What is the condition characterized by digging skin, causing scars, bruising, and affecting mental health?

Excoriation (Skin Picking) Disorder

The condition you're describing is Excoriation Disorder (also called Skin Picking Disorder or Dermatillomania), characterized by recurrent picking of one's skin leading to skin lesions, scars, and bruising, accompanied by unsuccessful attempts to decrease or stop the behavior, and is classified as an obsessive-compulsive and related disorder with significant mental health impact. 1

Diagnostic Features

Excoriation disorder is defined by:

• Recurrent skin picking leading to skin lesions 1
• Repeated unsuccessful attempts to decrease or stop the behavior 1
• Significant distress or functional impairment 2
• Not primarily motivated by appearance concerns (which would indicate body dysmorphic disorder instead) 2

The disorder commonly affects easily accessible areas and results in visible tissue damage, scarring, bruising, and potential infection 3, 4

Mental Health Impact

This condition carries substantial psychiatric burden:

• Approximately half of patients with body-focused repetitive behaviors report self-harm related to appearance concerns 2
• High rates of comorbidity with OCD, anxiety disorders, depression, autism spectrum disorder, and borderline personality disorder 3, 4
• Significant psychosocial dysfunction and quality of life impairment 4
• Risk of severe complications including infection, extensive tissue damage requiring emergency care, and muscle exposure in extreme cases 3

Treatment Algorithm

First-Line: Cognitive-Behavioral Therapy

Start with CBT incorporating habit reversal training as the primary intervention: 2

• Awareness training to identify triggers 2
• Development of competing responses (alternative behaviors when urge arises) 2
• Self-monitoring tools to track picking episodes 2
• Exposure with response prevention techniques 2
• Family involvement, particularly for younger patients 2

Second-Line: Pharmacological Intervention

Add medication when CBT alone is insufficient, particularly with moderate-to-severe functional impairment: 2

SSRIs are the most effective pharmacological option based on controlled trials: 4, 5

• Recommended for patients aged 12-18 years who haven't responded to CBT 2
• Most promising results for mitigating severity and frequency of skin-picking 5
• Increasingly used in combination with psychotherapy 5

N-Acetylcysteine as alternative or adjunct: 2

• Well-established glutamatergic agent with minimal side effects 2
• Dosed at 1200-2400 mg/day in divided doses 2
• Second most effective pharmacological intervention after SSRIs 4

Adjunctive Approaches

• Online self-help programs with educational materials and CBT-based exercises show moderate effect sizes 2
• Regular stress management and relaxation training to reduce picking triggers 2
• Topical wound care and antibiotics for active lesions 3

Critical Pitfalls to Avoid

Do not confuse with body dysmorphic disorder: In BDD, picking is driven by attempts to improve appearance of perceived defects, whereas excoriation disorder picking is not primarily motivated by appearance concerns 2, 6

Screen for medication-induced picking: Stimulants can cause or exacerbate compulsive skin picking; consider dose reduction or medication holiday if stimulants are contributing 2

Assess suicide risk: The chronic, painful nature with significant quality of life impact warrants mental health risk assessment 2

Require multidisciplinary approach: Both dermatologic treatment of lesions and psychiatric treatment of underlying disorder are necessary—treating wounds alone without addressing the compulsive behavior ensures perpetuation 6, 7