A 19-year-old woman is brought by her mother because she spends up to two hours daily picking at the skin of her face and arms, producing multiple crusted erosions and scars. She says she feels mounting tension before picking and relief afterwards, and she has repeatedly tried to stop without success. She denies any concern about a defect in her appearance, and dermatological evaluation finds no primary skin disease explaining the lesions. What is the most likely diagnosis?

• A Trichotillomania (hair-pulling disorder)
• B Body dysmorphic disorder
• C Excoriation (skin-picking) disorder ✓
• D Obsessive-compulsive disorder

Explanation

Excoriation disorder, added as a separate diagnosis in DSM-5, requires recurrent skin-picking resulting in lesions, repeated failed attempts to stop, and significant distress or impairment, with tension preceding and relief following the act. Body dysmorphic disorder is excluded here because she has no preoccupation with an imagined or slight appearance defect; picking driven purely by such a preoccupation would instead be classified under BDD. Trichotillomania involves pulling hair rather than picking skin.

Reference: Kaplan and Sadock's Synopsis of Psychiatry, 11th ed.

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Written and medically reviewed by the StethoPrep medical team.