Educational Disclaimer: This case study is for educational and informational purposes only. It does not constitute medical advice, clinical guidance, or a substitute for professional psychiatric evaluation. All diagnostic criteria referenced are from the DSM-5-TR (APA, 2022). Clinicians should rely on their professional training, direct patient assessment, and current evidence-based guidelines when making diagnostic and treatment decisions.

Clinical Vignette

Patient: "Ms. B," 26-year-old digital marketing associate, presenting with chronic facial skin lesions that she acknowledges are self-inflicted.

Chief Concern: "I've been picking at my face for 8 years. I spend 1-2 hours in front of the mirror every night searching for imperfections to pick. My face is scarred and I use heavy makeup to cover it. I've tried to stop thousands of times."

History of Present Illness: Ms. B reports an 8-year pattern of recurrent skin picking, primarily targeting her face (cheeks, jawline, forehead), with additional picking at her arms and chest. Her picking follows a ritualized pattern: she examines her face in a magnifying mirror, identifies any perceived irregularity (tiny bump, pore, slight texture change), and picks, squeezes, or uses tools (tweezers, pins) to extract or smooth the area. She spends 1-2 hours nightly in this behavior. Picking episodes produce wounds that then 'need' further attention as they heal (picking at scabs). She has visible facial scarring (post-inflammatory hyperpigmentation, some atrophic scarring). She uses full-coverage foundation daily and has declined attendance at beach, pool, and gym activities to avoid makeup-free exposure. She reports both automatic picking (while watching TV, without awareness) and focused picking (deliberate, in front of mirror, searching for targets). She has attempted to stop many times using various strategies (covering mirrors, wearing gloves, applying healing ointments), all providing temporary relief.

Past Psychiatric History: Saw a dermatologist for 'acne' at age 19, who recognized the picking component and referred to psychiatry. She did not follow through. No psychiatric treatment to date.

Family History: Mother: trichotillomania (hair pulling from eyelashes). No other psychiatric history.

Mental Status Exam: Wearing heavy foundation (visible makeup layers). When asked to remove makeup, revealed: multiple active excoriations (5-6 on cheeks and jawline at various healing stages), post-inflammatory hyperpigmentation, and 3 atrophic scars. No primary dermatological lesion visible (lesions are all pick-induced). Affect embarrassed. Mood 'ashamed.' No depression. No OCD symptoms. Insight excellent.

Step 1: Excoriation Disorder DSM-5-TR Criteria

Criterion A: Recurrent skin picking resulting in skin lesions.

Eight-year pattern of daily skin picking. Multiple active excoriations, post-inflammatory hyperpigmentation, and atrophic scarring. All lesions are self-induced. MET.

Criterion B: Repeated attempts to decrease or stop skin picking.

Multiple cessation strategies attempted (covering mirrors, gloves, topical ointments). All provided temporary relief only. MET.

Criterion C: Clinically significant distress or impairment.

1-2 hours nightly. Uses heavy makeup. Avoids social and recreational activities (beach, pool, gym). Significant distress about scarring. MET.

Criterion D: Not attributable to substance or medical condition.

No primary dermatological condition. No substance effects. All lesions are self-induced. MET.

Criterion E: Not better explained by another mental disorder.

Not driven by OCD obsessions (no contamination or symmetry concerns driving the picking). Not driven by BDD (she is not preoccupied with a perceived defect; she picks at normal skin because of a compulsive urge, not because she believes her appearance is defective). Not psychotic (no delusional parasitosis). MET.

Step 2: BFRB Family Context

Excoriation Disorder belongs to the body-focused repetitive behavior (BFRB) family alongside Trichotillomania:

Feature Excoriation Disorder Trichotillomania OCD Skin-Related This Patient
Repetitive behavior Skin picking Hair pulling Ritualized (obsession-driven) Skin picking (BFRB)
Trigger Urge/sensation + sensory seeking Urge/sensation + tactile seeking Intrusive thought Urge + visual search for 'imperfections'
Awareness pattern Both automatic and focused Both automatic and focused Always aware (ego-dystonic) Both patterns present
Gratification Relief/satisfaction upon extraction Satisfaction upon pulling Anxiety reduction only Satisfaction on extraction
Family clustering Clusters with other BFRBs Clusters with other BFRBs Clusters with OCD Mother: trichotillomania

Treatment Approach

Excoriation Disorder shares the BFRB pathophysiology with Trichotillomania. The mother's hair pulling confirms family clustering. Treatment uses the same approach: Habit Reversal Training (HRT) with competing response, stimulus control (mirror restrictions), and NAC as pharmacological augmentation.

Diagnostic Formulation

Diagnostic Conclusion

Excoriation (Skin-Picking) Disorder (L98.1): All 5 DSM-5-TR criteria met. Eight-year pattern of daily facial skin picking with scarring. Both automatic and focused picking patterns. Family history of BFRBs (mother: trichotillomania). Treatment: HRT (awareness training, competing response, stimulus control), NAC 1200-2400mg/day, and dermatological co-management for scar treatment after picking behavior is controlled.

Teaching Points

  • Excoriation Disorder is classified under Obsessive-Compulsive and Related Disorders in DSM-5-TR, alongside Trichotillomania. Both are body-focused repetitive behaviors (BFRBs) with shared phenomenology (urge-driven, both automatic and focused, resulting in tissue damage).
  • Distinguishing Excoriation from OCD-driven skin picking: In Excoriation Disorder, the picking is urge-driven (similar to an itch that must be scratched). In OCD, skin picking would be driven by an intrusive OBSESSION (e.g., contamination fear requiring 'decontamination' of the skin). The treatment differs accordingly.
  • Like Trichotillomania, Excoriation has both automatic (out-of-awareness) and focused (deliberate) patterns. Stimulus control strategies (limiting mirror time, removing magnifying mirrors, wearing bandages on fingertips) target automatic picking. Competing response training targets focused picking.
  • Dermatological co-management is essential. After the picking behavior is controlled, patients often benefit from treatment of existing scarring (chemical peels, laser treatment, topical retinoids). Addressing scarring prematurely (while picking continues) is futile.
  • Excoriation Disorder must be distinguished from Delusional Parasitosis (psychotic conviction that insects are infesting the skin) and BDD-related picking (picking driven by preoccupation with a perceived appearance flaw). The distinction determines whether antipsychotic (delusional parasitosis), BDD-focused CBT, or BFRB-specific HRT is the appropriate treatment.