What is excoriation disorder (dermatillomania)?
Excoriation Disorder, also known as Dermatillomania or skin-picking disorder, is a mental health condition that falls under the category of Obsessive-Compulsive and Related Disorders in the DSM-5. It is distinguished by repeated and compulsive picking at one’s own skin, which frequently results in tissue damage, scarring, and infection. Individuals with excoriation disorder may spend hours each day picking at perceived flaws, minor blemishes, or even normal skin. This behavior is often accompanied by feelings of guilt, shame, and distress, as the individual is aware of the negative consequences but is unable to stop.
The condition can significantly affect a person’s daily functioning, emotional well-being, and self-esteem. Excoriation disorder is often comorbid with other mental health conditions like anxiety, depression, or body dysmorphic disorder (BDD), making it difficult to treat. While the exact cause is unknown, it is thought that dermatillomania develops and persists due to a combination of genetic, neurological, and environmental factors.
This disorder affects approximately 1–5% of the general population, with females having a higher prevalence. Despite its widespread prevalence, excoriation disorder is underdiagnosed and undertreated, owing in part to the condition’s associated shame and embarrassment. Early detection and intervention are critical for avoiding long-term physical and psychological effects.
Traditional Treatments for Excoriation Disorder (Dermatillomania)
Traditionally, excoriation disorder has been managed using a combination of behavioral therapy, pharmacotherapy, and self-care techniques. The primary goal is to assist individuals in reducing or eliminating skin-picking behavior while addressing the underlying emotional and psychological triggers that cause the compulsion. The following provides an overview of the most commonly used traditional treatment approaches.
1. Cognitive behavior therapy (CBT)
Cognitive Behavioral Therapy (CBT) is widely regarded as the best treatment for excoriation disorder. Individuals use CBT to identify the thoughts, emotions, and behaviors that contribute to their skin-picking habits. By restructuring negative or obsessive thought patterns, patients can gradually regain control of their urges and develop healthier coping mechanisms.
- Habit Reversal Training (HRT): Habit Reversal Training is a specialized form of cognitive behavioral therapy that is frequently used to treat excoriation disorder. HRT aims to raise awareness of the urge to pick at the skin and replace it with alternative behaviors (known as competing responses). A person may be taught to clench their fists, use a stress ball, or apply lotion to their skin when they have the urge to pick.
- Stimulus control: Another important aspect of CBT for excoriation disorder is stimulus control, which entails changing the environment to reduce triggers for skin picking. This could include wearing gloves to prevent skin contact, covering mirrors that may prompt picking, or using fidget toys to keep the hands occupied.
2. Acceptance and Commitment Therapy(ACT)
Acceptance and Commitment Therapy (ACT) is another type of psychotherapy that has shown promise for treating excoriation disorder. ACT emphasizes accepting negative emotions and thoughts without judgment, as opposed to avoiding or suppressing them. ACT reduces emotional distress, which frequently leads to skin-picking behavior, by encouraging people to engage in values-based actions despite uncomfortable feelings.
Patients learn to acknowledge their urges but not act on them, instead focusing on long-term goals and personal values. Over time, this mindfulness-based approach helps to weaken the grip of compulsive behaviors while increasing psychological flexibility.
3. Pharmacotherapy
Medications can also be effective in treating excoriation disorder, particularly when it coexists with other conditions such as anxiety or depression. Pharmacotherapy aims to reduce compulsive behaviors while also addressing underlying emotional states that contribute to the disorder.
- Selective Serotonin Reuptake Inhibitors (SSRIs): SSRIs, such as fluoxetine (Prozac) and sertraline (Zoloft), are frequently prescribed to people with excoriation disorder. These medications raise serotonin levels in the brain, which can help alleviate obsessive thoughts and compulsive behavior. While not all patients respond to SSRIs, they are frequently the first line of treatment for people experiencing moderate to severe symptoms.
- N-Acetylcysteine (NAC): NAC, an over-the-counter supplement, has received attention as a possible treatment for excoriation disorder. NAC is thought to work by regulating glutamate levels in the brain, which may help to reduce compulsive skin-picking behaviors. Early research has yielded promising results, particularly in terms of reducing the frequency and severity of picking episodes.
- Antipsychotic medications: In severe or treatment-resistant cases of dermatillomania, antipsychotic medications, like aripiprazole, may be used. These medications are usually reserved for people with co-occurring conditions such as obsessive-compulsive disorder (OCD) or psychosis because they help regulate dopamine levels, which are thought to contribute to compulsive behaviors.
4. Behavioral Intervention and Self-Monitoring
Behavioral interventions, such as self-monitoring and journaling, are frequently used to help people track their skin-picking habits and identify triggers. Patients are encouraged to keep a diary of their thoughts, feelings, and skin-picking behaviors. This process raises awareness of patterns and triggers, resulting in valuable insights that can be used to guide treatment.
- Mindfulness techniques: Mindfulness exercises are frequently used in traditional therapies to help patients stay present and reduce anxiety-related behaviors. Deep breathing, progressive muscle relaxation, and meditation are techniques that can help people manage stress and emotions that cause skin picking.
5. Support groups and peer support
Support groups are an important resource for people with excoriation disorder. Peer support allows people to share their experiences in a safe, nonjudgmental environment, which can help them feel less isolated and ashamed. Many support groups exist both online and in person, providing an extra layer of emotional and social support.
Limitations of Traditional Treatments
While traditional treatments have been effective for many people with excoriation disorder, they have significant limitations. Not all patients respond to pharmacotherapy or behavioral interventions, and the disorder’s chronic nature causes frequent relapses. Furthermore, the shame and stigma associated with dermatillomania may deter people from seeking treatment in the first place. These challenges have fueled the demand for novel approaches that go beyond traditional methods, offering more personalized and effective solutions.
Innovations in Treating Excoriation Disorder (Dermatillomania).
Recent advances in our understanding of excoriation disorder have resulted in the development of novel treatments aimed at providing more comprehensive and long-term relief for people who engage in skin-picking behaviors. These breakthrough innovations address both the psychological and neurological aspects of the disorder, providing new hope to those who have not responded to conventional treatments.
1. Neuromodulation and transcranial magnetic stimulation (TMS)
Transcranial Magnetic Stimulation (TMS) is a new treatment for excoriation disorder in which magnetic fields stimulate specific areas of the brain involved in impulse control and decision-making. TMS has been used successfully to treat depression and obsessive-compulsive disorder (OCD), and it is currently being investigated as a potential treatment for dermatillomania.
TMS targets the prefrontal cortex, a brain region responsible for regulating impulsive behavior and executive function. TMS, which modulates neural activity in this area, may help reduce the compulsive urge to pick at the skin, resulting in improved behavioral control.
2. Virtual Reality (VR) Therapy.
Virtual Reality (VR) therapy is a novel approach that is gaining popularity in the treatment of excoriation disorder. VR therapy provides immersive, controlled environments in which patients can practice habit reversal techniques and exposure therapy in a safe setting.
For example, a patient with excoriation disorder may be exposed to virtual scenarios that include common skin-picking triggers (e.g., mirrors, perceived blemishes). They can practice alternative behaviors and learn to manage the emotional and cognitive responses that trigger skin-picking urges under the supervision of a therapist. VR therapy provides a more interactive and engaging way to practice cognitive behavioral techniques, potentially increasing treatment adherence and effectiveness.
3. Digital Therapeutics and Mobile Health Applications
Digital therapeutics open up new possibilities for treating excoriation disorder. These app-based platforms send evidence-based interventions, like Cognitive Behavioral Therapy (CBT), directly to patients’ smartphones or tablets. Mobile health apps provide a convenient and accessible way for people to participate in therapy, track their progress, and get real-time help.
Some apps use gamification to encourage users to practice habit reversal techniques by rewarding or assigning points for meeting daily goals. Others offer interactive modules that teach patients mindfulness, stress management, and self-monitoring skills. Some platforms use artificial intelligence (AI) to personalize the therapy experience by adapting content to the patient’s specific needs and progress.
4. Pharmacogenomics and Personalised Medicine
Pharmacogenomics is the study of how a person’s genetics influence their response to medications. Pharmacogenomic testing can be used in the treatment of excoriation disorder to tailor pharmacotherapy to the patient’s genetic profile, ensuring maximum effectiveness while minimising potential side effects. This personalized approach to medicine represents a significant step forward in treating conditions such as excoriation disorder (dermatillomania), where responses to medications like SSRIs or antipsychotics can vary greatly between individuals.
For example, genetic testing can reveal specific markers related to how a patient metabolizes certain drugs, allowing clinicians to determine the most effective medication and dosage. Pharmacogenomics also enables the identification of individuals who are at risk for side effects from specific medications, such as increased anxiety or other adverse reactions, resulting in a more tailored and effective treatment plan. This method reduces the trial-and-error process common in traditional pharmacotherapy and increases the likelihood of a successful therapeutic outcome.
5. Ketamine and Psychedelic-Assisted Therapy
While still largely experimental, the use of ketamine and other psychedelics in psychiatric treatments is gaining traction, particularly for compulsive behaviors such as skin picking. Ketamine has already been shown to be effective in treating resistant forms of depression and obsessive-compulsive behaviors, and preliminary research suggests it may also benefit those suffering from excoriation disorder.
Ketamine-assisted therapy is thought to work by dramatically increasing neuroplasticity, allowing the brain to form new neural connections and unlearn compulsive behaviors. Patients undergoing ketamine therapy frequently report reductions in compulsions and urges, making it a viable option for those who have not responded to other treatments. Similarly, psilocybin-assisted therapy (the active compound in magic mushrooms) is being investigated for its ability to disrupt compulsive thought patterns, but more research is needed in the context of excoriation disorder.
6. Deep brain stimulation (DBS)
Deep Brain Stimulation (DBS) is an advanced neuromodulation technique in which electrodes are surgically implanted in specific areas of the brain. While DBS has traditionally been used to treat severe neurological and psychiatric conditions such as Parkinson’s disease and major depression, it is now being investigated for its potential to treat severe, treatment-resistant cases of excoriation disorder.
DBS modulates neural activity in areas of the brain involved in impulse control and compulsion, such as the ventral striatum or anterior cingulate cortex, reducing the urges associated with skin picking. Although this is a more invasive treatment option that is currently reserved for the most severe cases, preliminary clinical trials have shown promising results in reducing compulsive behaviors in excoriation disorder patients who have not responded to other interventions.
7. Nutrition and Gut Health Approaches
Recent research on the gut-brain axis—the link between gut health and mental health—indicates that nutritional interventions may help manage excoriation disorder. Emerging evidence suggests that the gut microbiota can influence brain function and mood regulation, potentially affecting compulsive behaviors.
Dietary interventions that promote gut health, such as the use of probiotics, prebiotics, and a diet rich in omega-3 fatty acids, may aid in mood stabilization and compulsion reduction. Some research has also linked inflammation and nutrient deficiencies (such as magnesium or B-vitamin deficiency) to increased anxiety and stress, which may lead to skin-picking episodes. Addressing these nutritional imbalances may improve individuals’ overall mental health and reduce skin-picking behaviors.
Holistic and Alternative Therapies for Excoriation Disorder (Dermatillomania)
Holistic and alternative treatments for excoriation disorder have gained popularity as complements to more traditional approaches. These treatments emphasize the mind-body connection, with a focus on stress reduction, emotional regulation, and overall well-being.
1. Mindfulness & Meditation
Mindfulness-based interventions are extremely effective for treating compulsive behaviors, including excoriation disorder. Mindfulness enables people to stay present in the moment and observe their thoughts and urges without acting on them. This can reduce the intensity of the urge to pick at the skin while also providing a sense of emotional control.
Mindfulness-Based Cognitive Therapy (MBCT) combines mindfulness and traditional cognitive therapy techniques to help people become more aware of their automatic thoughts and reactions related to skin picking. Over time, this practice teaches patients to accept their urges rather than engage in destructive behaviors.
Meditation practices, particularly those focusing on body awareness, can help reduce anxiety and compulsions, making them useful tools for people with excoriation disorder.
2. Yoga and Physical Exercise
Yoga combines physical movement, breathing control, and meditation to provide both physical and psychological benefits. Yoga has been shown to reduce stress, improve emotional regulation, and increase mindfulness, all of which are important for people who struggle with skin-picking behaviors.
Regular physical exercise also stimulates the release of endorphins, the body’s natural mood elevators, which can help alleviate the emotional distress that frequently leads to excoriation. Exercise promotes healthy sleep patterns, lowers anxiety, and boosts self-esteem—all of which can help reduce the frequency and severity of skin-picking episodes.
3. Acupuncture and Traditional Chinese Medicine(TCM)
Acupuncture is a Traditional Chinese Medicine practice that involves inserting thin needles into specific points on the body to regulate energy flow and promote balance. Acupuncture is thought to help reduce stress, anxiety, and emotional disturbances that lead to compulsive behaviors such as skin picking.
While more research is needed to determine the specific effects on excoriation disorder, some people say that acupuncture sessions help them feel calmer and more in control of their urges. Furthermore, herbal remedies commonly used in Traditional Chinese Medicine (such as ashwagandha or ginseng) may help regulate mood and reduce anxiety, potentially alleviating the urge to pick.
4. Aromatherapy and Essential Oil
Aromatherapy is the use of essential oils to promote relaxation, stress reduction, and emotional well-being. Certain oils, such as lavender, bergamot, and chamomile, are known for their calming properties and can be used to treat the anxiety or stress that frequently causes skin-picking episodes.
Diffusing essential oils in the environment or applying them topically as part of a daily self-care routine may help people with excoriation disorder relax and resist the urge to pick.
5. Art Therapy and Creative Expression.
Art therapy enables people with excoriation disorder to express their emotions and behaviors in a creative and nonjudgmental manner. Individuals who use visual art to express their thoughts and feelings can process their experiences and gain insights into their compulsions. Art therapy has been shown to improve emotional regulation and reduce stress, making it an effective complementary treatment for dermatillomania.
Creative activities such as painting, drawing, or sculpting can also provide a healthy outlet for tactile stimulation, offering a viable alternative to skin picking.
6. Nutritional Therapy
As previously stated, optimizing nutrition can be an important part of treating excoriation disorder. Nutritional therapy focuses on nutrient balance to promote mental health and reduce compulsive behaviors. A diet high in anti-inflammatory foods, such as fruits, vegetables, whole grains, and healthy fats, may help to reduce stress and improve brain function.
7. Hypnotherapy
Hypnotherapy is another alternative treatment that has shown promise in treating excoriation disorder. Hypnotherapy involves inducing a state of deep relaxation and increased focus, during which people are more open to therapeutic suggestions. Hypnotherapy can help people reframe their thought patterns and reduce compulsive urges by addressing the subconscious motivations that drive skin-picking behavior.
