with their values and goals [30, 31].
Dialectical behaviour therapy (DBT) uses a combination of cognitive-behavioural techniques with mindfulness practices to improve emotional regulation, better tolerate and handle unpleasant emotions, and increase social functioning. DBT courses targeted at these benefits may be especially helpful for those with SPD who suffer from emotional dysregulation and interpersonal difficulties [28].
Alternative therapies, such as acupuncture, hypnotherapy, and biofeedback, have also been explored as potential adjunctive treatments for SPD. While evidence pointing to the efficacy of such therapies is lacking, they may aid in the management of stress, anxiety, and skin picking behaviours. However, future studies are required which focus on their efficacy for alleviating the symptoms of SPD and their mechanisms of action [28].
Challenges and future directions
Barriers to treatment
Despite advances in understanding skin picking disorder (SPD), several barriers to effective treatment and management persist, hindering the well-being of individuals affected by the disorder. One significant barrier is the lack of awareness and recognition of SPD among healthcare professionals. Due to its overlap with other psychiatric conditions and its relatively recent inclusion in diagnostic manuals, SPD may be underdiagnosed or misdiagnosed, leading to delays in accessing appropriate treatment [32, 33].
Moreover, the negative judgements that continue to exist regarding mental health conditions, including SPD, may deter sufferers from accessing treatment or even mentioning their symptoms to healthcare providers. In other words, fear of judgment or misunderstanding from others may prevent individuals with SPD from seeking the support and treatment they need, further exacerbating the negative effects of such a condition [32].
Limited access to specialized care and evidencebased treatments is another barrier to effective management of SPD. Many healthcare settings may lack resources or expertise in treating SPD, leading to suboptimal care or reliance on generalist approaches that may not address the unique needs of individuals with the disorder. Additionally, financial constraints or insurance limitations might restrict access to psychotherapy or pharmacotherapy, further impeding treatment options for individuals with SPD [34].
Research gaps
Despite growing interest in skin picking disorder, several gaps in research still exist, highlighting the need for further investigation to advance our understanding of the disorder and improve treatment outcomes. One area requiring attention is the underlying neurobiological mechanisms of SPD. While neuroimaging studies have provided valuable insights into the neural circuits involved in the disorder, studies must continue to investigate the specific neurotransmitter systems and brain regions implicated in SPD [35].
Additionally, longitudinal studies examining the natural course and progression of SPD over time are lacking. Long-term follow-up studies are required to assess the permanence of symptoms, factors influencing treatment response, and predictors of outcomes in individuals with SPD. Moreover, research focusing on the development of reliable and valid assessment tools for SPD is essential for accurate diagnosis and monitoring of treatment progress [35].
Furthermore, randomised controlled trials (RCTs) evaluating the efficacy of both pharmacological and psychotherapeutic interventions for SPD are required. While cognitive-behavioural therapy (CBT) has shown promise as a first-line treatment for SPD, research is lacking on its efficacy according to different populations and settings. Similarly, studies investigating the efficacy of pharmacological agents, such as selective serotonin reuptake inhibitors (SSRIs) or glutamatergic modulators, are warranted to inform evidence-based treatment guidelines for SPD.
Conclusions
This review has provided a comprehensive overview of skin picking disorder (SPD), encompassing its epidemiology, aetiology, clinical presentation, treatment approaches, challenges, and future directions. SPD is a relatively common psychiatric condition characterized by repetitive picking at one’s own skin, leading to significant physical and psychological distress. The disorder is associated with a range of genetic, neurobiological, and psychological factors, highlighting its complex aetiology.
The clinical presentation of SPD includes various symptoms such as compulsive skin picking behaviours, emotional distress, and impaired social functioning. Additionally, SPD is commonly associated with additional psychiatric conditions, such as anxiety disorders and obsessive-compulsive disorder, further complicating its diagnosis and treatment.
Implications
The findings of this review suggest a number of considerations for clinicians, research, and policy. Clinically, healthcare professionals should be aware of the prevalence and impact of SPD, incorporating screening and assessment for the disorder into routine practice. This is because early identification and intervention can help prevent the progression of SPD and mitigate its adverse outcomes. Evidence-based psychotherapeutic interventions, such as cognitive-behavioural therapy, should also be prioritized in the treatment of SPD given their efficacy in addressing underlying cognitive and behavioural factors.
Moreover, healthcare policies should prioritize the provision of accessible and affordable mental health services for individuals with SPD, ensuring equitable access to evidence-based treatments. Public awareness campaigns and educational initiatives can help reduce the stigma surrounding SPD and promote understanding and acceptance of the disorder.
From a research perspective, further investigation is needed to address existing gaps in knowledge and advance our understanding of SPD. Longitudinal studies are needed to elucidate the natural course and progression of the disorder, as well as identify risk factors and protective factors associated with its development. Additionally, research focusing on the neurobiological mechanisms underlying SPD may inform the development of novel pharmacological interventions targeting specific neurotransmitter systems implicated in the disorder.
Recommendations
Based on the evidence highlighted in this review, we suggest the following recommendations to address skin picking disorder effectively. Firstly, interdisciplinary collaboration between mental health professionals, dermatologists, and primary care providers is essential for the comprehensive assessment and management of SPD. Integrated care models that incorporate both psychological and dermatological interventions can optimize treatment outcomes and address the complex needs of individuals with SPD.
Secondly, public awareness and understanding of SPD must be promoted, destigmatizing the disorder and promoting early help-seeking behaviours. Educational initiatives targeting healthcare providers, educators, and the general public can help raise awareness of SPD and its impact on individuals’ lives.
Furthermore, investment in research aimed at identifying novel treatment approaches and interventions for SPD is warranted. Innovative technologies, such as virtual reality therapy or smartphone applications, may hold promise for delivering accessible and engaging interventions for individuals with SPD. Additionally, genetic and neurobiological research may uncover potential biomarkers or targets for pharmacological interventions, paving the way for personalized treatment approaches tailored to individuals’ specific needs.
In conclusion, addressing skin picking disorder requires a multifaceted approach involving clinical, research, and policy efforts. By raising awareness, promoting early intervention, and advancing our understanding of the disorder, we can improve outcomes and quality of life for individuals affected by SPD.
