Captive of the mirror: ‘I pick at my face all day, every day’

Lying in the hospital bed, her face covered in bandages, Ms. S talked of suicide while awaiting reconstructive surgery on her nose: “If the only way to stop is by killing myself, I will.” When asked what she wanted to stop, she replied, “The picking. I pick at my face all day, every day.”

Ms. S, age 22, had picked a hole through the bridge of her nose, and her face was scarred and covered with scabs. Every morning for 5 years, she had gotten up, dressed, and then—after washing her face—felt intense, uncontrollable urges to pick at her face. Hours would go by and she was still picking, even as her face started to bleed: “I try to resist, but I can’t.”

Ms. S started picking her face when she was 17. She missed so much of high school because of time spent picking that she did not graduate. She now lives alone on medical disability. Conscious of her facial scarring, she rarely goes out in public. “People stare at me as if I’m a zoo animal; it’s so painful,” she says.

After her plastic surgery, she told the staff psychiatrist she had never sought help because she thought no one would understand her behavior. “It doesn’t make sense to me, and I’ve lived with it for years.”

Patients such as Ms. S often suffer in isolation for years, unaware that skin picking is a psychiatric disorder that can be treated successfully. Some are referred to psychiatrists through hospital emergency rooms or by dermatologists; others commit suicide, as Ms. S threatened to do.

In our practice, we recognize skin picking in patients with comorbid mood and anxiety disorders, body dysmorphic disorder (BDD), substance use disorders, impulse control disorders such as trichotillomania or kleptomania, and personality disorders.

Based on recent evidence and our experience, we discuss three steps to help you diagnose pathologic skin picking. We then examine treatment options that have shown benefit for skinpicking patients, including habit reversal psychotherapy and medications.

WHAT IS SKIN PICKING?

Pathologic skin picking is repetitive, ritualistic, or impulsive picking of normal skin, leading to tissue damage, personal distress, and impaired functioning.¹ The behavior has been described for more than 100 years but remains poorly understood, under-diagnosed, and under-treated.^2,3

Most people pick at their hands or face to a limited extent,⁴ and picking does not by itself suggest a psychiatric disorder. Pathology exists in the focus, duration, and extent of the behavior, as well as reasons for picking, associated emotions, and resulting problems. Persons with pathologic skin picking report irresistible, intrusive, and/or senseless thoughts of picking or impulses to pick, accompanied by marked distress.¹ Pathologic skin picking is recurrent and usually results in noticeable skin damage, although many patients try to camouflage the lesions or scarring with makeup.

Pathologic skin picking’s prevalence is unknown. One early study estimated that 2% of dermatology patients suffer from skin picking.¹ Two clinical studies found that 3.8% of college students⁴ and 28% of patients with BDD meet diagnostic criteria.^5,6

TWEEZERS, RAZOR BLADES, KNIVES…

Persons who engage in pathologic skin picking typically spend substantial time picking. Most often they pick the face, but any body part—lips, arms, hands, or legs—may be the focus. They may pick at blemishes, pimples, scars, or healthy skin. Some use their hands and fingernails to pick, and others use pins, tweezers, razor blades, or knives. Picking may worsen in the evening.^2,7

Although picking episodes may last only a few minutes, many patients have multiple episodes each day. Some pick for as long as 12 hours every day,^2,5 which often leads to scarring and disfigurement. In one study, 90% of patients had at least minor tissue damage, 61% suffered infections, and 45% had “deep craters” because of picking.²

Reasons for picking. Many patients pick to relieve discomfort or tension.¹ Others pick to improve their appearance, as in BDD, or to remove perceived dirt or contaminants, as in obsessive-compulsive disorder (OCD).^1,5 Still others say they pick as a habit, with minimal awareness.¹ Itching or uneven skin may also cause the behavior.^1,3 We have found that a patient may pick for several of these reasons. Most report:

• tension before picking
• satisfaction during picking
• guilt, shame, and dysphoria after picking.¹

Social impairment. Shame after picking episodes often leads patients to cover lesions with clothing or makeup and to avoid social contact.⁷ Substantial social and occupational impairment have been reported^3,5,7 because of the hours spent picking and from avoiding people because of disfigurement.

Physical injury. Skin picking may cause serious injuries. Some of our patients have required emergency medical intervention and sutures after picking through a major blood vessel (such as the facial artery). One woman—who picked at a pimple on her neck with tweezers—lacerated her carotid artery, causing a near-fatal hemorrhage that required emergency surgery.⁸

Suicide risk. In a series of 123 patients with BDD, 33 (27%) excessively picked their skin and 10 of those who picked their skin (33%) had attempted suicide.5 In a case series of 31 patients with skin picking, 10% had attempted suicide.² We know of several young women whose chief complaint was skin picking and who committed suicide.⁵

Gender. The gender ratio of patients with skin picking remains unclear. In two case series that totaled 65 patients, 87% to 92% of those with pathologic skin picking were female.^2,7 In the series of patients with BDD, 58% of the 33 who compulsively picked their skin were female.⁵ On the other hand, most of 28 patients seen in a dermatology clinic for neurotic excoriations were male.⁹

Onset and chronicity. Pathologic skin picking may develop at any age, but it usually manifests in late adolescence or early adulthood, often after onset of a dermatologic illness such as acne² or in response to itching.³ Although long-term studies have not been done, the disorder appears to often be chronic, with waxing and waning of picking intensity and frequency.^1,2

Table 1

Skin picking: 3 steps to diagnosis and treatment

Comorbid psychopathology. In clinical settings, common comorbid psychopathologies include mood disorders (in 48% to 68% of patients with skin picking), anxiety disorders (41% to 64%), and alcohol use disorders (39%).²

In one patient sample, 71% of skin pickers met criteria for at least one personality disorder (48% had obsessive-compulsive personality disorder, and 26% met criteria for borderline personality disorder).²

Table 2

Medications with evidence of benefit for skin picking*

PRIMARY VS. SECONDARY DISORDER

Is skin picking an independent disorder or a symptom of other psychiatric disorders? Although skin picking is not included in DSM-IV and has no formal diagnostic criteria, some forms of this behavior may belong among the impulse control disorders.

Patients often report an urge to pick their skin in response to increasing tension,^1,3 and picking results in transient relief or pleasure.^1,2 This description mirrors that of other impulse control disorders, such as trichotillomania and kleptomania. In fact, one study found that trichotillomania and kleptomania were common comorbidities among patients with skin picking (23% and 16%, respectively).² In 34 patients with psychogenic excoriation, only 7 (21%) appeared to have skin picking as a primary complaint, unaccounted for by another psychiatric disorder.⁷

Skin picking may also be a symptom of other psychiatric disorders. To determine whether another disorder is present, we ask patients why they pick their skin. Patients may be reluctant to reveal either the picking or the underlying disorder because of embarrassment and shame. The diagnosis can often be clarified by asking about the following conditions:

Body dysmorphic disorder. Nearly 30% of patients with BDD pick their skin to a pathologic extent.^5,6 The purpose of picking in BDD is to remove or minimize a nonexistent or slight imperfection in appearance (such as scars, pimples, bumps).^5,6

Obsessive-compulsive disorder. Patients with OCD may pick their skin in response to contamination obsessions.¹ Picking is often repetitive and ritualistic, and—as with compulsions—the behavior may reduce tension.¹⁰

Genetic disorders. Skin picking may be a symptom of Prader-Willi syndrome, a genetic disorder characterized by muscular hypotonia, short stature, characteristic facial features, intellectual disabilities, hypogonadism, hyperphagia, and an increased obesity risk. In one study, 97% of patients with Prader-Willi syndrome engaged in skin picking.¹¹

Delusional disorder. Delusions of parasitosis may result in skin picking, as patients attempt to remove imagined parasites or other vermin from on or under their skin.¹²

Dermatitis artefacta. Patients may consciously create skin lesions to assume the sick role. Onethird of patients presenting to dermatologists with a disease that is primarily psychiatric may be suffering from dermatitis artefacta.¹³

TREATMENT RECOMMENDATIONS

Successful clinical care of pathologic skin picking requires perseverance and patience from both patient and clinician.

Treatment begins with a thorough dermatologic examination for medical causes of skin picking (such as atopic dermatitis or scabies) and to treat excoriations (such as with antibiotics for infection). After the dermatologist has ruled out a medical cause, carefully assess the patient’s picking behavior and related psychiatric problems (Table 1).

• If picking is secondary to a psychiatric disorder, begin by providing appropriate treatment for that disorder.
• If picking results from BDD or OCD, we recommend habit reversal therapy combined with medication.
• If picking appears to be an independent impulse control disorder, simultaneous habit reversal therapy and medication is usually necessary to reduce symptoms.

SSRIs are a reasonable first medication because of evidence for their efficacy in reducing skin picking. Higher dosages—comparable to those used in treating OCD—are usually required to improve skin-picking behavior. You may need to try another SSRI if the first trial results in partial or no response.

In our experience, augmenting an SSRI with naltrexone, 50 mg/d, helps reduce intrusive urges to pick and is worth considering if SSRI therapy results in only partial response.

Children or adolescents. Depending upon symptom severity, a trial of habit reversal therapy may be appropriate before you recommend using medication.

EVIDENCE FOR DRUG THERAPY

Although few treatment studies have been done, skin picking does appear to respond to medication (Table 2).

Because no medications are approved to treat skin-picking behavior, inform patients of any “off-label” uses and the scientific or clinical evidence for considering medication treatment.

Case reports and case series. Selective serotonin reuptake inhibitors (SSRIs) appear most effective in patients with picking behavior, including:

• fluvoxamine, 300 mg/d, in one case report⁸
• fluoxetine, 20 to 80 mg/d, in several case reports.^5,14-15

In a series of 33 patients with BDD and compulsive skin picking, one-half (49%) of a variety of SSRI treatment trials improved BDD symptoms and skin picking behavior. The percentage of patients who improved was not examined. Dermatologic treatment alone was effective for only 15% of patients.⁵

Medications other than SSRIs have also been studied. One patient improved within 3 weeks of taking the tricyclic antidepressant clomipramine, 50 mg/d.³ Another patient picked her skin less often 4 weeks after inositol, 18 grams/d, was added to citalopram, 40 mg/d. Inositol, a nonprescription isomer of glucose, is a precursor in the phosphatidylinositol second-messenger cycle, which may play a role at certain serotonin receptors.¹⁶ The patient was given 6 grams dissolved in water three times daily.

Case reports have also suggested that olanzapine, pimozide, doxepin, and naltrexone may be beneficial in reducing skin excoriations. These reports often involved patients with psychiatric and medical comorbidities.^17-20

Table 3

Habit reversal: 5 components in patient learning

Open-label studies. In an open-label study of 28 patients with neurotic excoriation treated in a dermatology clinic, 68% improved within 1 month with sertraline, mean dosage 95 mg/d.⁹ Similarly, open-label fluvoxamine, mean dosage 112.5 mg/d, was effective in reducing skin excoriation in 7 of 14 patients treated for 12 weeks in a psychiatric setting.²¹

Double-blind studies. In a double-blind study using fluvoxamine with supportive psychotherapy in patients with psychocutaneous disorders, all five patients with acne excoriee improved after 4 weeks of medication treatment (none was randomized to placebo).²²

In a 10-week, double-blind study, 10 patients were assigned to fluoxetine, mean dosage 53.0 ± 16.4 mg/d, and 11 to placebo. A patient self-report visual analog scale showed that fluoxetine was significantly more effective than placebo in reducing picking behavior. Two other measures did not show significant improvement, however, perhaps because of the small sample size.²³

In a third study, 8 of 15 patients responded to open-label fluoxetine, 20 to 60 mg/d after 6 weeks. The responders were then randomized to 6 additional weeks of fluoxetine or placebo. All four patients assigned to continue active medication maintained their improvement. Symptoms returned to baseline by week 12 in the four assigned to placebo.²⁴

EVIDENCE FOR HABIT REVERSAL THERAPY

No controlled trials have examined psychosocial treatments for skin picking, but several psychotherapeutic interventions appear promising. Habit reversal has shown promise in three case reports totaling seven patients and appears to reduce picking behavior within a few weeks.^25-27

In a case series, three patients were successfully treated with habit reversal (Table 3) and cognitive-behavioral techniques, consisting of:

• awareness training (using a skin-picking diary)
• competing response techniques (such as making a fist or squeezing a ball)
• emotion regulation skills
• psychoeducation
• cognitive restructuring (such as using Socratic questioning to produce rational alternatives) in situations that elicit the urge to pick.²⁸

In another case series, 22 dermatology patients with skin picking received psychotherapy with insight-oriented and behavioral components. Therapy included attention to developmental issues and active conflicts, cognitive restructuring, and tools to manage aggression and social relations. Although treatment duration varied— the mean was weekly for 14 months—skin lesions healed in 17 patients (77%).²⁹

Related resources

• Obsessive-Compulsive Foundation http://www.ocfoundation.org
• Koran LM. Obsessive-compulsive and related disorders in adults: A comprehensive clinical guide. Cambridge, UK: Cambridge University Press, 1999.
• Phillips KA. The broken mirror: Recognizing and treating body dysmorphic disorder. New York: Oxford University Press, 1996.

Drug brand names

• Citalopram • Celexa
• Clomipramine • Anafranil
• Doxepin • Sinequan
• Fluoxetine • Prozac
• Fluvoxamine • Luvox
• Naltrexone • ReVia
• Olanzapine • Zyprexa
• Pimozide • Orap
• Sertraline • Zoloft

Disclosure

Dr. Grant reports no financial relationship with any company whose products are mentioned in this article or with manufacturers of competing products.

Dr. Phillips receives research support from Eli Lilly and Co., Forest Pharmaceuticals, and Gate Pharmaceuticals; she is a speaker for or consultant to Eli Lilly and Co., Forest Pharmaceuticals, and UCB Pharma.

Lying in the hospital bed, her face covered in bandages, Ms. S talked of suicide while awaiting reconstructive surgery on her nose: “If the only way to stop is by killing myself, I will.” When asked what she wanted to stop, she replied, “The picking. I pick at my face all day, every day.”

Ms. S, age 22, had picked a hole through the bridge of her nose, and her face was scarred and covered with scabs. Every morning for 5 years, she had gotten up, dressed, and then—after washing her face—felt intense, uncontrollable urges to pick at her face. Hours would go by and she was still picking, even as her face started to bleed: “I try to resist, but I can’t.”

Ms. S started picking her face when she was 17. She missed so much of high school because of time spent picking that she did not graduate. She now lives alone on medical disability. Conscious of her facial scarring, she rarely goes out in public. “People stare at me as if I’m a zoo animal; it’s so painful,” she says.

After her plastic surgery, she told the staff psychiatrist she had never sought help because she thought no one would understand her behavior. “It doesn’t make sense to me, and I’ve lived with it for years.”

Patients such as Ms. S often suffer in isolation for years, unaware that skin picking is a psychiatric disorder that can be treated successfully. Some are referred to psychiatrists through hospital emergency rooms or by dermatologists; others commit suicide, as Ms. S threatened to do.

In our practice, we recognize skin picking in patients with comorbid mood and anxiety disorders, body dysmorphic disorder (BDD), substance use disorders, impulse control disorders such as trichotillomania or kleptomania, and personality disorders.

Based on recent evidence and our experience, we discuss three steps to help you diagnose pathologic skin picking. We then examine treatment options that have shown benefit for skinpicking patients, including habit reversal psychotherapy and medications.

WHAT IS SKIN PICKING?

Pathologic skin picking is repetitive, ritualistic, or impulsive picking of normal skin, leading to tissue damage, personal distress, and impaired functioning.¹ The behavior has been described for more than 100 years but remains poorly understood, under-diagnosed, and under-treated.^2,3

Most people pick at their hands or face to a limited extent,⁴ and picking does not by itself suggest a psychiatric disorder. Pathology exists in the focus, duration, and extent of the behavior, as well as reasons for picking, associated emotions, and resulting problems. Persons with pathologic skin picking report irresistible, intrusive, and/or senseless thoughts of picking or impulses to pick, accompanied by marked distress.¹ Pathologic skin picking is recurrent and usually results in noticeable skin damage, although many patients try to camouflage the lesions or scarring with makeup.

Pathologic skin picking’s prevalence is unknown. One early study estimated that 2% of dermatology patients suffer from skin picking.¹ Two clinical studies found that 3.8% of college students⁴ and 28% of patients with BDD meet diagnostic criteria.^5,6

TWEEZERS, RAZOR BLADES, KNIVES…

Persons who engage in pathologic skin picking typically spend substantial time picking. Most often they pick the face, but any body part—lips, arms, hands, or legs—may be the focus. They may pick at blemishes, pimples, scars, or healthy skin. Some use their hands and fingernails to pick, and others use pins, tweezers, razor blades, or knives. Picking may worsen in the evening.^2,7

Although picking episodes may last only a few minutes, many patients have multiple episodes each day. Some pick for as long as 12 hours every day,^2,5 which often leads to scarring and disfigurement. In one study, 90% of patients had at least minor tissue damage, 61% suffered infections, and 45% had “deep craters” because of picking.²

Reasons for picking. Many patients pick to relieve discomfort or tension.¹ Others pick to improve their appearance, as in BDD, or to remove perceived dirt or contaminants, as in obsessive-compulsive disorder (OCD).^1,5 Still others say they pick as a habit, with minimal awareness.¹ Itching or uneven skin may also cause the behavior.^1,3 We have found that a patient may pick for several of these reasons. Most report:

• tension before picking
• satisfaction during picking
• guilt, shame, and dysphoria after picking.¹

Social impairment. Shame after picking episodes often leads patients to cover lesions with clothing or makeup and to avoid social contact.⁷ Substantial social and occupational impairment have been reported^3,5,7 because of the hours spent picking and from avoiding people because of disfigurement.

Physical injury. Skin picking may cause serious injuries. Some of our patients have required emergency medical intervention and sutures after picking through a major blood vessel (such as the facial artery). One woman—who picked at a pimple on her neck with tweezers—lacerated her carotid artery, causing a near-fatal hemorrhage that required emergency surgery.⁸

Suicide risk. In a series of 123 patients with BDD, 33 (27%) excessively picked their skin and 10 of those who picked their skin (33%) had attempted suicide.5 In a case series of 31 patients with skin picking, 10% had attempted suicide.² We know of several young women whose chief complaint was skin picking and who committed suicide.⁵

Gender. The gender ratio of patients with skin picking remains unclear. In two case series that totaled 65 patients, 87% to 92% of those with pathologic skin picking were female.^2,7 In the series of patients with BDD, 58% of the 33 who compulsively picked their skin were female.⁵ On the other hand, most of 28 patients seen in a dermatology clinic for neurotic excoriations were male.⁹

Onset and chronicity. Pathologic skin picking may develop at any age, but it usually manifests in late adolescence or early adulthood, often after onset of a dermatologic illness such as acne² or in response to itching.³ Although long-term studies have not been done, the disorder appears to often be chronic, with waxing and waning of picking intensity and frequency.^1,2

Table 1

Skin picking: 3 steps to diagnosis and treatment

Comorbid psychopathology. In clinical settings, common comorbid psychopathologies include mood disorders (in 48% to 68% of patients with skin picking), anxiety disorders (41% to 64%), and alcohol use disorders (39%).²

In one patient sample, 71% of skin pickers met criteria for at least one personality disorder (48% had obsessive-compulsive personality disorder, and 26% met criteria for borderline personality disorder).²

Table 2

Medications with evidence of benefit for skin picking*

PRIMARY VS. SECONDARY DISORDER

Is skin picking an independent disorder or a symptom of other psychiatric disorders? Although skin picking is not included in DSM-IV and has no formal diagnostic criteria, some forms of this behavior may belong among the impulse control disorders.

Patients often report an urge to pick their skin in response to increasing tension,^1,3 and picking results in transient relief or pleasure.^1,2 This description mirrors that of other impulse control disorders, such as trichotillomania and kleptomania. In fact, one study found that trichotillomania and kleptomania were common comorbidities among patients with skin picking (23% and 16%, respectively).² In 34 patients with psychogenic excoriation, only 7 (21%) appeared to have skin picking as a primary complaint, unaccounted for by another psychiatric disorder.⁷

Skin picking may also be a symptom of other psychiatric disorders. To determine whether another disorder is present, we ask patients why they pick their skin. Patients may be reluctant to reveal either the picking or the underlying disorder because of embarrassment and shame. The diagnosis can often be clarified by asking about the following conditions:

Body dysmorphic disorder. Nearly 30% of patients with BDD pick their skin to a pathologic extent.^5,6 The purpose of picking in BDD is to remove or minimize a nonexistent or slight imperfection in appearance (such as scars, pimples, bumps).^5,6

Obsessive-compulsive disorder. Patients with OCD may pick their skin in response to contamination obsessions.¹ Picking is often repetitive and ritualistic, and—as with compulsions—the behavior may reduce tension.¹⁰

Genetic disorders. Skin picking may be a symptom of Prader-Willi syndrome, a genetic disorder characterized by muscular hypotonia, short stature, characteristic facial features, intellectual disabilities, hypogonadism, hyperphagia, and an increased obesity risk. In one study, 97% of patients with Prader-Willi syndrome engaged in skin picking.¹¹

Delusional disorder. Delusions of parasitosis may result in skin picking, as patients attempt to remove imagined parasites or other vermin from on or under their skin.¹²

Dermatitis artefacta. Patients may consciously create skin lesions to assume the sick role. Onethird of patients presenting to dermatologists with a disease that is primarily psychiatric may be suffering from dermatitis artefacta.¹³

TREATMENT RECOMMENDATIONS

Successful clinical care of pathologic skin picking requires perseverance and patience from both patient and clinician.

Treatment begins with a thorough dermatologic examination for medical causes of skin picking (such as atopic dermatitis or scabies) and to treat excoriations (such as with antibiotics for infection). After the dermatologist has ruled out a medical cause, carefully assess the patient’s picking behavior and related psychiatric problems (Table 1).

• If picking is secondary to a psychiatric disorder, begin by providing appropriate treatment for that disorder.
• If picking results from BDD or OCD, we recommend habit reversal therapy combined with medication.
• If picking appears to be an independent impulse control disorder, simultaneous habit reversal therapy and medication is usually necessary to reduce symptoms.

SSRIs are a reasonable first medication because of evidence for their efficacy in reducing skin picking. Higher dosages—comparable to those used in treating OCD—are usually required to improve skin-picking behavior. You may need to try another SSRI if the first trial results in partial or no response.

In our experience, augmenting an SSRI with naltrexone, 50 mg/d, helps reduce intrusive urges to pick and is worth considering if SSRI therapy results in only partial response.

Children or adolescents. Depending upon symptom severity, a trial of habit reversal therapy may be appropriate before you recommend using medication.

EVIDENCE FOR DRUG THERAPY

Although few treatment studies have been done, skin picking does appear to respond to medication (Table 2).

Because no medications are approved to treat skin-picking behavior, inform patients of any “off-label” uses and the scientific or clinical evidence for considering medication treatment.

Case reports and case series. Selective serotonin reuptake inhibitors (SSRIs) appear most effective in patients with picking behavior, including:

• fluvoxamine, 300 mg/d, in one case report⁸
• fluoxetine, 20 to 80 mg/d, in several case reports.^5,14-15

In a series of 33 patients with BDD and compulsive skin picking, one-half (49%) of a variety of SSRI treatment trials improved BDD symptoms and skin picking behavior. The percentage of patients who improved was not examined. Dermatologic treatment alone was effective for only 15% of patients.⁵

Medications other than SSRIs have also been studied. One patient improved within 3 weeks of taking the tricyclic antidepressant clomipramine, 50 mg/d.³ Another patient picked her skin less often 4 weeks after inositol, 18 grams/d, was added to citalopram, 40 mg/d. Inositol, a nonprescription isomer of glucose, is a precursor in the phosphatidylinositol second-messenger cycle, which may play a role at certain serotonin receptors.¹⁶ The patient was given 6 grams dissolved in water three times daily.

Case reports have also suggested that olanzapine, pimozide, doxepin, and naltrexone may be beneficial in reducing skin excoriations. These reports often involved patients with psychiatric and medical comorbidities.^17-20

Table 3

Habit reversal: 5 components in patient learning

Open-label studies. In an open-label study of 28 patients with neurotic excoriation treated in a dermatology clinic, 68% improved within 1 month with sertraline, mean dosage 95 mg/d.⁹ Similarly, open-label fluvoxamine, mean dosage 112.5 mg/d, was effective in reducing skin excoriation in 7 of 14 patients treated for 12 weeks in a psychiatric setting.²¹

Double-blind studies. In a double-blind study using fluvoxamine with supportive psychotherapy in patients with psychocutaneous disorders, all five patients with acne excoriee improved after 4 weeks of medication treatment (none was randomized to placebo).²²

In a 10-week, double-blind study, 10 patients were assigned to fluoxetine, mean dosage 53.0 ± 16.4 mg/d, and 11 to placebo. A patient self-report visual analog scale showed that fluoxetine was significantly more effective than placebo in reducing picking behavior. Two other measures did not show significant improvement, however, perhaps because of the small sample size.²³

In a third study, 8 of 15 patients responded to open-label fluoxetine, 20 to 60 mg/d after 6 weeks. The responders were then randomized to 6 additional weeks of fluoxetine or placebo. All four patients assigned to continue active medication maintained their improvement. Symptoms returned to baseline by week 12 in the four assigned to placebo.²⁴

EVIDENCE FOR HABIT REVERSAL THERAPY

No controlled trials have examined psychosocial treatments for skin picking, but several psychotherapeutic interventions appear promising. Habit reversal has shown promise in three case reports totaling seven patients and appears to reduce picking behavior within a few weeks.^25-27

In a case series, three patients were successfully treated with habit reversal (Table 3) and cognitive-behavioral techniques, consisting of:

• awareness training (using a skin-picking diary)
• competing response techniques (such as making a fist or squeezing a ball)
• emotion regulation skills
• psychoeducation
• cognitive restructuring (such as using Socratic questioning to produce rational alternatives) in situations that elicit the urge to pick.²⁸

In another case series, 22 dermatology patients with skin picking received psychotherapy with insight-oriented and behavioral components. Therapy included attention to developmental issues and active conflicts, cognitive restructuring, and tools to manage aggression and social relations. Although treatment duration varied— the mean was weekly for 14 months—skin lesions healed in 17 patients (77%).²⁹

Related resources

• Obsessive-Compulsive Foundation http://www.ocfoundation.org
• Koran LM. Obsessive-compulsive and related disorders in adults: A comprehensive clinical guide. Cambridge, UK: Cambridge University Press, 1999.
• Phillips KA. The broken mirror: Recognizing and treating body dysmorphic disorder. New York: Oxford University Press, 1996.

Drug brand names

• Citalopram • Celexa
• Clomipramine • Anafranil
• Doxepin • Sinequan
• Fluoxetine • Prozac
• Fluvoxamine • Luvox
• Naltrexone • ReVia
• Olanzapine • Zyprexa
• Pimozide • Orap
• Sertraline • Zoloft

Disclosure

Dr. Grant reports no financial relationship with any company whose products are mentioned in this article or with manufacturers of competing products.

Dr. Phillips receives research support from Eli Lilly and Co., Forest Pharmaceuticals, and Gate Pharmaceuticals; she is a speaker for or consultant to Eli Lilly and Co., Forest Pharmaceuticals, and UCB Pharma.

Lying in the hospital bed, her face covered in bandages, Ms. S talked of suicide while awaiting reconstructive surgery on her nose: “If the only way to stop is by killing myself, I will.” When asked what she wanted to stop, she replied, “The picking. I pick at my face all day, every day.”

Ms. S, age 22, had picked a hole through the bridge of her nose, and her face was scarred and covered with scabs. Every morning for 5 years, she had gotten up, dressed, and then—after washing her face—felt intense, uncontrollable urges to pick at her face. Hours would go by and she was still picking, even as her face started to bleed: “I try to resist, but I can’t.”

Ms. S started picking her face when she was 17. She missed so much of high school because of time spent picking that she did not graduate. She now lives alone on medical disability. Conscious of her facial scarring, she rarely goes out in public. “People stare at me as if I’m a zoo animal; it’s so painful,” she says.

After her plastic surgery, she told the staff psychiatrist she had never sought help because she thought no one would understand her behavior. “It doesn’t make sense to me, and I’ve lived with it for years.”

Patients such as Ms. S often suffer in isolation for years, unaware that skin picking is a psychiatric disorder that can be treated successfully. Some are referred to psychiatrists through hospital emergency rooms or by dermatologists; others commit suicide, as Ms. S threatened to do.

In our practice, we recognize skin picking in patients with comorbid mood and anxiety disorders, body dysmorphic disorder (BDD), substance use disorders, impulse control disorders such as trichotillomania or kleptomania, and personality disorders.

Based on recent evidence and our experience, we discuss three steps to help you diagnose pathologic skin picking. We then examine treatment options that have shown benefit for skinpicking patients, including habit reversal psychotherapy and medications.

WHAT IS SKIN PICKING?

Pathologic skin picking is repetitive, ritualistic, or impulsive picking of normal skin, leading to tissue damage, personal distress, and impaired functioning.¹ The behavior has been described for more than 100 years but remains poorly understood, under-diagnosed, and under-treated.^2,3

Most people pick at their hands or face to a limited extent,⁴ and picking does not by itself suggest a psychiatric disorder. Pathology exists in the focus, duration, and extent of the behavior, as well as reasons for picking, associated emotions, and resulting problems. Persons with pathologic skin picking report irresistible, intrusive, and/or senseless thoughts of picking or impulses to pick, accompanied by marked distress.¹ Pathologic skin picking is recurrent and usually results in noticeable skin damage, although many patients try to camouflage the lesions or scarring with makeup.

Pathologic skin picking’s prevalence is unknown. One early study estimated that 2% of dermatology patients suffer from skin picking.¹ Two clinical studies found that 3.8% of college students⁴ and 28% of patients with BDD meet diagnostic criteria.^5,6

TWEEZERS, RAZOR BLADES, KNIVES…

Persons who engage in pathologic skin picking typically spend substantial time picking. Most often they pick the face, but any body part—lips, arms, hands, or legs—may be the focus. They may pick at blemishes, pimples, scars, or healthy skin. Some use their hands and fingernails to pick, and others use pins, tweezers, razor blades, or knives. Picking may worsen in the evening.^2,7

Although picking episodes may last only a few minutes, many patients have multiple episodes each day. Some pick for as long as 12 hours every day,^2,5 which often leads to scarring and disfigurement. In one study, 90% of patients had at least minor tissue damage, 61% suffered infections, and 45% had “deep craters” because of picking.²

Reasons for picking. Many patients pick to relieve discomfort or tension.¹ Others pick to improve their appearance, as in BDD, or to remove perceived dirt or contaminants, as in obsessive-compulsive disorder (OCD).^1,5 Still others say they pick as a habit, with minimal awareness.¹ Itching or uneven skin may also cause the behavior.^1,3 We have found that a patient may pick for several of these reasons. Most report:

• tension before picking
• satisfaction during picking
• guilt, shame, and dysphoria after picking.¹

Social impairment. Shame after picking episodes often leads patients to cover lesions with clothing or makeup and to avoid social contact.⁷ Substantial social and occupational impairment have been reported^3,5,7 because of the hours spent picking and from avoiding people because of disfigurement.

Physical injury. Skin picking may cause serious injuries. Some of our patients have required emergency medical intervention and sutures after picking through a major blood vessel (such as the facial artery). One woman—who picked at a pimple on her neck with tweezers—lacerated her carotid artery, causing a near-fatal hemorrhage that required emergency surgery.⁸

Suicide risk. In a series of 123 patients with BDD, 33 (27%) excessively picked their skin and 10 of those who picked their skin (33%) had attempted suicide.5 In a case series of 31 patients with skin picking, 10% had attempted suicide.² We know of several young women whose chief complaint was skin picking and who committed suicide.⁵

Gender. The gender ratio of patients with skin picking remains unclear. In two case series that totaled 65 patients, 87% to 92% of those with pathologic skin picking were female.^2,7 In the series of patients with BDD, 58% of the 33 who compulsively picked their skin were female.⁵ On the other hand, most of 28 patients seen in a dermatology clinic for neurotic excoriations were male.⁹

Onset and chronicity. Pathologic skin picking may develop at any age, but it usually manifests in late adolescence or early adulthood, often after onset of a dermatologic illness such as acne² or in response to itching.³ Although long-term studies have not been done, the disorder appears to often be chronic, with waxing and waning of picking intensity and frequency.^1,2

Table 1

Skin picking: 3 steps to diagnosis and treatment

Comorbid psychopathology. In clinical settings, common comorbid psychopathologies include mood disorders (in 48% to 68% of patients with skin picking), anxiety disorders (41% to 64%), and alcohol use disorders (39%).²

In one patient sample, 71% of skin pickers met criteria for at least one personality disorder (48% had obsessive-compulsive personality disorder, and 26% met criteria for borderline personality disorder).²

Table 2

Medications with evidence of benefit for skin picking*

PRIMARY VS. SECONDARY DISORDER

Is skin picking an independent disorder or a symptom of other psychiatric disorders? Although skin picking is not included in DSM-IV and has no formal diagnostic criteria, some forms of this behavior may belong among the impulse control disorders.

Patients often report an urge to pick their skin in response to increasing tension,^1,3 and picking results in transient relief or pleasure.^1,2 This description mirrors that of other impulse control disorders, such as trichotillomania and kleptomania. In fact, one study found that trichotillomania and kleptomania were common comorbidities among patients with skin picking (23% and 16%, respectively).² In 34 patients with psychogenic excoriation, only 7 (21%) appeared to have skin picking as a primary complaint, unaccounted for by another psychiatric disorder.⁷

Skin picking may also be a symptom of other psychiatric disorders. To determine whether another disorder is present, we ask patients why they pick their skin. Patients may be reluctant to reveal either the picking or the underlying disorder because of embarrassment and shame. The diagnosis can often be clarified by asking about the following conditions:

Body dysmorphic disorder. Nearly 30% of patients with BDD pick their skin to a pathologic extent.^5,6 The purpose of picking in BDD is to remove or minimize a nonexistent or slight imperfection in appearance (such as scars, pimples, bumps).^5,6

Obsessive-compulsive disorder. Patients with OCD may pick their skin in response to contamination obsessions.¹ Picking is often repetitive and ritualistic, and—as with compulsions—the behavior may reduce tension.¹⁰

Genetic disorders. Skin picking may be a symptom of Prader-Willi syndrome, a genetic disorder characterized by muscular hypotonia, short stature, characteristic facial features, intellectual disabilities, hypogonadism, hyperphagia, and an increased obesity risk. In one study, 97% of patients with Prader-Willi syndrome engaged in skin picking.¹¹

Delusional disorder. Delusions of parasitosis may result in skin picking, as patients attempt to remove imagined parasites or other vermin from on or under their skin.¹²

Dermatitis artefacta. Patients may consciously create skin lesions to assume the sick role. Onethird of patients presenting to dermatologists with a disease that is primarily psychiatric may be suffering from dermatitis artefacta.¹³

TREATMENT RECOMMENDATIONS

Successful clinical care of pathologic skin picking requires perseverance and patience from both patient and clinician.

Treatment begins with a thorough dermatologic examination for medical causes of skin picking (such as atopic dermatitis or scabies) and to treat excoriations (such as with antibiotics for infection). After the dermatologist has ruled out a medical cause, carefully assess the patient’s picking behavior and related psychiatric problems (Table 1).

• If picking is secondary to a psychiatric disorder, begin by providing appropriate treatment for that disorder.
• If picking results from BDD or OCD, we recommend habit reversal therapy combined with medication.
• If picking appears to be an independent impulse control disorder, simultaneous habit reversal therapy and medication is usually necessary to reduce symptoms.

SSRIs are a reasonable first medication because of evidence for their efficacy in reducing skin picking. Higher dosages—comparable to those used in treating OCD—are usually required to improve skin-picking behavior. You may need to try another SSRI if the first trial results in partial or no response.

In our experience, augmenting an SSRI with naltrexone, 50 mg/d, helps reduce intrusive urges to pick and is worth considering if SSRI therapy results in only partial response.

Children or adolescents. Depending upon symptom severity, a trial of habit reversal therapy may be appropriate before you recommend using medication.

EVIDENCE FOR DRUG THERAPY

Although few treatment studies have been done, skin picking does appear to respond to medication (Table 2).

Because no medications are approved to treat skin-picking behavior, inform patients of any “off-label” uses and the scientific or clinical evidence for considering medication treatment.

Case reports and case series. Selective serotonin reuptake inhibitors (SSRIs) appear most effective in patients with picking behavior, including:

• fluvoxamine, 300 mg/d, in one case report⁸
• fluoxetine, 20 to 80 mg/d, in several case reports.^5,14-15

In a series of 33 patients with BDD and compulsive skin picking, one-half (49%) of a variety of SSRI treatment trials improved BDD symptoms and skin picking behavior. The percentage of patients who improved was not examined. Dermatologic treatment alone was effective for only 15% of patients.⁵

Medications other than SSRIs have also been studied. One patient improved within 3 weeks of taking the tricyclic antidepressant clomipramine, 50 mg/d.³ Another patient picked her skin less often 4 weeks after inositol, 18 grams/d, was added to citalopram, 40 mg/d. Inositol, a nonprescription isomer of glucose, is a precursor in the phosphatidylinositol second-messenger cycle, which may play a role at certain serotonin receptors.¹⁶ The patient was given 6 grams dissolved in water three times daily.

Case reports have also suggested that olanzapine, pimozide, doxepin, and naltrexone may be beneficial in reducing skin excoriations. These reports often involved patients with psychiatric and medical comorbidities.^17-20

Table 3

Habit reversal: 5 components in patient learning

Open-label studies. In an open-label study of 28 patients with neurotic excoriation treated in a dermatology clinic, 68% improved within 1 month with sertraline, mean dosage 95 mg/d.⁹ Similarly, open-label fluvoxamine, mean dosage 112.5 mg/d, was effective in reducing skin excoriation in 7 of 14 patients treated for 12 weeks in a psychiatric setting.²¹

Double-blind studies. In a double-blind study using fluvoxamine with supportive psychotherapy in patients with psychocutaneous disorders, all five patients with acne excoriee improved after 4 weeks of medication treatment (none was randomized to placebo).²²

In a 10-week, double-blind study, 10 patients were assigned to fluoxetine, mean dosage 53.0 ± 16.4 mg/d, and 11 to placebo. A patient self-report visual analog scale showed that fluoxetine was significantly more effective than placebo in reducing picking behavior. Two other measures did not show significant improvement, however, perhaps because of the small sample size.²³

In a third study, 8 of 15 patients responded to open-label fluoxetine, 20 to 60 mg/d after 6 weeks. The responders were then randomized to 6 additional weeks of fluoxetine or placebo. All four patients assigned to continue active medication maintained their improvement. Symptoms returned to baseline by week 12 in the four assigned to placebo.²⁴

EVIDENCE FOR HABIT REVERSAL THERAPY

No controlled trials have examined psychosocial treatments for skin picking, but several psychotherapeutic interventions appear promising. Habit reversal has shown promise in three case reports totaling seven patients and appears to reduce picking behavior within a few weeks.^25-27

In a case series, three patients were successfully treated with habit reversal (Table 3) and cognitive-behavioral techniques, consisting of:

• awareness training (using a skin-picking diary)
• competing response techniques (such as making a fist or squeezing a ball)
• emotion regulation skills
• psychoeducation
• cognitive restructuring (such as using Socratic questioning to produce rational alternatives) in situations that elicit the urge to pick.²⁸

In another case series, 22 dermatology patients with skin picking received psychotherapy with insight-oriented and behavioral components. Therapy included attention to developmental issues and active conflicts, cognitive restructuring, and tools to manage aggression and social relations. Although treatment duration varied— the mean was weekly for 14 months—skin lesions healed in 17 patients (77%).²⁹

Related resources

• Obsessive-Compulsive Foundation http://www.ocfoundation.org
• Koran LM. Obsessive-compulsive and related disorders in adults: A comprehensive clinical guide. Cambridge, UK: Cambridge University Press, 1999.
• Phillips KA. The broken mirror: Recognizing and treating body dysmorphic disorder. New York: Oxford University Press, 1996.

Drug brand names

• Citalopram • Celexa
• Clomipramine • Anafranil
• Doxepin • Sinequan
• Fluoxetine • Prozac
• Fluvoxamine • Luvox
• Naltrexone • ReVia
• Olanzapine • Zyprexa
• Pimozide • Orap
• Sertraline • Zoloft

Disclosure

Dr. Grant reports no financial relationship with any company whose products are mentioned in this article or with manufacturers of competing products.

Dr. Phillips receives research support from Eli Lilly and Co., Forest Pharmaceuticals, and Gate Pharmaceuticals; she is a speaker for or consultant to Eli Lilly and Co., Forest Pharmaceuticals, and UCB Pharma.