Digging for the Diagnosis

DISCUSSION
Known in the DSM-5 and ICD-10 as skin-picking disorder, this condition has also been called dermatillomania. For unknown reasons, its incidence is far greater among women than men.

While it has been posited as a form of obsessive compulsive disorder (OCD), dermatillomania responds poorly, if at all, to standard OCD treatments. It is considered by others to more closely resemble addiction because, despite knowing its harm, patients persistently pick at the skin and often report a subsequent sense of relief.

This patient’s type IV skin lent itself to postinflammatory hyperpigmentation upon injury. Although she knew this, she still felt that she could somehow pick the darkness away.

Bloodwork was done to rule out other conditions, such as porphyria, hematologic disease, and renal or liver disease. Had a recent biopsy not been performed, this would have been included to rule out systemic disease.

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The patient was given a topical steroid cream to put on any itchy lesions and counseled to avoid picking or scratching them, since this was the only way her skin could ever clear.

TAKE-HOME LEARNING POINTS

• One common term for this patient’s disorder is dermatillomania, though the DSM-5 and ICD-10 refer to it as skin-picking disorder.
• This patient experienced postinflammatory hyperpigmentation, which caused her considerable embarrassment.
• Many affected patients have unresolved underlying psychologic issues that contribute to their problem.
• The solution (which may require extensive counseling): Stop picking, and the dark lesions will eventually resolve.