A patient with acne excoriée most commonly presents as a young Caucasian female with excoriated acne and scars. As a result of the self-inflicting nature of the condition, patients will tend to excoriate regions that are more easily accessible. Therefore, the distribution of scars or excoriations over the body can provide a useful clue to clinicians. The patient with acne excoriée can have a distribution of lesions resembling the shape of butterfly wings on the back, referred to as the “butterfly sign.” In the butterfly sign, there is sparing of the upper, lateral sides of the back bilaterally resulting from the fact that the patient cannot reach these areas. Similarly, there tends to be more involvement of the extensor arm as compared to the medial arm, and more involvement of the anterior thigh as compared to the posterior thigh. Often, patients report a sense of tension immediately prior to picking at their skin, and a sense of relief after the behavior is complete [25].

Acne excoriée is a psychodermatological condition that refers to the behavior of picking acne lesions. The primary pathophysiologic source is in the psyche and not in the skin. Acne excoriée is characterized by picking or scratching at acne or skin with minor epidermal abnormalities [26]. It is an acne-involved subtype of excoriating behavior referred to by various names such as neurotic excoriation, psychogenic excoriation, pathological/compulsive skin picking, or dermatotillomania.

Though the patient has a skin condition, there is a primary psychiatric disturbance focusing on acne. The disturbance can simply be the habit of picking; however, there can also be a more serious source for the behavior. Patients with acne excoriée can have a variety of underlying psychopathology, but depression and anxiety appear to be the two most common underlying psychiatric conditions. Many patients also report compulsion for picking at the skin associated with poor self-image [27]. The formation of scars as a result of excoriation causes even more negative psychosocial impact, further exacerbating social isolation, depression, and anxiety, thereby leading to a vicious cycle.

Approximately 2 % of dermatology clinic patients are found to have some form of psychogenic excoriation [26]. The age of onset of the condition typically ranges from 15 to 45 years, and the duration of symptoms has a range of 5 and 21 years [26]. Though onset of this condition generally occurs in adulthood, acne excoriée is one of the most common presentations of psychodermatology in the pediatric age group [27]. There is an increase in females compared to males with acne excoriée, and the female to male ratio for all psychogenic excoriations is 8:1 [25, 26]. There are more case studies in the literature involving Caucasian patients with acne excoriée compared with African Americans or other racial groups, but there are no confirmatory studies of racial distribution in the general population. In addition, the lifetime prevalence of the condition is unknown.

Patients with acne excoriée can have comorbidity of mood and anxiety disorders, and thus present with severe psychosocial impairment. Mood disorders are found in 48–68 % of patients and include major depression, dysthymia (persistent mild depression), and bipolar disorders [28, 29]. Anxiety disorders are found in 41–65 % of patients, and include generalized anxiety disorder, agoraphobia, panic disorder, social and more specific phobia, obsessive-compulsive disorder, and post-traumatic stress disorder [29, 30]. Additionally, if a patient has a mood or anxiety disorder, he or she frequently has other psychiatric disorders related to the mood or anxiety disorder, particularly a compulsive-impulsive spectrum disorder, including body dysmorphic disorder, eating disorder, substance use disorder, or an impulse control disorder, which includes kleptomania, compulsive buying, and trichotillomania [31]. For very rare patients, acne excoriée may even present as a manifestation of a delusional disorder [32].

Significant functional impairment is a common occurrence. Patients are often embarrassed to admit their behavior to a physician. Many report impairment in social functioning including avoidance of activities that expose their skin to the public, such as sexual activity, going to the beach, and attending sports and community events [26, 33]. Patients will often use cosmetics, bandages, and clothing to hide their excoriations.

As a result of the psychiatric nature of the condition, there are no laboratory measures to make the diagnosis of acne excoriée. Instead, diagnosis is based on clinical presentation. The approach that we recommend includes taking a thorough history, conducting a detailed physical examination, and assessing the patient for an underlying psychiatric disorder that may be related to the condition. In particular, evaluating the patient for the exact nature of the underlying psychopathology such as depression, anxiety, and OCD is key.