Treating Skin Picking with Acceptance-Enhanced Behavior Therapy

Excoriation or skin picking has often been in the shadow of its nearest relative, trichotillomania or repetitive hair pulling. One good thing to come out of the DSM-5 was that it finally made skin picking disorder an official diagnosis—excoriation. Prior to the DSM-5, there was no official diagnosis for this condition. I suspect the lack of official diagnosis slowed research into skin picking disorder. As a consequence, there are few published treatment studies for excoriation.

A recent study looked at the use of an acceptance-based protocol that was originally created for trichotillomania. The protocol is Woods & Twohig’s Trichotillomania: An ACT-enhanced Behavior Therapy Approach therapist guide, part of the respected Treatments That Work series of treatment manuals published by Oxford Press. The protocol combines Habit Reversal Training (HRT) with Acceptance and Commitment Therapy (ACT). From the study description, the protocol remains largely the same as the published trichotillomania version, except that information about hair pulling is swapped out for skin picking.

The study

Four people with excoriation completed courses of AEBT. Three of the four completed treatment in 10-sessions—the standard protocol length—whereas the 4^th completed 25 sessions of treatment. All four responded to treatment, although the individual who completed 25 sessions (“Rose”) struggled with periodic lapses (sudden increases in picking) during treatment. Of note: one of the primary treatment responders (“Amy”) completed all but the initial session through web-based video-conferencing. Treatment appeared to successfully address both skin picking as well as co-occurring problems including anxiety, depression, and life stress.

Because this is a small, uncontrolled study, results should be interpreted cautiously. However, it provides some additional evidence that the AEBT protocol is as effective for skin picking as it is for hair pulling. One prior multiple baseline study of AEBT included 2 participants with skin picking and also found reductions in pulling.

For therapists interested in treatment excoriation and trichotillomania, the AEBT protocol is a commercially available and flexible treatment manual with very good research support for hair pulling and some very promising evidence for its use in treating excoriation. Additionally, this study provides some evidence that treatment produces changes in conditions that are co-morbid with picking such as anxiety and mood problems. I draw from the treatment manual in my own practice and have found the handouts and treatment framework particularly helpful.

If you’re interested in reading the full study, you can download a pre-publication copy here.