Diagnostic Criteria for Skin-Picking Disorder
Skin-picking disorder (excoriation disorder) requires four core diagnostic criteria: recurrent skin picking that produces skin lesions, repeated unsuccessful attempts to decrease or stop the behavior, clinically significant distress or functional impairment, and confirmation that the picking is not primarily motivated by appearance concerns (which would indicate body dysmorphic disorder instead). 1
Core Diagnostic Criteria
The diagnosis is established when all of the following are present:
Criterion A: Recurrent skin picking leading to visible skin lesions - This is the fundamental behavioral feature that must be documented through clinical examination 1, 2
Criterion B: Repeated unsuccessful attempts to decrease or stop the picking behavior - The patient must have tried to control the behavior without success, distinguishing this from casual or occasional picking 2
Criterion C: Clinically significant distress or functional impairment - The behavior must cause substantial problems in social, occupational, school, or other important areas of functioning 1
Criterion D: Not primarily motivated by appearance concerns - This is the critical differentiating feature from body dysmorphic disorder, where picking is specifically intended to improve perceived defects in appearance 3
Key Differential Diagnostic Consideration
The most important clinical distinction is between excoriation disorder and skin picking in body dysmorphic disorder, as treatment approaches differ significantly. 3
In excoriation disorder, picking represents compulsive behavior that may provide temporary relief or occur during states of boredom or anxiety, but is not driven by attempts to improve appearance 3
In body dysmorphic disorder, picking is specifically motivated by trying to fix or improve perceived appearance defects in the skin 3
Carefully assess the patient's motivation and thought process during picking episodes to avoid misdiagnosis 3
Clinical Features That Support But Are Not Required for Diagnosis
Field survey data reveals important nuances about symptoms that are common but not universal:
"Urges" or "needs" to pick are frequently present and correlate with severity, but are not endorsed by all patients and should not be required diagnostic criteria 2
"Resistance" to picking is also not universally present and should not be included as a mandatory criterion 2
The disorder shows female predominance with variable age of onset, commonly in adolescence and adulthood 4
Risk Assessment Considerations
Approximately half of patients with body-focused repetitive behaviors report self-harm related to their condition, indicating substantial psychiatric burden 1
Skin picking can lead to significant medical complications including infection, scarring, and tissue damage 5
Thorough assessment of comorbid conditions is essential, as the disorder is associated with significant psychiatric comorbidity including anxiety, depression, and obsessive-compulsive spectrum disorders 4, 6