“My fingernail itches. I need to scratch it with my skin.” ― Jarod Kintz, This Book Has No Title

Skin-picking disorder, also known as dermatillomania; neurotic excoriation; compulsive skin picking; or, psychogenic excoriation, is a disorder in which the patient picks at their skin repeatedly to the point that the picking is severe enough to damage tissue, and causes significant distress with work/school, social and other daily activities. It can begin in childhood or adulthood.  Skin-picking disorder can cause a sufferer great physical distress as well.  It often causes significant pain both while and after the picking episode, as well as lead to sores, scarring and potential disfigurement.  Other medical problems can result such as infection of the picking sites, and in extreme cases requires surgery.  Classified as an impulse control disorder, skin-picking disorder research suggests that the urge to pick is more similar to an obsessive-compulsive disorder (OCD).  However, others have postulated that the disorder may actually be more similar to a substance abuse disorder.

It is common for individuals with skin-picking disorder to suffer from symptoms of general anxiety and/or depression.  Not all people who pick at their skin have the disorder.  It is not at all uncommon for persons with no particular mental health problem to pick at their on an occasional and intermittent basis.  Picking at healing scabs, or other “blemishes”, does not meet the necessary criteria for skin-picking disorder unless it is severe enough to lead to problems in other areas of their lives.  Other health issues, such as certain dermatologic conditions and medications/drugs withdrawal, can also result in skin picking behaviors, but is not considered skin-picking disorder.

Where, when, why and how people pick at their skin is highly variable.  Most individuals that suffer from skin-picking disorder pick at their skin on more than a single part of their body.   The face is the most commonly picked at area of the body.  Other common areas include: back of arms, legs, shoulders, feet, hands, lips, and finger and toe cuticles.  Most patients report having a primary area of the body they focus their picking on, but often move from one area to another in order to allow the principal area to heal.  Additionally, although the vast majority of skin-picking is done by use of the persons fingernails, it is not uncommon for sufferers to use implements such as tweezers, or actually bite off the skin (particularly of the finger cuticles and hands).

There are a variety of reasons people demonstrate skin-picking behaviors.  Some pick out of boredom, others out of habit, some in an attempt to deal with anxiety, anger, grief and other negative feelings, and yet others in an attempt to cope with tension.  Many pick at their skin being totally unaware that they are doing so.  Oftentimes the feelings of relief experienced by the skin picking are often quickly followed by feelings of guilt and shame.

The precise cause, or causes, of skin-picking disorder are unknown.  However, it is believed to be as a result of both environmental and biological factors.  It is estimated that as many as 1 in 20 people may suffer from skin-picking disorder.  Although found in both men and women, research suggests that the disorder is much more frequent in women.

As previously noted, skin-picking disorder research suggests that the urge to pick is very similar to an obsessive-compulsive disorder (OCD).  Individuals with skin-picking disorder repetitively pick at their skin often in response to recurrent urges or thoughts about touching or picking.  In this way skin-picking disorder is similar to OCD in which people exhibit repetitive behaviors in response to other types of recurring thoughts and impulses.  Sufferers of skin-picking disorder are indeed more like than the general population to have OCD as well.

The two main strategies for treating skin-picking disorder are pharmacological and behavioral intervention.  Oftentimes, lack of awareness of available treatment and embarrassment keep people with this condition from seeking treatment.  Two recent studies showed that only 30-45% of sufferers every sought treatment for their skin-picking behavior.

SSRI’s (selective serotonin re-uptake inhibitors) have been shown to be highly effective in treating OCD.  It is precisely this success that argues in this class of medication’s favor for the treatment of skin-picking disorder.  However, review of the literature fails to demonstrate proof positive of their benefits only because there have not been large enough double-blind placebo-controlled investigations of their use in the treatment of skin-picking disorder.  Topamax (topiramate), an anticonvulsant/mood stabilizer medication, was shown to decrease skin-picking behaviors in a small group of individuals.  Behavioral interventions such a cognitive behavioral therapy (CBT), habit reversal training, and acceptance and commitment therapy (ACT) have all been shown to be somewhat beneficial in diminishing picking behavior.

Glenn E. Miller, M.D. is a Board Certified Psychiatrist.  Educated as a pharmacist, physician and psychiatrist Dr. Miller has been in private practice in Santa Barbara for more than twenty years.  Dr. Miller is co-author of Ancient Herbs, Modern Medicine: Improving Your Health by Combining Chinese Herbal Medicine and Western Medicine.  Opinions in the column are Dr. Miller’s and not necessarily those of this newspaper.  Send questions or topics you would like covered to glenn@healthymindhealthyfuture.com