Neurotic excoriations are lesions produced by patients as a result of repetitive skin picking (e.g., Gutpa et al., 1987; Stein et al., 1993). The behavior takes the form of an extensive cleaning ritual (Van Moffaert, 1992), and the patients intend to remove small irregularities on the skin. In more severe cases the habit is uncontrollable and may turn into an urge to dig deep into the skin. Unlike patients with dermatitis artefacta, those with neurotic excoriations usually admit the self-inflicted nature of their lesions (Gutpa et al., 1987). Skin picking occurs secondary to delusions of parasitosis, but these patients have a psychotic character and differ from those with typical presentations of neurotic excoriations. 

We have seen about forty patients over the past few years suffering from neurotic excoriations. Many engage in picking for several hours per day. Patients frequently require dermatological interventions for their skin wounds and infections. Some of our patients reported medical hospitalizations and surgical revisions for wounds that did not heal because they were not able to stop picking. Recently a patient  who picked a hole through the skin and neck muscles and nearly lacerated her carotid artery. In this case the skin picking had an almost fatal outcome (O9 Sullivan et al., 1997). The lesions are in areas of the body that the patients can easily reach, such as face, upper and lower extremities, and upper back (Obermayer, 1955). They are usually a few millimeters in diameter and crusted, weeping or scarred (Griesemer & Nadelson, 1979, Obermayer, 1955). The excoriations are produced with fingernails or small instruments such as tweezers or pins. Picking occurs most frequently in the evening or at night (Freunsgaard, 1984; Zaidens, 1964).

Visual inspection and touching of the skin often precedes picking. Patients describe an uncontrollable urge to pick blemishes, and a temporary feeling of relief when blemishes are removed. This is soon replaced by a sense of disgust, depression or anxiety (Phillips & Taub, 1995).

Stressful circumstances usually increase picking behaviors. Some patients describe being in an almost trancelike state while picking at lesions. Patients often report that they try to resist the urge, but they usually find it difficult to control. A few of the patients we saw in our clinic looked somewhat disfigured because of scarring that resulted from skin picking. Most of them had mild acne. Patients were very embarrassed about their behavior and camouflaged the resulting lesions with make-up or clothing. Skin picking typically does not occur in the presence of other people. Occasional patients reported picking at other people's skin. Several studies described patients suffering from neurotic excoriations as "perfectionistic or having obsessive-compulsive traits, depressive symptoms, anxiety, hysteria, hypochondriasis" (for a review see Gutpa, et al., 1986). The lack of modern diagnostic criteria limits the value of these studies. Skin picking has many similarities with OCD, since it is ego-dystonic, repetitive, ritualistic and temporarily relieves tension (Gutpa & Gutpa, 1993; Stein et al. 1993; Stout, 1990). The compulsive and self-destructive quality of the behavior also resembles nailbiting and Trichotillomania. Phillips and Taub (1995) showed that skin picking may be a symptom of body dysmorphic disorder. It can also occur in tourette's disorder (APA, 1994), stereotypic movement disorder (APA, 1994) or prader-willi syndrome (Hellings & Warnock, 1994; Warnock & Kestenbaum, 1992).

Demographics and Course

No data is available on the rate of occurrence of neurotic excoriations in the general population, but the incidence is estimated to be 2% among dermatology patients (Griesemer, 1978). Prevalence is higher in women than in men (Freunsgaard, 1984; Fisher & Pearce, 1974) and the mean age of onset is in the range of 30 to 40 years. However, some researchers reported a peak in the 20s (Obermayer, 1955). The intensity of compulsive skin picking seems to fluctuate, and the mean duration of symptoms is reported to be 5 years (Seitz, 1953) with the majority of patients having symptoms for 10-12 years (Freunsgaard, 1984).

Treatment

Although dermatologic treatment may help to improve the skin condition, the treatment for neurotic excoriations is primarily psychiatric. Several case reports describe that these patients benefit from treatment with serotonin reuptake inhibitors (Gutpa & Gutpa, 1993; Stein et al., 1993; Stout, 1990). In our anecdotal experience, the patients responded well to the use of SRI medications and/or with behavior therapy. Sometimes, symptoms have been completely eliminated with these approaches. The following are two cases of patients suffering from compulsive skin picking who responded well to cognitive-behavior therapy:

Case 1

Ms. A, a 22 year old woman, had been picking at blemishes on her face and back for about 3 hours per day. She was 16 years old.  She had mild acne and her skin was somewhat scarred as a result of the picking. She had constant and severe urges to pick at her skin and reported having no control over the picking. Ms. A frequently avoided leaving the house or going to work because she was embarrassed about the redness or scabs that resulted from the picking. She was often late for work because she could not stop picking at her skin. It took her a long time to apply make-up to cover up the damaged skin. When she started to abuse alcohol and began cutting her skin with a knife to stop the urge to pick, her parents became  worried. They encouraged her to seek treatment in our clinic. At the time of her intake evaluation she met criteria for major depression, obsessive-compulsive personality disorder and had some obsessions and compulsions focusing on symmetry and exactness. She been treated with a trial of supportive psychotherapy (1 year) and fLuvoxamine (200 mg/d for 10 weeks). She did not relieve her symptoms. She refused to take any further medication, and requested cognitive-behavior therapy. The cognitive aspect of the treatment focused on changing distorted and unrealistic perfectionistic beliefs. The behavioral aspect focused on helping her to engage in activities that were incompatible with skin picking. She learned to identify and regulate intense negative emotions that triggered the picking. After 14 sessions of cognitive behavior therapy her symptoms improved. After 3 months of treatment, she still occasionally picked at her skin. It did not interfere with social or occupational functioning.

Case 2 

Mrs. B, a 39 year old woman, had been picking at the skin on her feet to relieve tension for about 1-3 hours per day. The skin picking had originally been triggered by cracked heels or dehydrated skin. By the time she sought treatment she had been picking her skin for about 3 months. She mostly picked at healthy skin. The picking usually resulted in bleeding, extensive pain and difficulty walking. She was so embarrassed about the skin picking that she avoided all social and work settings. Mrs. B. described severe anxiety if the skin picking was interrupted. The urge that she always needed to carry out the behavior until she had a small pile of skin. Her history was remarkable for depression, alcohol abuse, and subclinical contamination fears. She had been treated with Fluoxetine 60 mg/d for 10 weeks. This did not relieve her symptoms. She began weekly cognitive behavioral therapy , focusing on cognitive restructuring and emotion regulation skills. The skin picking was very much improved after just 9 sessions and improvement was maintained at 6 months follow-up.