- Best ResultsVariable
- Treatment RecoveryVariable
- Procedure TimeVariable
- Skin SpecialistDermatologist, psychiatrist
- Duration of ResultsCan be permanent
- Back to WorkVariable
Skin Picking Disorder
Skin picking disorder is also known as dermatillomania. This is a common condition that affects 5% of the population. Depression, stress & anxiety are predisposing factors. This is a form of obsessive-compulsive disorder. Skin scars are a frequent sequela of skin picking. If you are serious about treatment, a team consisting of medical dermatologists, psychiatrist & psychologist can help you.
FactsFacts on skin picking disorder or dermatillomania
- This is a form of obsessive-compulsive disorder
- Patients have an uncontrollable urge to pick
- Dermatillomania is a disorder of exclusion
- Treatments include cognitive behaviour therapy & SSRIs
- Anti-anxiety drugs can reduce the urge to pick
- Skin picking can lead to scars
- Skin scars are best treated when this condition is in complete remission
- Hypopigmented scars are treated with lasers, surgery & pigment stimulators
- Most cases require a team of dermatologists, psychiatrists & psychologists
What are the symptoms of skin picking disorder or dermatillomania?
Dermatillomania is also known as skin picking disorder, obsessive skin picking, or neurotic excoriations. The predominant symptom is the urge to pick skin on the face, trunk and limbs. Nail picking, cuticle picking, & hair plucking are also examples of dermatillomania.
Most patients are anxious or stressed. Picking provides relief & satisfaction. In most cases patients are unaware of their actions as it is often an unconscious behaviour.
How is skin picking disorder / dermatillomania classified medically?
This is a true medical condition that has been defined as a psychiatric disorder under DSM-5. This is a form of obsessive-compulsive disorder,
In order to receive a diagnosis in this category, the person must:
- Experience some of the symptoms listed above (picking)
- Be under clinical distress or impairment
- Have symptoms that are not caused by a medical, substance or dermatological condition
- Have symptoms that cannot be explained by another psychiatric disorder
In order for an accurate diagnosis to be made, help from a medical professional should be sought. If you are serious about getting help, the three professions that should be involved include a medical dermatologist, psychiatrist & psychologist.
Disclaimer: I am a procedural dermatologist, namely my job is to fix up scarring post dermatillomania. My medical colleagues at Clinic Cutis can assist in your treatment.
How common is it?
Very. Reports of up to 5% of the population, hence 1 in 20. This is more common for females & people with higher anxiety levels.
I personally had two forms of dermatillomania, namely trichotillomania, hair pulling as well as cuticle picking. I still have the latter.
(Even though I have some insight regarding this condition, I do not treat obsessive skin picking. This is best treated by a medical dermatologist. My work is entirely procedural.)
What is the difference between picking acne & true skin pickers/ dermatillomania?
Picking acne is known as acne excoriee or picking acne. Unlike true skin picking associated with dermatillomania (where there is no primary pathology), there is a substrate for acne pickers. The outcome for picking acne is excellent if acne lesions are treated effectively. A medical dermatologist can discuss effective ways to stop acne lesions from recurring, and hence cure acne excoriee.
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What is hair picking or trichotillomania?
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.
Who to see?
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.
What can a psychologist do?
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.
What can a psychiatrist do?
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.
What can a dermatologist do?
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.
How to reduce the effects of scarring?
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.
What treatments are there for scarring from skin picking/dermatillomania?
Scar revision is more productive on the face & neck, & less successful on the limbs & trunk. The aim of scar revision is to –
- 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.
- 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.
What can be done for dark scars or post inflammatory hyperpigmentation?
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.
What can be done for white scar or post inflammatory hypopigmentation?
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
What DIY or home remedies are there?
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.
When do I get involved in the treatment of dermatillomania?
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.
What does LLED or light treatment do for skin?
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.
How to approach facial scars?
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.
How to approach scars on the limbs and trunk?
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.
What does phototherapy do?
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.
How do I get help for my picking scars?
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.
Davin’s viewpoint on treating scars for dermatillomania
This is a common condition. It is also known as neurotic excoriations, obsessive picking, or skin picking disorder. Trichotillomania is another example of picking. Acne excoriee is frequently referenced as part of this disorder of obsessive compulsion, however this is incorrect. With acne there is a substrate to pick. When acne is treated, picking stops. Picking acne heralds a better prognosis compared to dermatillomania, providing patients have insight.
Skin picking disorder can be successfully treated if patients want to be treated. Early & effective treatment will mitigate skin scars. People who don’t accept their condition or have little or no insight will be left with marked, extensive scars that can be difficult to treat. The trifecta of management is via a medical dermatologist (not me), psychologist & psychiatrist. A dermatologist is required to exclude organic causes including metabolic, immunobullous, endocrine, paraneoplastic & inflammatory causes. In some cases tests are required, including special skin biopsies.
A psychiatrist can prescribe SSRI medications to help reduce obsessive compulsive disorders & anxiety. A psychologist can teach distracting techniques including CBT. Other helpful methods of relaxation include meditation, yoga, acupuncture & fuzzy stuff like aromatherapy. Remember, the greatest predictor of skin scarring is the time taken to effective control. I do encourage patients to seek early help.
Disclaimer: I am a procedural dermatologist. I do not treat skin picking disorder. This is a medical condition that requires close follow up. My work is focused on surgical treatments. If you have active picking, my colleagues at Clinic Cutis can assist in providing you a diagnosis & referring you to a team of psychologist & if required, psychiatrist for medications.
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