Women more likely to suffer skin picking

4 minute read

Around 3.5% of the population has excoriation disorder, which is more common than other forms of OCD.

Excoriation disorder is more common than other forms of obsessive-compulsive disorders, research suggests.

But often only the more severe cases of the skin-picking disorder come to the attention of doctors, experts said.

According to a systematic review and meta-analyses of 19 international studies including more than 38,000 people with a mean age of 33, an estimated 3.5% of people have the condition.

Females are 50% more likely to be affected than males, the analysis found.

“Individuals with excoriation disorder often spend hours per day picking at their skin, which may cause shame and embarrassment and may lead to physical (noticeable scars, scabs) and psychosocial (missed work, school, and other obligations) impairment,” the researchers wrote in Journal of Psychiatric Research.

“Additionally, excoriation disorder often co-occurs with other psychiatric disorders, including depression, anxiety, obsessive-compulsive disorder (OCD), and substance use disorders, which may contribute to higher skin-picking symptom severity.”

The researchers said the condition had a slightly higher prevalence than other obsessive-compulsive and related disorders including OCD, body dysmorphic disorder and trichotillomania.

“Excoriation disorder remains a difficult-to-treat condition with limited efficacious therapeutic options.”

Sydney dermatologist Associate Professor Saxon Smith said it was difficult to know how many people had excoriation disorder in Australia but it was probably higher than people were aware.

“Something like this will go under-reported more often than not with a lot of patients, or may be dismissed as an inconsequential part of their overall health.

“It is usually only the more extreme versions of it that find their way to their doctors.

Professor Smith said excoriation disorder could occur in patients with OCD, depression or anxiety and other underlying psychiatric predispositions.

Excoriation disorder was an automation process that many people have and is magnified during periods of physiological or psychological stress, he added.

“Ultimately, you have to recognise that some people are skin pickers, some people are nail biters, some people are hair twirlers or hair biters.

“These are the automations that we all have and they become more apparent in times of stress or pressure or when we’re unwell.

“It just is something that needs to be acknowledged with the patient and the patient acknowledge it, and then find ways to help them through that.”

If the excoriation disorder was linked to an underlying psychosocial predisposition, treating the underlying condition will help, he said.

But there may be challenges in helping patients identify those the underlying triggers.

“Ultimately, it’s about supporting the patient to come to the realisation that what they are doing is contributing to it, but also trying to help the skin to recover.

“We might use long arm sleeves so they can’t get at their arms as much, and they might have to wear at night if that’s when they’re often doing it when they’re really unaware.”

“If they are in a period of increased psychosocial stress, the supporting measures include getting in touch with a psychiatrist or psychologist.

Professor Smith said medications may also play a role.

“Knowing that there is an OCD component to some of these which lends itself to a low-dose old fashioned tricyclic antidepressants or SSRIs that may be beneficial.

“If they’re scratching or excoriating themselves at night and they’re not sleeping well you can harness the dual purpose of amitriptyline to help as a sleeping tablet for night-time sleep.

“It also has a membrane stabilising property to help decrease the agitation within the nerves, which are hyperactive and sending that sensation of itch that drives the excoriation physiologically and psychologically, and the small doses help the overall underlying predisposition.”   

Professor Smith said it was importantto rule out organic causes such as coeliac disease or the autoimmune disorder bullous pemphigoid, which was common in older patients.

“They might have B12 and iron deficiencies and anaemia which can contribute to these itching skin sensations.

“Looking for underlying issues is always important because as we’ve always said, it’s organic until proven otherwise. And then make sure we support them through the process.

“It’s important to make sure you’re not missing anything. That can include an age-appropriate malignancy screen, because pruritis which is the driver for the excoriation or is the sensation or thought of it, which is why they often start picking, has many different precipitants and sometimes haematological malignancies need to be excluded.”

Journal of Psychiatric Research 2023, online 4 April

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