Excoriation Disorder: The Details On Treatment You Need To Know
You've tried covering the mirror, cutting your nails, and promising yourself this is the last time. It hasn't stuck, and that's not because you're doing it wrong. This page covers how excoriation disorder is diagnosed, which treatment has the most support, and what it looks like week to week.
By Nathan Peterson, LCSW, OCD and BFRB therapistWhat is excoriation disorder?
Excoriation disorder is the clinical name for skin picking disorder, also called dermatillomania or compulsive skin picking. It means picking at your skin over and over, to the point of sores or damage, and not being able to stop even when you try.
Picking can happen on purpose, like going after a bump that feels wrong, or without noticing, like while you scroll or drive. It's a body-focused repetitive behavior (BFRB), in the same family as hair pulling and nail biting.
How is excoriation disorder diagnosed?
A mental health professional, like a psychologist, psychiatrist, or licensed therapist, makes the diagnosis. They'll ask about your picking, how long it's been going on, and how it affects your life. The DSM-5 criteria boil down to this:
- Picking at your skin over and over, leading to sores or skin damage
- Trying again and again to cut back or stop
- The picking causes distress, or gets in the way of work, school, or relationships
- It isn't caused by a drug, a medication, or a skin or medical condition
- It isn't better explained by another mental health condition
Skin picking often shows up alongside anxiety, depression, OCD, or ADHD, so a good assessment looks at the whole picture. If you want a starting point before you talk to someone, try the free skin picking test.
Excoriation disorder treatment
The main treatment for skin picking is a behavioral therapy called habit reversal training, or HRT. It's a type of CBT made for BFRBs. It focuses on your hands and your setup, not on arguing with your thoughts. Some therapists add acceptance-based skills too, so you can let the urge be there without acting on it.
Habit reversal training, step by step
1. Awareness training
You learn when, where, and how you pick, including the warning signs, like your fingers searching for a bump or leaning in toward the mirror. A week or two of tracking usually shows a clear pattern.
2. Competing response
When the urge shows up, you do something with your hands that makes picking hard, like making a fist, clasping your hands, or holding an object. You keep it up for about a minute, or until the urge drops. The urge is allowed to stay. Your hands go somewhere else while it does.
3. Social support
Someone you trust can point out when they see you picking and notice when you use your competing response. It's optional, and it only works if you both agree on how they'll do it.
I know, "make a fist" sounds way too simple. The simple part is the point. The work is doing it every time, especially the times you don't want to.
The ComB model
The ComB (comprehensive behavioral) model builds on HRT. It looks at everything that feeds your picking and gives you a tool for each piece:
- Sensory: a rough patch, a raised bump, a scab that feels uneven
- Cognitive: thoughts like "I'll get this one" or "it has to be smooth"
- Affective: stress, boredom, frustration, or feeling restless
- Motor: habits like touching your face while you read or rubbing your fingertips together
- Place: the spots it happens most, like the bathroom mirror, bed, or the car
Changing the setup is a big part of it. That can mean dimmer bathroom light, a timer at the mirror, bandages on your fingertips, fidgets where you scroll, or covering the spots you pick most.
Medication
No medication is approved specifically for excoriation disorder. Some doctors prescribe medication to help, and researchers are still studying which ones help and for whom. That's a conversation for your doctor or psychiatrist, and it usually works best alongside behavioral treatment.
Start with awareness. For the next week, write down every time you pick: where, when, which fingers, and what you felt right before. (Yes, you'll forget some. Write down that you forgot.)
That list is step one of HRT. If you want the rest of the steps laid out for you, that's what the course below is for.
Common questions about excoriation disorder treatment
Is there a cure for excoriation disorder?
There's no pill that makes it disappear. With treatment, picking can drop a lot and the urges get easier to ride out. Some people stop altogether. Others still get the urge sometimes and know what to do with it.
Can I treat skin picking at home or online?
Yes. Habit reversal training is skills you practice in your own life, so it works well online or self-guided. You can start with a structured course and add a therapist if you want more support.
How do I find a therapist for skin picking?
Look for someone who specifically treats BFRBs and uses habit reversal training or the ComB model. The TLC Foundation for Body-Focused Repetitive Behaviors keeps a provider directory at bfrb.org. It's fine to ask a therapist how they treat skin picking before you book.
Should I see a dermatologist too?
If your skin is infected, scarring, or not healing, yes. A dermatologist can treat the skin, and treating acne or other skin problems can take away some of the spots that set off picking. It works best alongside behavioral treatment.
