Our skin is often covered with tiny imperfections – blemishes, moles, cuts and spots that we’re all guilty of picking at from time to time. Consider the temptation of that bulbous yellow head of a spot ready to erupt, or peeling back a scab that’s been there for days to find the newly healed skin beneath.
But for some, skin picking is not an occasional guilty pleasure, but an obsessive condition known as excoriation disorder. Or to give it a medical name, dermatillomania. It is relatively common in the general population. Self inflicted skin disorders, of which dermatillomania is one example, account for around 2% of clinical appointments in dermatology.
Dermatillomania is more than just finding satisfaction in popping a volcanic spot. It is a disorder that can have serious and even fatal consequences. It is characterised by consistent picking at the skin, which becomes a habit, much as nail biting or thumb sucking does. This may focus upon the different pigmented spots that are visible (such as moles or freckles), in an attempt to reduce their appearance or dig them from the skin.
If the patient also has an associated dermatological disorder such as eczema, psoriasis or acne which causes lesions to develop, this may exacerbate a heightened desire to eliminate the rash from the skin.
But the patient may also attack unblemished skin, either with the nails or using sharp objects as tools, like needles or tweezers to gouge and scrape at perceived imperfection. Some may also go as far to bite at the skin with their teeth. The skin picking may persist for long periods of the day, becoming an unconscious habit. In some cases, it may even extend into sleeping hours.
The disorder creates progressive skin damage. Normally after sustaining a cut or injury, the area of tissue becomes flooded with restorative cells. This includes white blood cells and fibroblasts which fight infection and weave the ends of a wound back together. Constant picking of a wound disrupts the matrix and web that these cells work around, like builders on a set of scaffolding. This interferes with the normal healing processes, and can result in permanent scarring. To complicate matters further, wounds that stay open can also introduce infection into the skin and deeper tissues.
Related disorders
There are other related disorders that have a close association with dermatillomania. Hair and nails are both extensions of the skin, and the similarly named condition trichotillomania (often shortened to trich) is another example.
This is where the patient persistently plucks or pulls at their hairs. Like skin picking, patients with trich may describe intense relief or satisfaction in plucking, and may become agitated in the periods when they leave their hair alone.
Hair plucking isn’t limited to the scalp – the lashes, eyebrows and pubic regions may also be targeted. Some may also proceed to eat the hair – a condition called tricophagia. This is a subtype of the eating disorder pica, where there is a craving for inorganic substances, or those with no nutritional value.
What causes the problem in the first place? There are many triggers for dermatillomania, which a doctor will try to establish in order to help. Often treating the condition involves exploring and addressing any obvious cues to start picking. Sometimes it may be as simple as being bored, or lack of engagement in a daily routine. In other cases, an association is found with mental health disorders, like anxiety or depression.
Dermatillomania shares many traits with obsessive-compulsive disorder (OCD), a two-fold condition. OCD patients become afflicted with persistent intrusive thoughts (obsessions) which compel them to carry out actions which help them alleviate the associated unpleasantness (compulsions). A common example is frequent hand washing to relieve the stress that comes from obsessive thoughts about coming into contact with germs via touch. Jack Nicholson won an Oscar for his portrayal of Melvin Udall in the 1997 film As Good as It Gets, a character who exhibits many of these traits.
How to manage the compulsion to pick
There are several techniques that a skin picking patient can do to manage these urges themselves. Part of tackling habits is to provide a form of distraction. This might be using hand-held devices such a stress ball or fidget toy, to detract attention. Patients can also use simple strategies to making picking and plucking more difficult, such as wearing gloves or hats as barriers.
In more severe cases, clinical intervention may be required as treatment. Medical treatment for either existing skin or mental health conditions acting as a trigger may help, as may cognitive-behavioural therapy (CBT). This seeks to disconnect negative thoughts and behaviours which drive poor mental health, and make a more positive change.
It goes to show therefore that, for some people, the quest for dermatological perfection is more than skin deep. Our minds and skin share close physical and psychological bonds and while the habitual picking of dermatillomania might seek to iron out imperfections in skin, it could also be counter intuitive. And become a deeply ingrained obsession.