Compulsive Skin Picking: A Particularly Problematic BDD Symptom
Posted by Ashley in Diseases and ConditionsSkin picking has been recognized for many years in the dermatology literature, with labels such as “neurotic excoriation”. This behavior has been reported in a high percentage of patients with body dysmorphic disorder (BDD), a distressing or impairing preoccupation with a minimal or nonexistent defect in one’s appearance. BDD patients who pick their skin are more likely than BDD patients who do not pick to consult a dermatologist.
Skin picking also occurs in other psychiatric disorders, including trichotillomania and obsessive-compulsive disorder, as well as various medical and developmental conditions. Morbidity may be considerable; including psychological distress, skin infections, scarring, and surgical intervention. Many of these patients first present for treatment to a primary care physician, dermatologist, or surgeon, rather than a psychiatrist.
Patients typically describe skin picking as compulsive - something they feel driven to do and are unable to resist. This behavior can consume many hours a day and picking can so deep as to threaten or expose underlying vessels, which occasionally requires emergency surgical intervention.
Ironically, the picking can be time consuming and extensive enough to result in considerable disfigurement, even to the extent that dermatological or surgical intervention is required. In such cases, although the skin lesions may be obvious, the patient still qualifies for the BDD diagnosis because the lesions are self-inflicted and the person’s appearance was within normal limits prior to initiation of picking. It should be emphasized that although this behavior is self-injurious, these patients do not intend to harm themselves; they do so only as an unfortunate byproduct of attempts to improve the appearance of their skin.
Although skin picking commonly occurs as a symptom of BDD (in one third of skin pickers) this behavior is heterogeneous and can occur as a symptom of a variety of underlying disorders. In one series (n = 31) during a study, skin picking was considered the result of obsessive - compulsive disorder in 52% of cases.
In other cases, picking appeared to be a habit that is not triggered by an obsessional thought.
The diagnosis of BDD can easily be missed and emphasizes the need for careful differential diagnosis of skin picking. The term “neurotic excoriation” is excessively broad and lacks treatment implications.
This differential should instead include several conditions whose behavioral expression involves recurrent picking at skin, including delusional parasitosis, self-mutilatory conditions, tic disorders, and habit disorders. The mentioned conditions can overlap in their presentation and phenomenology, and clearly differentiating among them is sometimes difficult.
While it is sometimes difficult to determine the cause of the picking, if the patient indicates that it is driven by appearance concerns and is intended to make the skin look better, it is likely the result of BDD. For example, patients who pick in order to remove blemishes for the purpose of “smoothing out” or clearing their skin are candidates for a diagnosis of BDD, whereas those who pick to “cleanse” their skin may have obsessive - compulsive disorder.
These people constitute a challenging group of patients who are probably best treated with a combination of dermatologic treatment (to heal and minimize skin damage due to picking) and psychiatric treatment (to decrease the severe preoccupation and picking behavior).
Resources: Curing dermatillomania isn’t as difficult as you may think, too many people rely on lengthy and expensive therapy sessions or medications; Compulsive skin picking can be cured without leaving the house. If you’d like to know how to cure this disorder please keep readingDermatillomania Cure











