Physical and Dermatological Examination
The clinical evaluation of someone with Excoriation Disorder entails a broad physical and psychiatric examination. The physical examination serves two purposes: first, to assess the extent of the picking and to develop appropriate interventions based on the damage to the skin (for example, does the person need antibiotics? Has a more systemic illness resulted from the picking such as bacteremia, cellulitis, or joint infection?); and second, to assess for possible dermatological or infectious etiologies of the skin picking.
In terms of the possible etiologies, there are many dermatological conditions that result in scratching or picking: scabies, atopic dermatitis, psoriasis, and blistering skin disorders to name only a few. Patients should be sent for a thorough dermatological consultation which may include microscopic examination of lesions for scabies, the Wood’s lamp examination for fungal infections, patch testing for allergies, skin biopsies, and laboratory investigations of thyroid, parathyroid, liver, and kidney problems.
In children, the examination should also focus on the possibility that skin picking is associated with pervasive developmental disorders or Prader-Willi Syndrome. Prader-Willi syndrome is a rare genetic disorder that is often associated with hyperphagia, hypogonadism, and frequent skin picking. Picking in individuals with Prader-Willi or with developmental disabilities may require specialized treatment interventions, such as combinations of differential reinforcement, providing preferred items and activities (e.g., toys), wearing protective clothing (e.g., helmets or gloves), and response interruption and redirection.