How to Diagnose Dermatillomania

An official diagnosis of dermatillomania (also called skin picking or excoriation disorder) should be completed by a qualified healthcare professional. Keep in mind that although awareness of body-focused repetitive behaviors (BFRBs) increased in recent years, there are still many healthcare providers who are not trained to differentiate BFRBs from related disorders. However, preliminary self-diagnosis can be helpful for determining next steps.

First,  it is important to understand that skin picking is not a problem because occasionally removing flaky skin or old scabs is normal. It only becomes a problem when a person finds it difficult to stop and the picking causes wounds. Therefore, it is useful to look at different skin disorders and their symptoms. Second, there are official diagnostic criteria specified in DSM5. Third, a person can use an online questionnaire as a means of self-diagnosis. Then, confirm the diagnosis with a physician, dermatologist,  psychiatrist, or qualified mental health provider.

Behaviors

The simplest description of dermatillomania is as an urge to pick at the skin. But the behavior patterns and sometimes the underlying motives for the behaviors, vary depending on the area of focused picking. 

• Compulsive face picking rarely starts with a visible problem. Somebody with this issue may choose a spot that does not have any visible imperfections, however, with persistent picking, turn it into a bleeding wound. Then, the person avoids others because the wound makes them ugly which contributes to increased stress and anxiety. Some people use compulsive face picking to avoid others because they feel unworthy of affection.
• Scalp Picking involves finding blemishes and imperfections at the scalp. They can be imagined or real, but with persistent scratching and pulling a person will develop wounds on the head, which becomes a valid target for more scratching and picking, creating a vicious cycle hard to break. When taken to the extreme, this behavior can even cause bald spots. 
• Picking at the acne often starts during the teenage years, when hormonal changes can cause an outbreak of pimples. Teenagers tend to have issues with self-esteem as they transition from childhood to adulthood, and the onset of acne can make those issues worse. Although they think picking the acne will get rid it, the opposite often occurs. The most important problem with skin picking acne is that it can cause infection, skin discoloration, and scarring. 
• Lip picking consists of peeling, biting, or chewing the skin on or around the lips. While many people often pull or bite off a bit of peeled skin on their lips, compulsive lip pickers go beyond that. Driven by stress, boredom, or worry, they cause so much harm to their lips that bleeding and injury occurs and ordinary activities, such as eating or kissing, feel unpleasant or even painful.
• Nail picking involves biting, chewing, and picking one's nails and cuticles. Again, it is normal to bite or pick off damaged bits of nails that get stuck on whatever a person is handling, but when it becomes a matter of biting and picking until the nails, cuticles, or surrounding skin bleed, it's a sign of dermatillomania. Students suffering from nail picking often stop during school breaks, only to start over when they return to a stressful environment. 
• Picking scabs can start as a coincidence. A person can have a scab caused by an accident and start picking at it. If it comes when the person is under stress or vulnerable, the picking may have a soothing effect. Then it becomes a self-perpetuating behavior that relieves anxiety and makes the person feel more anxious because the constant picking is painful.

Regardless of where the skin picking occurs on the body when it becomes excessive and causes injury, it is often a sign of disorder and may require professional assistance.

Official Diagnostic Criteria

The DSM-5 is the manual for the classification of mental disorders used by mental health providers, psychiatrists, and some doctors. Doctors also use the ICD-10 classification system. However, for the purposes of determining whether skin picking meets the diagnostic criteria for a disorder, SkinPick.com and its therapists use the DSM-5.   

There are 4 criteria for a clinical mental health diagnosis of compulsive skin picking:

• Significant time spent picking. Regardless of whether the picking behaviors or cyclical, episodic, or consistent, a person will spend several hours at a time engaged in the behaviors. Time spent picking gets to the point where it interferes with daily life. For example, arriving late to school or work because picking took too long that morning or forgetting appointments because of picking. A secondary aspect of time spent picking is there is often additional time spent covering up the damage from picking to prevent others from noticing.
• Picking behaviors result in breaking the skin, wounds, or skin lesions. Often, there are repeated layers of skin damage which can lead to infections, scars, or other skin problems.
• Despite multiple attempts to stop the picking behaviors by oneself, they cannot. Most people with skin picking disorder know it is an undesirable behavior and they want to stop, but cannot.
• Picking behaviors cause significant distress. Whether stress causes picking or picking causes stress, the impact of both causes people with the behaviors to isolate from others so they do not feel judged, they may suffer decreased performance at work or school, and they internalize feelings of guilt, shame, and embarrassment which causes psychological distress.

Self-Diagnosis

Self-diagnosis is challenging because our perception of ourselves and our behavior may not be accurate. For example, some people inflate symptoms as worse than they really or on the other end of the spectrum, ignore them. However, self-diagnosis, such as through our online dermatillomania test, can help someone realize if they have a problem. Keep in mind not all online questionnaires are based on research. Before taking one, determine whether the test is valid. For example, our online test is adapted from several evidence-based tests validated by research. Based on the results of an online questionnaire, a person can decide to see a qualified health provider for a thorough assessment.

Contact a Qualified Health Provider

In anticipation of discussing skin picking with a doctor, there are several things to consider. A primary care physician or a dermatologist can inspect wounds for infections and evaluate any old scars that did heal. However, some physicians are not well-informed about compulsive skin picking. There are some dermatologists who specialize in psychodermatology and often have a better understanding of the complications related to compulsive skin picking. Either way, a medical provider needs to know that the wounds result from compulsive skin picking so they can treat the wounds and provide information about how to care for the skin even if picking continues.

While it's important to talk to a medical professional who can take care of physical wounds, a behavioral health professional (psychiatrist/psychologist/therapist) can address the mental and emotional aspects of the disorder and how those relate to behaviors. This blog post gives some recommendations for finding the right therapist. Also, skin picking often comes with other mental illnesses, such as obsessive-compulsive disorder, body dysmorphic disorder, anxiety, depression, and substance abuse. After a comprehensive assessment, a therapist will work out a treatment plan to help the person change the undesirable behavior. Cognitive-behavioral therapy (CBT), with an emphasis on habit reversal training, is considered the most effective therapy for this disorder.

It is important to note that sometimes even doctors can underestimate the severity of skin picking. If they suggest to “just stop doing it”, do not be discouraged, but look for a professional who has experience working with excoriation disorder.