This article provides information about the skin-picking disorder Dermatillomania – what it is, and what to do about it.
Skin is the human body’s largest organ, so it is only natural we would give it attention. Sometimes, we may give it negative attention: we’ve all squeezed the odd pimple, or maybe we bite our cuticles when we’re nervous. However, if someone spends hours picking at their skin, if picking causes deep tissue damage or if it interferes with their daily life, either by being time consuming or by obliging them to cover parts of their skin and avoid certain activities – then they may be suffering from dermatillomania.
Dermatillomania – also called excoriation syndrome or skin-picking disorder – is a form of Body Focused Repetitive Behaviour (BFRB). Other BFRBs are compulsive hair pulling, nose picking, nail biting, hair eating etc. People may suffer from one type of BFRB or from several. BFRBs are currently classified as a form of Obsessive Compulsive Disorder (OCD) and are often linked to anxiety. However, research also suggests they have a lot in common with substance abuse disorder and may be viewed and possibly treated as an addiction as well as a compulsion.
The percentage of BFRB sufferers among people with autism and ADHD is significantly higher than in the general population (up to 25% compared to 5%). This may be due to higher levels of anxiety, or the behaviour may be a form of sensory stimming – research on this point is still ongoing.
Unfortunately, dermatillomania is still a relatively unknown condition. When not dismissed as a bad habit, it’s often misdiagnosed as self-harm. While impact on the skin may appear similar, it’s important to distinguish between the two: self-harmers seek pain when they injure themselves, but skin-pickers seldom experience pain as they pick. They often report a sensation of “trance”, a relief from stress and anxiety, and even pleasure while they are engaged in picking. Thus, while self-harm involves the wish to hurt oneself, dermatillomania is self-grooming gone rogue. Skin-pickers are also less likely to use tools such as knives or scissors for picking, possibly because part of the addictive element is the contact between hand, skin, and sometimes mouth.
That said, dermatillomania does cause bodily harm; if left untreated, it could result in permanent tissue damage and scars, but also lead to serious and even dangerous medical complications such as contracting various bacteria, MRSA, staph infection, cellulitis or sepsis, through open wounds and sores.
In addition to its physical impact, dermatillomania comes with a heavy emotional burden. Sufferers experience shame, self-loathing and isolation. Other side effects are depression and fatigue, low self-esteem and body image issues, avoidance of intimacy and difficulties at school and in the workplace.
Despite its severity, dermatillomania can often go undetected. Teenagers and even children are very apt at concealing their picking. If you think your child may be picking, watch out for long periods spent in the bathroom, unexplained blood stains on clothes and bedding, preference for long sleeves in the summer or reluctance to visit the seaside or the pool. Other signs could be frequent nose bleeds from nose picking, sudden limping as a result of picking feet or toes, refusal to remove caps or hats due to wounds on the scalp, etc.
Helping someone with dermatillomania is not easy. To start with the don’ts: do not shame your child for it, or use threats to make them stop, as this will only make them retreat and hide their picking. Resist the urge to say: “don’t pick!”. Understand that picking is not a choice or a bad habit but a compulsion. Instead, you could direct them to an alternative activity that offers a similar sensation, such as peeling plaster off a wall, tearing a piece of cloth, squeezing out tubes etc., or encourage them to use a sensory or fidget toy (like this finger-picking stone for example). You could hold and massage their hands and fingers, and if picking has already occurred: disinfect and dress the wound, while remaining calm and non-judgmental.
A key in fighting dermatillomania is recognising triggers. Notice when the picking occurs: is it at school, during certain activities or after meeting certain people? Try to reduce any situation that causes the anxiety which leads to picking. If your child picks when they are bored or distracted, offer a more active or interactive pastime. If they tend to pick when they are in the bath or shower, remove mirrors and offer to keep them company in the bathroom. Encourage your child to recognise their personal triggers and picking patterns by keeping a skin picking log on paper, or by using an app such as Skinpick.
In addition, reduce any possible skin triggers. For example, if your child picks mosquito bites, protect them from getting bitten in the first place. If they pick their facial acne, consult your GP about preventing acne outbursts. If their nails or toenails are the problem area, keep nails short and offer them manicure or pedicure. While this may seem excessive, the more you reduce the triggers, the better. If you think of dermatillomania as similar to substance abuse, imagine how hard it must be if the substance you are trying to avoid is always with you wherever you go.
Beyond family support, it is important to seek professional help. Your first address is your GP. Be prepared that you may need to explain what the condition is, as not all doctors will be familiar with it. They will then be able to refer you to suitable therapies.
The following methods have proved effective in treating dermatillomania and other BFRBs:
Cognitive Behavioural Therapy – works on habit reversal and impulse control training. Unfortunately waiting periods for CBT in Sheffield are very long.
Conversation therapy – a longer psychological path. While therapists specialising in BFRBs are few and far between, many counsellors with knowledge of OCD would be able to help.
Medication – medication used for managing OCD and anxiety can also help reduce the urge to pick.
Group therapy and support groups – With therapy being difficult to access, support groups, whether overseen by professionals or peer-led, can be extremely helpful, especially for young people. With the shame and isolation experienced by sufferers, such groups offer a safe space to talk about dermatillomania with people who share the condition. Attendees can exchange experience and tips, and find accountability buddies for undertaking no-picking challenges. OCD Action organises in-person group meetings in Sheffield for people aged 16+ across the OCD spectrum; call 07766950479 for details. They also have online meetings for adults and a dedicated online group for 16-20-year-olds.
There are also several Facebook groups, online forums and Instagram accounts dedicated to dermatillomania. These groups are mostly private, and posts can only be seen by members, but you should be aware of the privacy risks involved in social media. Users should also be mindful of triggers in the form of pictures, and check whether engaging with such content is beneficial to them.
An important note to carers: if your child is already seen by Ryegate or CAMHS, inform them about your concerns over dermatillomania, and push for help. If picking occurs in school, talk to the SENCO and teachers about how to assist your child by preventing picking, or offering help after a picking episode (“distract/disinfect” is a useful shorthand).
Finally, the best remedy for dermatillomania is raising awareness about it. BFRB Awareness Week takes place during 1-7 October. Please help keep the conversation going.