Skin excoriation disorder: pathophysiology and treatment

Abstract

Skin picking disorder (SPD; excoriation disorder) is a psychiatric condition characterized by recurrent, compulsive manipulation of the skin, resulting in tissue damage. This condition predominantly affects women, with symptom onset typically coinciding with puberty, influenced by physiological and emotional changes, as well as concomitant dermatoses such as acne.

The most frequently affected sites include the face, arms, and hands, localized to easily accessible areas, with a notable predominance on the non-dominant side of the body. These repetitive behaviors are considered a form of behavioral addiction, given their association with a premonitory urge, a sense of gratification during the act, and a persistent, compulsive pattern of repetition.

Neurobiologically, cortico-striatal-thalamo-cortical (CSTC) circuits -which mediate habit formation and reward processing- are implicated in SPD pathogenesis. A considerable proportion of patients initially seek medical attention from dermatologists. A patient-centered approach, emphasizing empathetic engagement, is critical to establish therapeutic rapport and optimize outcomes.

Cognitive-behavioral therapy (CBT), particularly habit reversal training, remains the first-line psychological intervention, aiming to replace maladaptive behaviors with more adaptive alternatives. Pharmacotherapy guidelines prioritize serotonergic agents (e.g., SSRIs) for their modulatory effects on impulsivity. In treatment-refractory cases (∼30%), emerging evidence supports glutamatergic modulation with N-acetylcysteine (1,200-2,400 mg/day) or memantine (10-20 mg/day) as viable alternatives.