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- Skin-picking disorder (SPD) is found in 2–3% of people.
- SPD occurs at any age, typically coinciding with the onset of puberty.
- The disorder may result in bruising, bleeding, infection, and permanent tissue damage.
Who picks at their skin? Most people would probably admit to sporadically picking at a scab or a pimple or pulling dry skin from their lips, but sometimes this behaviour becomes problematic, for example, when it affects physical appearance (scarring), becomes time-consuming, or leads to sepsis.
The emotional impact – e.g. shame, embarrassment, low self-esteem, and anxiety – may also be considerable. When skin-picking behaviour and its sequelae become clinically significant, (distressing or functionally impairing), a diagnosis of excoriation disorder may be warranted.
What is skin-picking disorder?
A relatively common mental health condition, SPD is found in 2–3% of people and is more widespread among females than males. It occurs at any age, with skin-picking behaviours typically starting in adolescence, coinciding with the onset of puberty. Acne or eczema may trigger the onset of skin-picking and SPD.
Although SPD has been documented in the medical literature since the 19th century, it has only recently been included as a distinct entity in main psychiatric classification systems like the Diagnostic and Statistical Manual of Mental Disorders. Diagnostic criteria include recurrent picking of skin, resulting in skin lesions; repeated attempts to decrease or stop the behaviour; and significant distress or impairment in social, occupational, or other important domains of functioning.
The goal of picking is usually to smoothen the skin or to make it “perfect”, but this often has the opposite effect, with picking resulting in bruising, bleeding, infection, and in some cases, permanent tissue damage. Most people have multiple picking sites, most commonly facial skin, followed by the hands, fingers, arms, and legs. Skin-pickers may also pick at healthy skin and minor skin irregularities. A range of behaviours, e.g. finding a particular scab, picking at it in a specific way, and examining, playing, and/or mouthing or swallowing the scab, are common.
Some people report that their picking occurs without their awareness (automatic picking) when they are engaged in sedentary activities, such as watching television or reading, whereas others pick their skin more intentionally. Focused picking can be a response to an urge or perhaps another negative emotion or in an attempt to correct perceived imperfections, or both (mixed picking).
Finally, people who pick report multiple skin-picking triggers, which may vary from individual to individual, and commonly include negative emotions such as stress, anger, and anxiety. Sedentary activities (as noted above), boredom and feeling tired are also associated with picking.
Causes of SPD
Motor impulsivity or the tendency to act on the spur of the moment without thinking has been suggested to be involved in SPD. The cortico-striatal-thalamic-cortical circuitry, which controls movement execution, habit formation and reward, in addition to other brain regions, has been implicated.
Data from animal studies and neurobiological investigations in humans have also suggested that the dopaminergic system plays a role in SPD. There is evidence of some heritability. Skin-picking is also often found in people with other body-focused repetitive behaviour disorders, such as hair-pulling disorder (trichotillomania). Neurobiological investigations suggest the involvement of a few candidate genes in SPD. Genome-wide association studies of SPD have not yet been conducted.
Impact of SPD
The impact of SPD is considerable. People with the condition spend a significant amount of time picking and covering up, leading them to be late for or miss appointments.
Other sequelae, such as feeling embarrassment or shame or avoiding situations or activities where the behaviour or resulting lesions can be detected, and loss of productivity, are common. Poor self-esteem, anxiety, and depression are typical. Infections, scarring, and in severe cases, physical disfigurement, are some of the possible medical sequelae of SPD.
Assessment
The 10-item, clinician-administered Yale-Brown Obsessive Compulsive Scale, modified for Neurotic Excoriation is used to assess the severity of SPD symptoms.
There are several self-report scales, including the eight-item, self-report Skin Picking Scale-Revised (SPS-R), to assess symptom severity and impairment. There are also two 12-item self-report measures, namely the Skin Picking Symptom Assessment Scale (SP-SAS) and the Milwaukee Inventory for the Dimensions of Adult Skin Picking (MIDAS). The former evaluates picking urges, thoughts, and behaviours during the previous week, whereas the latter is used to assess "automatic" and “focused” skin-picking. On all these scales, higher scores reflect greater severity of skin picking symptoms.
Treatment options
Individuals with SPD do not commonly seek help and if they do, the true reason for the skin lesions or skin “problems” may still be kept hidden. The few pickers that do seek treatment often go to a general practitioner or a dermatologist. Psychologists and psychiatrists with relevant expertise can also be approached for intervention.
All treatment starts with a comprehensive diagnostic and clinical assessment to identify the potential underlying causes and any comorbid disorders (e.g. depression and alcohol and/or substance use disorders). Once diagnosed, psychoeducation is the next step, during which accurate information on the condition and its treatment is provided.
Treatment options include different types of behavioural therapy (habit reversal or acceptance-enhanced behaviour therapy) and cognitive behavioural therapy, and various types of medication (antidepressants such as selective serotonin reuptake inhibitors [SSRIs] or antioxidants like N-acetyl cysteine) have shown promise.
There are several alternative interventions for SPD, including yoga, aerobic exercise, acupuncture, and hypnosis, either as monotherapy or as an adjunct to psychotherapy and/or pharmacotherapy. These methods have not been tested scientifically.
There are also no trials that have investigated the efficacy of combinations of psychotherapy and pharmacotherapy in SPD. However, it is well-known that in psychiatric conditions such as SPD a combination of treatments works best.
The clinical impact of SPD is considerable. Inclusion of SPD in diagnostic manuals has likely led to increased awareness of the condition, more research, and advances in treatment. While psychoeducation is important and behavioural treatments, SSRIs and nutraceuticals may be beneficial, additional controlled treatment trials are needed.
*Prof Christine Lochner is affiliated with the SAMRC Unit on Risk and Resilience in Mental Disorders in the Department of Psychiatry at Stellenbosch University. This article is based, in part, on her recent paper in Mental Health Matters.
