Dermatillomania

Dermatillomania, also called excoriation disorder (ED) or chronic skin-picking, is a psychiatric condition that can make someone constantly pick their own skin causing skin lesions.


What Is Dermatillomania?

It is a mental condition that manifests as repetitive, compulsive skin picking in the affected individual. Repetitive skin picking develops into pulling, scraping, squeezing, lancing, and even biting both healthy and damaged skin from various parts of the body. People with dermatillomania often target their face, fingers, hands, legs, and arms for picking the skin. They may exhibit this behavior pattern by using their fingers or an instrument, like tweezers or pins. They can spend hours in a day on their picking behavior, which can last for months or even years. It is a chronic condition that results in visible skin damage and disfigurement from lesions, open wounds, discoloration, scars, and infections. The symptoms may arise and disappear from time to time. The affected individual may try to resist the urge before giving in.

Also identified as psychogenic excoriation or neurotic excoriation, dermatillomania falls in the obsessive-compulsive spectrum and can cause severe physical or mental damage. A 2017 study 1 describes the condition as a “recurrent picking of skin, leading to skin lesions and significant distress or functional impairment.” Onset is usually observed during adolescence along with puberty. Repeated failed attempts to stop picking their skin by the sufferer may be common and this can further cause stress, anxiety, guilt and even depression. The condition is common with a prevalence rate ranging from 1.4% to 5.4%. Moreover, a 2004 survey 2 found that 16.6% of respondents suffered from pathologic skin picking (PSP) phenomenology. The severity of the disorder varies from mild to severe and treatment may be necessary when diagnostic criteria are met.

Understanding Dermatillomania

People may pick their skin occasionally, however, when the occasional skin picking develops into a chronic behavior, then it becomes neurotic excoriation. While the exact cause of the condition is still unknown, it may develop alongside other health conditions, such as obsessive-compulsive disorder (OCD), attention deficit hyperactivity disorder (ADHD), or autism. The condition can negatively impact a person’s quality of life (personal, professional, and social) along with overall health. Although the condition was documented in the medical literature since the 19th century, ED or dermatillomania has only recently been included as a distinct entity in mainstream psychiatric nosology. In the Diagnostic and Statistical Manual of Mental Disorders, 5th Edition (DSM-5), the condition is listed as “obsessive-compulsive and related disorders (OCRDs)” as it overlaps with conditions such as trichotillomania (TTM or hair-pulling disorder).

Skin picking disorder is considered a type of repetitive self-grooming behavior called Body-Focused Repetitive Behavior (BFRB). Other types of BFRBs include pulling or picking of the hair (trichotillomania) or nails that damage the body. The impact of the disorder should not be undervalued or overlooked as individuals with this condition spend a significant amount of time on repetitive picking and/or camouflaging, resulting in missing or getting late for work, school, or social activities. Additionally, multiple psychosocial sequelae, such as social embarrassment, avoiding activities where skin injuries can get detected, and loss of productivity in various spheres have been reported. Possible medical sequelae include infections, lesions, scarring, and even serious physical disfigurement. It must be noted that picking scabs or bumps from time to time is not an uncommon or extremely harmful habit. However, when this habit becomes a condition, apart from resulting in serious skin damage, the condition will also create lasting negative effects on one’s mental health condition along with his/her responsibilities at home, school, or work. In other words, the difference between dermatillomania and normal picking at skin imperfections and irregularities is that the behavior is chronic, leading to severe tissue damage, and leaves the individual with marked distress and dysfunction.

Symptoms Of Dermatillomania

People with the skin-picking disorder will pick at scabs, pimples, bumps, or other skin lesions until they bleed again or become inflamed. They may also pick at the skin around their fingernails and toenails. Sometimes, people with the disorder let the picked areas heal only to pick them again. It’s a cycle of habit and impulse that can be challenging to overcome. Individuals who suffer from this condition may exhibit symptoms like:

  • Skin picking
  • Digging into skin
  • Skin scratching
  • Compulsively rubbing skin
  • Repetitive touching
  • Squeezing skin repetitively

Other signs and symptoms of dermatillomania are:

1. Trying to Eliminate Imperfections

Some people frequently scratch the skin or try to clean any “imperfections” that they think are present on their skin, thereby resulting in additional lesions, cuts, and sores.

2. Spending Hours Picking Skin

Individuals with this condition will pick at their skin for hours, several times a day. This behavior can be a significant disruption to their social and professional lives.

3. Developing Scars & Infections

The disorder can lead to infections, lesions, and scars that last for long periods of time.

4. Avoiding Public Events

Frequent skin picking can leave skin covered in lesions, scars, and injuries. Thus, such individuals may avoid the beach, gym, or venues that require less clothing because of their skin’s appearance.

Understanding the signs and symptoms of the skin-picking disorder or dermatillomania can help one understand whether the behavior is a normal picking, or if it is signifying something more serious.

Causes Of Dermatillomania

It’s not yet known what exactly causes neurotic excoriation or skin picking disorder, but there are several theories catering to the same. People can develop skin picking disorder in response to:

1. An infection, rash, or injury resulting in scab

A person may develop the habit of skin picking due to a scab or a rash, which may further aggravate the level of skin damage. When a scab heals, it may itch which leads a person to scratch or pick it until it bleeds, thereby forming a new wound. They may then pick at the new scab, thereby developing a picking cycle and this behavioral pattern becomes a habit.

2. Stress or mental health conditions

In times of stress, people tend to pick or scratch their skin, pull their hair, or bite their nails to feel at ease. On the other hand, some people might feel compelled to pick their skin as a form of self-grooming or to remove real or imagined imperfections in the skin. A 2015 study 3 states that ”trauma may play a role in the development of both trichotillomania and skin picking”. The study also states that environmental factors, boredom, and lack of stimulation are possible triggers of such episodes. Although in most cases severe psychiatric comorbidity is not observed, some patients may have obsessive personality traits, depressive symptoms and suicidal thoughts.

3. Genetic Component

There may be a genetic component to dermatillomania since some people appear to have an inherited tendency to BFRBs such as skin picking and hair pulling. In one study of 40 individuals who had the condition, 43% had a first-degree relative with the disorder. Particular genes (e.g., Hoxb8 and SAPAP3) have been recognized as potential predictors of this disorder. The same study mentions that humans with the SAPAP3 gene only met the criteria for excoriation disorder (or skin picking disorder) 20% of the time. Thus, genetics appears to play a role in the development of this disorder.

Diagnosis Of Dermatillomania

It is not possible to self diagnose skin picking disorder. While one may suspect his/her symptoms being caused by the skin-picking disorder, the healthcare professional will eliminate any other underlying conditions before making a diagnosis. After performing a physical examination, your doctor will ask the patient about his/her behaviors and feelings while performing the habit. The doctor will also determine whether the lesions or scabs are the results of a skin disorder like eczema or psoriasis. Additionally, if the doctor suspects the patient suffering from the skin-picking disorder, they may refer you to a mental health professional.

A separate category for this area of disorders has been added to the DSM-5. In order to get diagnosed with neurotic excoriation, the person must:

  • Experience a few of the symptoms listed above
  • Be under clinical distress or impairment
  • Must have symptoms that are not a result of medical, substance, or dermatological condition
  • Must have symptoms that cannot be explained by another psychiatric disorder

Treatment Of Dermatillomania

When skin picking starts interfering with one’s physical health or emotional well-being, it’s time to consult an expert. Since not all mental health professionals are familiar with this condition, it is best to find a therapist who has prior experience in treating such conditions. There are a number of treatment approaches including:

1. Therapy

Habit reversal training (HRT), a form of cognitive behavioral therapy, is a common therapy for treating this disorder. The therapist will work with the patient to recognize the emotional and environmental factors that trigger the urge to pick. Once the patient develops an awareness of his/her particular triggers, the therapist will teach the patient various tactics for coping when those situations arise. The goal of such therapy is to learn the ways to manage the urges in a healthy way rather than pick on skin. According to a 2018 study 4 , “Habit reversal training (HRT) is a clinically effective treatment for body-focused repetitive disorders (BFRDs) such as trichotillomania, onychophagia, and dermatillomania.”

A 2017 study 1 states that cognitive behavioral interventions for skin picking disorder are also beneficial when presented in a self-help format that patients can reach themselves. The researchers found that an internet-based self-help treatment 5 obtained from the evidence-based cognitive-behavioral model can significantly help in reducing symptom severity. Decoupling (DC) is another technique that can also be helpful in “unlearning” skin-picking and replacing such habits with harmless behavior.

2. Stimulus Control (SC)

This type of therapy helps the patient to find ways to alter his/her physical environment so he/she feels less likely to pick. If the person picks at blemishes on the face, the therapist or the caregiver might put a piece of tape on the floor in front of the patient’s bathroom mirror as a reminder to stay far away from seeing the blemishes that trigger the desire to pick. If the patient targets his/her fingers, he/she might wear gloves or bandages as a physical barrier and a sign that reminds him/her to stop. A study states 6 that HRT is often implemented in combination with stimulus control (SC) to treat hair pulling and skin picking disorder. HRT has shown to be an efficacious intervention when combined with SC and it can reduce symptoms for 50-60% of individuals with such conditions.

3. Medication

A doctor may also recommend medications as part of a treatment strategy. To date, there is no FDA-approved drug specifically for the treatment of dermatillomania. However, selective serotonin reuptake inhibitors (SSRI) medications, such as Paxil and Zoloft, have been found to be effective for some people. A study states 7 that a number of SSRIs have demonstrated improvement in measures of skin-picking behavior. The results suggested that fluoxetine had improved symptoms significantly more than placebo. Apart from SSRIs, medications such as lamotrigine, glutamatergic agents, opioid antagonists, and inositol are used for the treatment of dermatillomania.

Tips To Cope With Dermatillomania

Living with skin picking disorder is distressing as it can leave a negative impact on one’s life. Here are a few ways to cope with the condition to reduce the symptoms and related stress.

1. Know the Triggers

In order to deal with dermatillomania, the first thing one should do is to identify and acknowledge the factors that trigger the picking behavior. There are a number of biological and environmental factors that contribute to the growth of frequent skin-picking patterns. It is important for the patients to be conscious of the distinct circumstance that affects them, in order to know the type of treatment that will work best for the condition. Whether it is depression or boredom, one must know the triggering factor clearly to move forward with the treatment.

2. Get Professional Help

Many individuals dealing with dermatillomania tend to bypass seeking help from an expert because they feel shame about their condition and skin lesions. However, consulting a therapist or psychiatrist is the best way to deal with the disorder. There are several psychotherapeutic approaches and interventions designed to reduce the symptoms and repair the damage caused by the disorder, such as cognitive-behavioral therapy. Additionally, medications can also help ease anxiety and stress as prescribed by professionals in order to deal with the triggers that cause neurotic excoriation.

3. Regular Physical Activity

This condition is mostly triggered by stress, anxiety, and negative moods. Thus, practicing a regular exercise routine is one of the best ways to reduce stress. Regular physical activity also keeps the mind occupied and reduces the urge to do body-focused repetitive behavior like hair pulling or skin picking. Aerobic exercises, such as biking and swimming, helps minimize muscle tension and enhance the overall mood of a person, reducing their impulse to engage in skin picking behavior. Additionally, engaging in activities like yoga and meditation can also relax the mind and ease stress.

4. Healthy Self-Care Rituals

Curate a healthy self-care routine that will help control anxiety, which often causes body-focused repetitive behaviors like dermatillomania. These self-care routines can be simple activities like listening to calming music, eating healthy, or adopting a regular skincare routine. Such small changes can go a long way in checking stress and reducing the urge to pick the skin. Caring for the body can also foster the development of a more positive mindset.

5. Strengthen Your Support System

The sufferer must build a strong support system of close friends and family. Since this condition tends to isolate the person from his/her close friends and family, a strong support system will encourage the person to cope with the condition while being mindful of the adverse effects of the condition. Many sufferers find it difficult to speak about it, which may not be the same with trusted close friends and family.

Treatment Can Help

No matter what treatment options one chooses, he/she must remember that dermatillomania is a complex condition and may require several different approaches. While some cases are successfully treated within a few weeks to a few months, others may require many more months to a year to eliminate the condition completely. Compulsive skin picking is not only a harmful habit, but it can also foster infections and embarrassment. Thus, the condition should not be allowed to continue indefinitely. One must find a qualified mental health professional with the skills to help a person live a life free from sores, scars, and embarrassment. Additionally, one must feel confident in his/her skin, regardless of conditions that cause physical scars or blemishes.

References:
  1. Lochner, C., Roos, A., & Stein, D. J. (2017). Excoriation (skin-picking) disorder: a systematic review of treatment options. Neuropsychiatric disease and treatment13, 1867–1872. https://doi.org/10.2147/NDT.S121138 [][]
  2. Keuthen NJ, Koran LM, Aboujaoude E, Large MD, Serpe RT. The prevalence of pathologic skin picking in US adults. Compr Psychiatry. 2010 Mar-Apr;51(2):183-6. doi: 10.1016/j.comppsych.2009.04.003. PMID: 20152300. []
  3. Özten, E., Sayar, G. H., Eryılmaz, G., Kağan, G., Işık, S., & Karamustafalıoğlu, O. (2015). The relationship of psychological trauma with trichotillomania and skin picking. Neuropsychiatric disease and treatment11, 1203–1210. https://doi.org/10.2147/NDT.S79554 []
  4. Dunbar AB, Magid M, Reichenberg JS. Habit reversal training for body-focused repetitive behaviors: a practical guide for the dermatologist. G Ital Dermatol Venereol. 2018 Aug;153(4):557-566. doi: 10.23736/S0392-0488.18.05949-7. Epub 2018 Apr 18. PMID: 29667792. []
  5. Gallinat, C., Moessner, M., Haenssle, H. A., Winkler, J. K., Backenstrass, M., & Bauer, S. (2019). An Internet-Based Self-Help Intervention for Skin Picking (SaveMySkin): Pilot Randomized Controlled Trial. Journal of medical Internet research21(9), e15011. https://doi.org/10.2196/15011 []
  6. Kristjánsson, L. V. (2017, June). Heim | Skemman. https://skemman.is/bitstream/1946/27693/5/Loka%C3%BAtg%C3%A1fa%20-%20L%C3%A1rus%20Valur%20Kristj%C3%A1nsson.pdf []
  7. Lochner, C., Roos, A., & Stein, D. J. (2017). Excoriation (skin-picking) disorder: a systematic review of treatment options. Neuropsychiatric disease and treatment13, 1867–1872. https://doi.org/10.2147/NDT.S121138 []
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