Q: What is the worst thing someone with acne can do to perpetuate the cycle of acne and cause it to scar?
A: Pick at their skin.
It's as simple as that. Picking at the skin delays healing of acne lesions, and causes rampant physical irritation to the skin. Anything that physically irritates the skin can make acne worse, so picking at existing lesions just creates more lesions, and the cycle continues.
But sometimes, stopping picking is easier said than done. For some people, picking becomes compulsive, and at that point it gets a diagnosis of excoriation disorder. When it's picking at acne lesions in particular, the diagnosis gets even more specific and is called acne excoriée. In this article, we will look more deeply into excoriation disorder and its connection to acne.
What Is Excoriation Disorder?
Excoriation disorder, also called skin picking disorder or dermatotillomania, is a psychiatric disorder in which people repetitively and compulsively pick at their skin, causing tissue damage. This skin picking is compulsive, meaning that people feel like they have to do it and they can’t stop even if they want to. People with excoriation disorder might pick at acne lesions, scabs, or other skin irregularities. When the picking is specifically on acne lesions, scientists refer to it as acne excoriée.1-4
The medical community points out that excoriation disorder has a connection to OCD in that people often feel powerless to stop and are highly distressed by it:
The fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), which is the manual that the American Psychiatric Association uses to diagnose mental illnesses, classifies excoriation disorder under the heading of obsessive-compulsive disorder and related disorders. This is because excoriation disorder has a connection with the genetic predispositions and symptoms of obsessive-compulsive disorder (OCD).4,16
A 2002 article in the journal Depression and Anxiety notes, “As is characteristic of obsessive-compulsive…spectrum disorders, patients acknowledge the self-inflicted nature of these lesions, and are distressed by their inability to control this behavior.”5
The DSM-5 gives the following criteria for a diagnosis of excoriation disorder:
- Recurrent skin picking that results in skin lesions.
- Repeated, unsuccessful attempts to decrease or stop skin picking.
- The skin picking causes clinically significant distress or impairment in important areas of functioning (such as functioning at work or in social situations).
- The skin picking cannot be attributed to the effects of a substance or another medical or mental condition.
The skin picking cannot be better explained by the symptoms of another mental disorder (such as delusions or intentional non-suicidal self-injury).6
How Does Excoriation Disorder Relate to Acne?
Excoriation disorder often begins with the onset of acne. However, unlike with many people who might pick at their acne lesions for a while and then stop, people with excoriation disorder continue picking at their skin even long after their acne clears.7
Repetitive picking of acne lesions delays the healing process, creates physical irritation that can lead to further acne breakouts, and dramatically increases the chances of scarring. Because of the irritation that picking causes, excoriation disorder can cause acne flares.8,9
According to a 2013 article in the British Journal of Dermatology, “A very small, observational study showed that picking at acne lesions worsened the inflammation and pustules.”8
Skin lesions caused by picking in people with excoriation disorder can range from just a few to hundreds. Repeated picking at these lesions can result not only in acne flares but also in significant tissue damage and even serious medical complications such as infections and septicemia, which is a life-threatening condition that results when an infection gets into the bloodstream.7
How Common Is Excoriation Disorder?
Excoriation disorder occurs in approximately 1%-5% of the general population, though it tends to occur more often in people with other psychiatric disorders such as OCD, anxiety, depression, or eating disorders.1,6-9It also tends to occur more often in females than in males.1,4
What Other Disorders Occur along with Excoriation Disorder?
Excoriation disorder often occurs along with other psychiatric disorders. In particular, studies have reported that excoriation disorder occurs alongside:
- Body dysmorphic disorder
- Obsessive-compulsive disorder
- Trichotillomania (hair pulling disorder)
- Eating disorders
- Substance use disorders2,7,10,11
While scientists don’t know exactly why excoriation disorder often occurs with these other disorders, at least some of the overlap is probably because they share biological characteristics.2,10
What Causes Excoriation Disorder?
Researchers don’t know what causes excoriation disorder, but both biological and psychological factors appear to contribute to it. Biological factors might include genetic predisposition. Psychological factors might include attempts to avoid uncomfortable emotions or reduce obsessive thoughts, or impulsivity (the tendency to act on a whim, without thinking about it).7,12In other words, someone might pick at their skin in a subconscious attempt to avoid thinking about the fact that they are unhappy.
While data examining the link to genetics is limited, some studies have shown that up to 43% of people with excoriation disorder may have inherited it from their parents. Other studies in twins have also shown a strong genetic influence on the development of excoriation disorder.7,13
In addition, scientists have identified two different genes that may play a role in predisposing someone to develop excoriation disorder.
- HOXB8 is a gene that helps regulate the formation of organs and tissues in a developing fetus. At least one study has found that altering this gene in mice is associated with excessive grooming that leads to hair loss and skin lesions.
- SAPAP3 is a gene that helps brain cells communicate with each other. A study in mice demonstrated that mice that were lacking this gene engaged in compulsive grooming behaviors that led to bald patches and open sores. Another study looking at families with OCD found that a variation in this gene was associated with the development of grooming disorders such as nail biting.7
How Do You Treat Excoriation Disorder?
Excoriation disorder can be treated both with medications and with psychotherapy. However, both of these types of treatments have had mixed results in the long term.12,14
Medications. Medications that can treat excoriation disorder include:
- Antidepressants, especially SSRIs (selective serotonin reuptake inhibitors) and TCAs (tricyclic antidepressants)
- Opiate antagonists, such as naltrexone
- Atypical antipsychotics, such as olanzapine3,4,12
Medications only work some of the time, and can take a long time to start working. For example, antidepressants often take two to six weeks to start working. In addition, medications such as antidepressants can have unpleasant side effects such as nausea, diarrhea, significant weight gain, insomnia, sedation, and loss of libido.3
Finally, while medications can help somewhat, they do not address any psychological factors that may contribute to excoriation disorder. For this reason, medications should ideally be given along with psychotherapy.12
Psychotherapy. There are several different psychotherapy approaches that can help with excoriation disorder:
- Cognitive behavioral therapy (CBT). Cognitive behavioral therapy involves learning to change problematic patterns of thinking and behavior. In CBT, therapists help their clients to first identify, then challenge, and then change their thoughts and behaviors related to skin picking.
- Acceptance and commitment therapy (ACT). Acceptance and commitment therapy is a form of cognitive behavioral therapy that uses mindfulness, acceptance, and behavioral change strategies to reduce skin picking behavior. Clients learn to identify urges to pick, and then learn to tolerate the uncomfortable emotions that arise when they do not pick.
- Habit reversal training (HRT). Habit reversal training involves learning to be aware of the urge to pick, and then replacing picking behaviors with healthier behaviors.4,12
All three of these therapies can be effective in treating excoriation disorder, at least in the short term. However, results have been inconsistent in the long term.4,12
If you feel like you can't stop picking at your skin, ask your doctor for a reference for someone who can help. Once you stop picking at your skin, you will be able to stay clear of acne much more easily, and you will dramatically reduce the chance that any acne that you do have will scar.