Management of patients who pick at their skin can be challenging. Etiologies and maintaining factors of skin picking are often unclear. Significant psychiatric overlay is often present, and the clinician is left with an overwhelming differential diagnosis and poorly focused management plans which can result in suboptimal clinical outcomes. The purpose of this article is to provide a conceptual framework for the evaluation and treatment of a patient presenting with excoriations. Ten diagnostic categories of pickers are described, and specific suggestions for treatment are offered.