7.2.4 Obsessive-compulsive skin disorders

Grading & Level of Importance: C




Obsessive–compulsive neurotic skin disorders.


Estimated prevalence in adults: 2.3%. Age of onset: 19.5 years. 
Persistent disorder for years (mean of 8.9 years).


Excoriation disorder: 1-5% of the population. Female preponderance. 
Onset at adolescence (most common), or adulthood (30 -45 years of age).


Body-focused repetitive behavior disorder. Prevalence onychophagia (nail biting): 25-60%.


Group of dermatoses secondary to a chronic psychiatric disorder characterized by obsessions and compulsions.


Excoriation disorder (neurotic excoriations): Repetitive picking of skin resulting in noticeable tissue damage.


Body-focused repetitive behaviors: onychophagia, dermatophagia, onychotillomania (nail picking), trichotillomania, cheek/lip biting, nose/ear picking, and knuckle cracking. 

Aetiology & Pathogenesis

Obsessive-compulsive and related disorders is a category of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5). 


Body-focused repetitive behaviors are included under ‘‘unspecified OCRD’’ in DSM-5. 


Some OC related-skin and hair disorders, such as trichotillomania (see chapter 7.2.1)

Signs & Symptoms

Excoriation disorders: 


-Grouped erosions at easily accessible sites.  Picking over areas of acne, scars, scabs, or insect bites.

-Acne excoriee: Acne lesions are scratched and picked. 


Body-focused repetitive behavior disorder. Variable clinical features such as:


Nail biting: paronychia and gingival injuries.


Rubbing of the proximal nail fold: nail matrix damage. 


Chronic biting of the skin: localized thickened plaques (lichenification). 


Cheek biting: transverse whitish ridges in the oral mucosa (morsicatio buccorum).  


Repeated attempts to decrease or stop skin picking 
Associated psychopathology (depression, anxiety, or stress). 


Acne excoriee: frequent facial involvement.


Body-focused repetitive behavior disorder: nails, fingers, oral mucosa, lips. Accessible skin areas.


Secondary infection, bleeding, and inflammation. 

Laboratory & other workups

No abnormalities.


Cutaneous ulceration without or minor associated inflammatory infiltrates. 


Chronic. Waxing and waning evolution.


DSM-5 diagnostic criteria.

Differential diagnosis

Psychogenic pruritus. Primary psychiatric disorders with secondary excoriations (e.g. delusional infestation or tactile hallucinations).


Skin picking secondary  to the physiological effects of a substance (e.g. cocaine) or a medical condition (e.g. scabies).


The differential diagnosis of cheek biting includes oral candidiasis, lichen planus and white sponge nevus. 


In nail biting: nail dystrophy, nail matrix damage and mycotic infections.

Prevention & Therapy

Cognitive-behavioral therapy (CBT) and habit reversal training.


Anti-depressive and anti-psychotic agents are helpful  by treating underlying anxiety.


N-acetylcysteine 1200 to 3000 mg/ day may reduce skin picking.


In patients with acne excoriee: Additional appropriate acne treatment.


Approximately 90% of individuals with OCD have other psychiatric co-morbidities. The most common co-morbid disorder in OCD is anxiety disorders, depression, impulse control and substance use disorders. The co-morbidity of OCD and depression significantly increases the risk of suicide. 

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