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Polly's Story: "I just can't stop picking my skin!"

Polly is a thirty-something who can't stop picking her skin. She’s under a lot of stress at home and work. When watching TV in the evenings, she picks on her face and forearms to the point of bleeding. Summers are stressful because she worries about others seeing the scabs and scars on her arms and legs. She'd like to get help with it, but she's so embarrassed that it's hard to talk to anyone.

Introduction 

Many people pick at their skin from time to time. People may pick at their acne, moles, freckles, sores, and scabs. They may even pick at things in their skin where others wouldn't see anything wrong. But when the picking becomes so severe that it causes problems in one’s life, it may be skin picking disorder.

Other terms used include dermatillomania, excoriation disorder and compulsive skin picking.

Do You Have A Problem with Skin Picking? 

Notice any of the following?

• Does picking at your skin take up a lot of time during the day?
• Do you have noticeable scars from skin picking?
• Do you feel upset when you think about how much you pick your skin?
• Does picking at your skin get in the way of your social or professional life? For example, do you avoid the beach or the gym because people might see your scars? Or do you spend a lot of time covering up sores before work or social events?

If you’ve answered yes to one or more questions, you might have a problem with skin picking. Read on to learn more...

How Common is it?

It is estimated that as many as 5% of the population (i.e. 1 in 20 people) have it. 

It usually starts around age 15-45, and mainly affects females. 

What Causes Skin Picking Disorder?

The exact causes are not known, however:

• People often report that the skin picking started after an infection or injury to their skin, and after that, they had a scab that they began to pick.
• Stress with work, school or relationships can make skin picking worse.

Common Signs and Symptoms 

Common signs and symptoms include the following:

• The behaviour may start after a minor skin problem on healthy skin
• It can lead to an irresistible urge to pick, scratch, dig or scrape the skin that damages the skin. Some people use instruments such as tweezers, pins, scissors or knives
• After picking the skin, the person feels a temporary relief from emotional distress and urge.
• People may spent large amounts of time picking their skin picking, often several hours per day, and worse in the evenings.
• The behaviour can happen when you aren’t even consciously aware of it, e.g. while watching TV. 
• People often try to resist or stop the behaviour, but it is difficult.
• People may be reluctant to show areas of damaged skin, thus will go to efforts to hide the areas affected.
• May cause problems in a person’s life at home, work or school, though many times, others may have no idea.

Why It Is Important to See a Doctor 

It is important to see a doctor, as medical conditions can contribute to skin picking, such as skin disorders (such as psoriasis and scabies), and conditions such as low iron or liver problems can lead to itchy skin.

Getting help for skin picking disorder is important, as people with skin picking may be at risk of other conditions such as depression, anxiety, obsessive-compulsive disorder (OCD), and others. Getting help for these other conditions can help with skin picking or vice-versa.

Self-Help Strategies

Self-Compassion

Self-compassion is about accepting that you are imperfect. For many people, a trigger is seeing an imperfection in their skin, which leads them to pick at it. Self-compassion helps us accept that there will always be imperfections in our skin and body. And it's okay, because everyone is imperfect, and that is part of being human.

Have you just picked your skin and feel guilty about it? Unfortunately, self-blame makes us feel more stressed, which doesn’t help. It’s not the end of the world. You are not alone. Many things can help.

Have a good skincare routine

Wash your face once or twice a day. Many experts recommend washing in the morning and once at night to remove dirt, makeup, oil or other grime. Use a mild soap to keep your face from getting too dry. Some people find that water alone is enough, without using any soap.

Use a skin moisturizer to keep your skin well hydrated because some people find that dry or itchy skin is a trigger.

Wash your hands before you pick. Washing your hands reduces the number of microbes, so if you pick, it reduces the chance of getting an infection. Use a hand lotion after you wash your hands to keep your hands from getting too dry.

Try a physical barrier.

It can help to put a physical barrier on your skin that makes it harder to pick, so that the urge to pick can pass...

• Wear gloves or mittens on your hands. There are custom ‘skin picking guards’ such as a mitten covering your thumb, 2nd and 3rd finger to make it harder to pick, without covering your whole hand, available from online retailers.
• Put on Band-Aids (™) such as blister band-aids that can stay on a few days.
• Put on a “skin protection sleeve” to protect a forearm, arm or leg from picking. Examples made by companies include UnnaSleeve (™).
  

Identify triggers and possible coping strategies

Typical triggers for skin picking include:

• Being bored. If so, always have something you can fidget with, e.g. stress ball, prickly stress ball, silly putty. Activities to keep busy, especially your hands, e.g. crocheting, knitting, etc.
• Do you pick when you are cooking? Hold a wooden spoon or spatula in your hands so that your hands are never free to pick.
• Seeing yourself in the mirror. If so, perhaps avoid, remove or cover up mirrors that are a trigger.
• Stresses at work, school, or home. If so, identify specific stresses and try to come up with ideas to help address them.
• Do you feel an urge to pick while in public? Put your hands in your pockets.

The TLC Foundation for Body-Focused Repetitive Behaviours has a large list of items and activities to keep your hands occupied such as:

• Silly putty
• Stress ball
• Painting your nails.
  

Other strategies reported as helpful by people with skin picking include:

• Strong sensory input, e.g. using ice to distract the person from picking.
  
• Put a safe, non-toxic glue on the child's skin, and let it dry. Then let the child take it off.
• Put on a thick coat of henna, as used in henna tattoos, and allow it to dry overnight.
• When you get the urge to pick, try not to pick right away, but try to resist the urge for longer and longer times.

Treatment

The good news is that there are various treatments for skin picking disorder.

Counseling/therapy (aka talk therapy): It can be helpful to see a professional such as a psychologist, social workers or psychotherapists. Professionals may use many strategies such as

• Habit reversal training: The therapist helps you identify the situations, stresses, and other factors that trigger skin picking. Then your therapist will help you find other things to do instead of skin picking, such as distracting yourself, e.g. squeezing a rubber ball. This will help ease stress and occupy your hands.
• Stimulus control: The therapist helps you make changes to your environment to help curb skin picking. For example, you might try wearing gloves or Band-Aids (™) to help prevent feeling the skin and getting the urge to pick. Or you might cover mirrors if seeing facial blemishes or pimples brings on skin picking.

Medications may be helpful such as

• Selective serotonin reuptake inhibitors (SSRIs) such as Fluoxetine (aka Prozac), Citalopram (aka Celexa), Escitalopram (aka Cipralex), Fluvoxamine (aka Luvox) and Sertraline (aka Zoloft)

Nutraeuticals may be helpful so as: 

• N-acetylcysteine is an over-the-counter nutraceutical that may be helpful. 

Are there skin problems? 

• If so, then your primary care provider may prescribe medications such as antibiotics for skin infection, or topical steroids to reduce skin irritation may be helpful.

Are there persistent skin problems, such as eczema or other conditions? 

• Ask your primary care provider about this, or ask about a skin doctor (dermatologist).
  

When and Where To Get Help

Are you having problems with skin picking? Start by seeing your primary care provider who can:

• Make sure that there aren’t any medical conditions that may be contributing, such as a skin condition, e.g. eczema.
• Deal with skin lesions, wounds, or scars.

There are various types of professionals who may be able to help such as:

• Psychiatrists: Your doctor can refer you to a psychiatrist.
• Psychologists and social workers: Can provide cognitive behavioural therapy (CBT) and/or habit reversal training (HRT).
• Dermatologist: May be helpful if there are problems such as infection, scarring, disfigurement or another skin condition.
• The Trichotillomania Learning Center keeps a list of trained professionals.
  • Can’t find a specialist in skin picking? Look for a therapist who treats obsessive-compulsive disorder (OCD), as treatments for both are similar

Back to Polly's Story: "You mean I'm not the only one with this?" 

Polly builds up the courage to speak to her family doctor about her skin picking. She is relieved to find she is not alone, and that other people have this condition too. Her family doctor does some tests to rule out other medical conditions that may be contributing. Her family doctor suggests a local publicly-funded service that provides counselling, and it greatly helps. She becomes aware of the stresses in her life, particularly her family and work. She learns to be more accepting and compassionate to herself. She accepts that her skin is not perfect and never will be. As a result, she is less stressed and less triggered. And now, when she watches TV, she crochets instead of picking, and it's now she even has enough creations to sell them online.

For More Information 

English

• The Trichotillomania Learning Center
  www.trich.org
• Stop Picking.com
  www.stoppicking.com 
• SkinPick.com
  Online resource and community for those with dermatillomania, including an App for self-monitoring of skin picking.
  www.skinpick.com 
• Canadian BFRB (Body-Focused Repetitive Behaviours) Support Network
  http://www.canadianbfrb.org 

French   

• Dermatillomanie France 
  http://dermatillomanie-france.com

About this Document

Written by Dr. Tania M. Fantin, Family Medicine Resident, Class of 2017 and Dr. Michael Cheng (psychiatrist). Reviewed by members of the eMentalHealth.ca Primary Care Team, which includes Dr’s M. St-Jean (family physician), E. Wooltorton (family physician), F. Motamedi (family physician), and M. Cheng (psychiatrist).

Disclaimer

This information is offered ‘as is' and is meant only to provide general information that supplements, but does not replace the information from your qualified expert or health provider. Always contact a qualified expert or health professional for further information in your specific situation or circumstance.

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