"Pick" wisely: An approach to diagnosis and management of pathologic skin picking

Manipulation of the skin is ubiquitous in most individuals along a spectrum of extent and severity. Skin picking that results in clinically evident changes or scarring to the skin, hair, and nails or significantly impairs intrapsychic, psychosocial, or occupational function is considered pathological picking. Several psychiatric conditions are associated with skin picking, including obsessive-compulsive disorder, body-focused repetitive behaviors, borderline personality disorder, and depressive disorder. It is also associated with pruritus and other dysesthetic disorders. Although pathologic skin picking, also known as excoriation disorder, is a distinct diagnosis in the Diagnostic and Statistical Manual of Mental Disorders (DSM5), this review attempts to further classify the diagnosis into the following 11 picker categories: organic/dysesthetic, obsessive-compulsive, functionally autonomous/habit, anxious/depressed, attention deficit hyperactivity disorder, borderline, narcissistic, body dysmorphic, delusional, guilty, and angry picker. An organized conceptualization of skin picking can guide providers toward a constructive management approach, ultimately increasing the likelihood of successful therapeutic outcomes.