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 reported3,5,7 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