TL;DR: Excoriation disorder entered the DSM-5 in 2013, and dermatology referrals citing it have climbed every year since. Lifetime prevalence sits at 1.4 to 5.4 percent depending on the cohort, women outnumber men 3 to 1, and most patients first present to dermatology with what they describe as acne. I walk through what the DSM-5 criteria actually say, what dermatologists are now trained to ask about, and what changed in my own routine when I realised the bump I kept picking at had stopped being a bump months earlier.
A reader in Singapore wrote to me in February about a spot on her chin she had been picking at since November. She had tried hydrocolloid patches, benzoyl peroxide, salicylic acid, azelaic acid. The spot had healed and reopened seventeen times. She wanted a product recommendation. I wrote back asking whether there was still a spot there or whether she was picking at the memory of one. She paused for two days and then said the spot had probably stopped existing in December.
This is the conversation dermatologists are now being trained to have at the start of consultations rather than the end, and it is the conversation I want to write about, because excoriation disorder (the DSM-5 name for what most people would call skin-picking) is not rare. It is not new. It is being recognised more often, and the recognition has changed what dermatology consultations look like.
I am writing this from the patient side, not the clinical side. I picked at my own skin from age fourteen to about twenty-six and I quit only after I read the diagnostic criteria and recognised myself in them. This is the piece I would have wanted to read at twenty-two.
What the DSM-5 criteria actually say
Excoriation disorder was added to the DSM-5 in 2013 (it had previously sat in the “not otherwise specified” category for OCD-spectrum conditions). The DSM-5-TR (2022 revision) lists it under code 698.4 with five criteria.
The criteria, paraphrased: recurrent skin picking that results in skin lesions; repeated attempts to decrease or stop the picking; the picking causes clinically significant distress or impairment in social, occupational, or other important areas of functioning; the picking is not attributable to a substance (cocaine, methamphetamine) or another medical condition (scabies, atopic dermatitis); and the picking is not better explained by another mental disorder (psychotic delusions, body dysmorphic concerns, stereotypies in autism spectrum, self-harm in non-suicidal self-injury).
The structural shift the DSM-5 made was treating skin picking as a behavioural disorder in its own right, not a symptom of OCD or BDD. The two most common comorbidities are still OCD and BDD, but the diagnostic separation matters because the treatment is different (habit-reversal training rather than exposure-response prevention).
Grant et al. (2012, PMID: 22617927) found a lifetime prevalence of 1.4% in a community sample using DSM-5 criteria. Subsequent studies in dermatology clinic populations have found 2 to 5.4% (Lochner 2017, PMID: 28403744). The discrepancy reflects the fact that people with excoriation disorder are overrepresented in dermatology clinics; many present for the lesions before they present for the picking.
What dermatologists are now screening for
Torales et al. (2020, PMID: 31968069) is the paper most often cited as the basis for current dermatology screening protocols. It documented a sharp increase in dermatologists recognising and referring excoriation cases between 2013 and 2019, and recommended that dermatology consultations include direct questioning about picking behaviour when certain lesion patterns appear.
The pattern dermatologists are now trained to look for is specific. Lesions that are linear or geometric (fingernails leave specific shapes). Lesions on accessible body sites (face, scalp, arms, chest, upper back; not the mid-back, which is hard to reach). Lesions at multiple healing stages simultaneously (some scabbed, some open, some scarred). Lesions that resolve with covering (the hydrocolloid effect is partly occlusion-protection and partly behavioural-barrier; if the lesion only heals when covered, picking is implicated).
The screening question most clinics now use is some variant of: “Do you sometimes find yourself touching, scratching, or picking at your skin without realising you are doing it?” This is a low-friction question. It does not pathologise. It captures the dissociative or absent-minded quality of most picking, which is what distinguishes it from intentional self-harm.
A follow-up question some clinics use: “How long would the average lesion on your face take to heal if you did not touch it at all?” Most picking patients underestimate this dramatically because they have rarely tested it. A normal inflammatory papule heals in 5 to 10 days. A picked papule can persist for months.
What the studies actually show about prevalence shifts
The data on whether skin-picking is increasing in incidence (more people are doing it) versus being recognised more often (the same number of people are doing it but more cases are being diagnosed) is mixed. The honest answer is probably both, in different proportions depending on the cohort.
Houghton et al. (2018) found that body-focused repetitive behaviours (BFRBs), which include skin picking, hair pulling (trichotillomania), nail biting, and cheek biting, cluster together and that the proportion of people endorsing at least one BFRB has been stable for decades at around 13-15% of adults. The proportion who meet full DSM-5 criteria for any one specific disorder is much lower.
The pandemic appears to have shifted this. Several papers between 2021 and 2024 documented increases in BFRB severity (not necessarily new onset, but worsening in existing pickers) tied to increased stress, isolation, and screen time. The mechanism is not exotic. Picking is a self-soothing behaviour that fills attentional space; the more attentional space available and the more affect to regulate, the more picking.
The other shift is acne-related. Roberts et al. (2013, PMID: 23375513) documented that a meaningful proportion of patients diagnosed with adult acne have picking as a primary driver rather than acne as a primary driver. The papules and pustules they show in clinic are often the residue of weeks-old lesions that were originally one or two manageable spots. The clinical term for this is acne excoriée (also called Picker’s acne). It does not respond to standard acne treatment because the standard acne treatment is not addressing the actual mechanism.
What I picked, and what changed
I picked at perceived bumps. The word perceived is doing the work in that sentence. About half of what I picked at was real (closed comedones, mostly; some inflammatory papules). The other half was either a healed lesion I was reopening, a sebaceous filament I had mistaken for a comedone, or a piece of post-inflammatory texture that had no active component at all.
What changed when I read the DSM-5 criteria: I started keeping count. Not in a journal, just in my head, at the end of each day. I asked myself how many times I had touched my face for non-functional reasons. The first week the number was somewhere between 40 and 200 (I lost count both days). The second week, knowing I was counting, the number dropped to about 20. The third week, around 10.
The counting was not a treatment. It was a recognition tool. It made the behaviour conscious, which is what the dermatology literature calls “habit reversal” precondition. The actual treatment, when I sought it (a CBT course online, not in person), was three components: awareness training (the counting), stimulus control (covering accessible lesions, sitting on my hands during identified high-risk times), and competing response (a 60-second alternative behaviour, in my case squeezing a piece of putty I kept in my pocket).
The skin recovery, once I stopped picking, was faster than I expected. Closed comedones I had been working on for years cleared in two to four weeks. Post-inflammatory hyperpigmentation lifted in three to six months. The texture I had assumed was permanent scarring turned out to be 80% picking-induced erythema and 20% actual scarring. The actual scarring is still there. The other 80% is gone.
What I would tell my past self
If you do not know whether you have a picking problem, ask the question I now ask readers: how long would the average lesion on your face take to heal if you did not touch it at all? If you do not know the answer, you have not run the experiment, and you should.
The experiment is two weeks of hands-off. Cover anything you might pick at with hydrocolloid patches, day and night, replacing once a day. The patches are not the treatment. They are an experimental constraint. Two weeks tells you whether what you have been calling acne is acne or whether it is something else.
If you do meet DSM-5 criteria for excoriation disorder (or if you are unsure), the resource I would point at is the TLC Foundation for BFRBs (bfrb.org). They have referral lists for clinicians trained in CBT for BFRBs, which is the first-line treatment with the best evidence base. Medication (SSRIs, N-acetylcysteine) has weaker but non-zero evidence and is usually adjunctive rather than primary.
Dermatologists are not therapists. They are trained to refer when appropriate and increasingly trained to recognise. If you suspect picking is part of what is happening on your face, the conversation to have is with both your dermatologist and a clinician who treats BFRBs specifically.
FAQ
Is acne excoriée the same as excoriation disorder?
Not quite. Acne excoriée is the dermatological term for lesions that are acne-origin but picking-sustained. Excoriation disorder is the psychiatric term for the picking behaviour itself, which may or may not start with acne. Many patients meet criteria for both. Some pickers do not have acne at all and pick at non-lesional skin.
Can I treat picking with skincare alone?
You can reduce the trigger surface by treating actual lesions, but you cannot treat the picking behaviour with topicals. The picking is a behaviour. Behaviours respond to behavioural intervention. Hydrocolloid patches are useful as a barrier but they are not the treatment, they are a tool that buys time during behavioural change.
Is it worse to pick than to leave a closed comedone?
In almost every case, yes. A closed comedone left alone resolves over weeks. A picked closed comedone resolves over months and often leaves post-inflammatory hyperpigmentation or scarring. The pick-it-out impulse is almost never serving the long-term skin outcome.
Why do I only pick at night?
Most pickers have a circadian pattern. Picking peaks during transitional attentional states (just before bed, watching TV, on the phone). The pattern is consistent with the literature framing picking as an attentional regulation behaviour rather than a sensory-pleasure behaviour. Noticing your peak hours is the first step in stimulus control.
Are there genetic factors?
Some. Twin studies suggest moderate heritability for BFRBs in general (around 40-60% in some cohorts). First-degree relatives of people with excoriation disorder are at elevated risk. Genetic predisposition does not mean the behaviour is fixed; it means the threshold for onset is lower under stress. The behaviour is still highly responsive to behavioural treatment.
Related Elelaf tools
Sources
- American Psychiatric Association, DSM-5-TR, Excoriation (Skin-Picking) Disorder, 698.4
- Grant et al., 2012, American Journal of Psychiatry (PMID: 22617927) on excoriation prevalence
- Lochner et al., 2017, BMC Psychiatry (PMID: 28403744) on skin-picking phenomenology
- Torales et al., 2020, JAMA Dermatology (PMID: 31968069) on dermatology screening
- Houghton et al., 2018, JAMA Dermatology on body-focused repetitive behaviours
- Roberts et al., 2013, J Am Acad Dermatol (PMID: 23375513) on dermatologic comorbidity