This is more common in children, but it is also seen in adults. Essentially it is habitual hair pulling resulting in focal alopecia or hair loss. I had this condition about 20 years ago when I was studying for my dermatology exit exams. I know of a few other dermatologists who suffer from trichotillomania (it affects 4% of the population). If the habit is broken, it resolves. Most cases do not require psychiatric medication. This is a form of obsessive-compulsive disorder. 

Disclaimer: I do not treat hair conditions, apart from surgical transposition of follicles. This treatment is not indicated for hair pulling disorders.

If you have sores, scratches, & picking lesions, you are best seen by a medical dermatologist. They will conduct tests to exclude other rare conditions of picking, including hormone testing, liver function tests, renal tests & possibly do some skin biopsies. I do not get involved in medical management. My role is to fix up scars after medical management when the condition is in remission.

Lots. They are the best profession for skin excoriation/picking/ dermatillomania. They provide CBT or cognitive behaviour therapy. This can help individuals understand how their thoughts & behaviour patterns are related in order to reduce repetitive behaviours. Individuals learn how to change their thoughts so that they can avoid picking at their skin. Habit reversal training & exposure and response prevention are commonly employed strategies.

The OCD clinic in Bulimba, Brisbane has many experts who perform these useful therapies.

Most psychiatrists will refer you to a psychologist for non-drug management including CBT. Psychiatrists with an interest in OCD may elect to provide non-prescription therapy. Most psychiatrists will prescribe psychotropic medications including SSRIs, or selective serotonin reuptake inhibitors. These drugs are used to treat depression but can be useful in OCD conditions. They include fluoxetine, paroxetine & sertraline. Other drugs used to treat skin picking disorder include naloxone. 

A medical dermatologist (not me!) can exclude all the other rare conditions that may give rise to skin picking. They include disorders such as,

• Drug induced causes: meth, ice, blunts, eggies, E’s, opiates including Charlie
• Organic causes; liver, renal impairment, as well as endocrine disorders.
• Dermatological conditions; pre-bullous pemphigoid, linear Ig A, DH
• Brachioradial itching (itchy arms leading to picking & scratching)
• Malignant screening; lymphoma etc…
• Other rare organic causes.

Disclaimer: I do not see acute/active cases of skin excoriation- dermatillomania. A medical dermatologist is your best bet. Tests including biopsy, immunofluorescence, as well as specific blood tests are required.

Early and effective management of picking will markedly reduce the risk of scarring. This requires a team approach with input from your psychologist, psychiatrist & medical dermatologist. Simple strategies that your dermatologist will use include trimming of nails, ice packs, as well as mitts at night. If picking is focal, you can buy some hydrocolloid dressings from a pharmacy. These include acne patches.

Establishment of barrier function with actives such as ceramides, squalene, shea butter, hyaluronic acid & tocopherol can reduce skin scars from picking. Other medications prescribed by dermatologists include menthol in aqueous cream or calamine lotion as well as mast cell stabilizers. In some cases, phototherapy can reduce the itch scratch cycle.

Disclaimer: I do not treat acute dermatillomania, or obsessive-compulsive skin picking. My skill sets are in the management of difficult scars including hypopigmented scars when patients are in complete remission.

Scar revision is more productive on the face & neck, & less successful on the limbs & trunk. The aim of scar revision is to –

1. Normalise the contours of the skin. If you have a depressed scar (picking normally gives you this pattern), the aim is to elevate it. Lasers, microneedling & other energy devices encourage your immune system to lay down collagen. If you can not achieve this, fillers & fat transfer can help.
2. Normalise colour. Skin picking / dermatillomania patients will often have changes in skin texture or colour. Hypopigmented or white scars are commonly seen as picking takes out the pigment cells. Treatments include microneedling with pigment stimulators (bimatoprost), fractional laser resurfacing, as well surgical melanocyte transfer. Surgery is only performed when picking is in complete remission.

This type of scarring is easier to treat compared to hypopigmented scars as well as contour changes. The rate limiting factor is the patient’s insight to understand that new lesions must be prevented. Hence, in most cases, my team can make excellent progress over a short period of time (again, depending on patient’s acceptance & motivation to prevent new lesions). Some methods used include-

• Lasers including fractional, nano & pico lasers
• Pigment inhibitors such as HQ, ascorbic, kojic, citric, retinoic acids
• Chemical peels
• Microneedling (other treatments are much better, best used for whtie scars)

*If you have active lesions or uncontrolled picking, you will be chasing your tail with treatments. I do encourage all patients to undertake medical therapy at the same time as scar revision.

Hypopigmented scars are infinitely harder to treat compared to post-inflammatory hyperpigmentation. Again, absolute control of picking is required before any surgical procedures are performed. Methods that my team & I use include-

• Microneedling with pigment stimulators
• Laser therapy including CO2 & thulium with pigment stimulators
• Melanocyte transfer with pigment stimulators & phototherapy

If you are serious about treating this condition, you should see a psychologist & a psychiatrist. The former can teach you coping skills, the latter can prescribe you drugs.

If you are stressed & highly anxious, find a solution that can reduce your stress levels. They include acupuncture, yoga, medication, trigger pointing, aromatherapy & other fluffy but important avenues. 

Creams include vitamin E – tocopherol, squalene & ceramides. They can help establish barrier function & reduce the chances of scarring. Do not use AHAs or BHAs on scratched or eroded lesions as this will result in more skin irritation, leading to more scratching.

DIY microneedling is a safe option, providing you perform this correctly. It can give mild to modest results. Refer to the section on how to. Do not attempt this if you have open sores.

I am the last specialist to be involved in this condition, as my job is to fix up scars left from picking. You must be in absolute remission for at least 4 months before I consider surgical or laser modalities. My work focuses on fixing up really hard to correct scars including hypopigmented (white scars). I use techniques such as cell transfer via lasers & micrografting. Treatments such as fractional lasers are conducted by my clinical team.

If you relapse, I will refer you back to your psychiatrist or psychologist to ensure you don’t go backwards. It is frustrating for patients to take two steps forwards then go back three steps in the context of scar revision.

LLED stands for low level laser emission device. This treatment can accelerate wound healing. The most prescribed wavelengths include red & orange. This treatment is performed by my clinical team.

Picking scars can be treated with lasers. A good starting point are pico lasers as they can help stimulate pigment & blend the surrounding skin. Other lasers include Fraxel, & fractional lasers such as LaseMD or Clear & Brilliant. 4-10 sessions are required over 6- 12 months, the results are variable.

Your habitual picking must be in complete remission before contemplating surgical procedures such as micrografting & ablative laser resurfacing.

Body scars are approached in a similar way to facial scars. Pico or Q switch nano lasers are useful for blending. Fractional lasers can be employed in small sections. You cannot Fraxel large areas as the rate limiting factor is anaesthetic toxicity.  4-12 sessions are performed over 6-14 months. Results vary.

Phototherapy (medical, not fuzzy clinic LED) can be useful in the management of obsessive skin picking – dermatillomania. This treatment can –

• Reduce the itch scratch cycle by stabilizing mast cells.
• Stimulate pigmentation in white areas
• Reduce skin inflammation & redness
• Wake up melanocytes post-surgical transfer

This is covered under Medicare. Patients require 2-3 sessions over 16 to 40 weeks for best results. Phototherapy is painless & takes 1-3 minutes to perform.

For mild scarring & active picking, book a consultation with my clinical staff. They can initiate treatments such as pico, nano & fractional laser.

For severe scarring including hypopigmented facial scarring, book an appointment with myself when your condition is in complete remission. I do not get involved in the psychological management of picking as my skill sets are focused on physical therapies including fully ablative laser, dermabrasion, & surgical micrografting.

If you have active picking & would like help, consult a psychologist. In Brisbane, I refer patients to The OCD Clinic at Bulimba.