Captive of the mirror: ‘I pick at my face all day, every day’
Liberate patients by changing their skin-picking habits and treating their impulsive urges
Suicide risk. In a series of 123 patients with BDD, 33 (27%) excessively picked their skin and 10 of those who picked their skin (33%) had attempted suicide.5 In a case series of 31 patients with skin picking, 10% had attempted suicide.2 We know of several young women whose chief complaint was skin picking and who committed suicide.5
Gender. The gender ratio of patients with skin picking remains unclear. In two case series that totaled 65 patients, 87% to 92% of those with pathologic skin picking were female.2,7 In the series of patients with BDD, 58% of the 33 who compulsively picked their skin were female.5 On the other hand, most of 28 patients seen in a dermatology clinic for neurotic excoriations were male.9
Onset and chronicity. Pathologic skin picking may develop at any age, but it usually manifests in late adolescence or early adulthood, often after onset of a dermatologic illness such as acne2 or in response to itching.3 Although long-term studies have not been done, the disorder appears to often be chronic, with waxing and waning of picking intensity and frequency.1,2
Table 1
Skin picking: 3 steps to diagnosis and treatment
| Step 1: Assess reasons for skin picking Dermatologic or medical disorder?
Psychiatric disorder?
Impulse control disorder, not otherwise specified? |
| Step 2: Assess picking severity Treat comorbid mood or anxiety disorders Treat skin picking if:
|
| Step 3: Provide recommended treatment For adults Habit reversal therapy plus medication is usually necessary For children and adolescents Habit reversal therapy alone for mild to moderate symptoms Habit reversal therapy plus medication for severe symptoms |
Comorbid psychopathology. In clinical settings, common comorbid psychopathologies include mood disorders (in 48% to 68% of patients with skin picking), anxiety disorders (41% to 64%), and alcohol use disorders (39%).2
In one patient sample, 71% of skin pickers met criteria for at least one personality disorder (48% had obsessive-compulsive personality disorder, and 26% met criteria for borderline personality disorder).2
Table 2
Medications with evidence of benefit for skin picking*
| Medication | Dosage | Type of evidence |
|---|---|---|
| SSRIs | ||
| Citalopram | 40 mg/d | Case report (effective only with inositol augmentation)16 |
| Fluoxetine | 20 to 80 mg/d | Case reports5,14-15 and two double-blind studies23-24 |
| Fluvoxamine | 100 to 300 mg/d | Case report,8 open-label study,21 and double-blind trial22 |
| Sertraline | 50 to 200 mg/d | Open-label study9 |
| Other agents | ||
| Clomipramine | 50 mg/d | Case report3 |
| Doxepin | 30 mg/d | Case report1 |
| Naltrexone | 50 mg/d | Case report20 |
| Olanzapine | 2.5 to 7.5 mg/d | Case report17 |
| Pimozide | 4 mg/d | Case report18 |
| * Off-label uses; little scientific evidence supports using medications other than SSRIs for treating skin picking. Inform patients of the evidence for using any medication, risk of side effects including change in cardiac conduction (pimozide, clomipramine), seizure risk (pimozide, clomipramine), and tardive dyskinesia (pimozide), and potential interactions with other medications (all of the above). | ||
PRIMARY VS. SECONDARY DISORDER
Is skin picking an independent disorder or a symptom of other psychiatric disorders? Although skin picking is not included in DSM-IV and has no formal diagnostic criteria, some forms of this behavior may belong among the impulse control disorders.
Patients often report an urge to pick their skin in response to increasing tension,1,3 and picking results in transient relief or pleasure.1,2 This description mirrors that of other impulse control disorders, such as trichotillomania and kleptomania. In fact, one study found that trichotillomania and kleptomania were common comorbidities among patients with skin picking (23% and 16%, respectively).2 In 34 patients with psychogenic excoriation, only 7 (21%) appeared to have skin picking as a primary complaint, unaccounted for by another psychiatric disorder.7
Skin picking may also be a symptom of other psychiatric disorders. To determine whether another disorder is present, we ask patients why they pick their skin. Patients may be reluctant to reveal either the picking or the underlying disorder because of embarrassment and shame. The diagnosis can often be clarified by asking about the following conditions:
Body dysmorphic disorder. Nearly 30% of patients with BDD pick their skin to a pathologic extent.5,6 The purpose of picking in BDD is to remove or minimize a nonexistent or slight imperfection in appearance (such as scars, pimples, bumps).5,6
Obsessive-compulsive disorder. Patients with OCD may pick their skin in response to contamination obsessions.1 Picking is often repetitive and ritualistic, and—as with compulsions—the behavior may reduce tension.10
Genetic disorders. Skin picking may be a symptom of Prader-Willi syndrome, a genetic disorder characterized by muscular hypotonia, short stature, characteristic facial features, intellectual disabilities, hypogonadism, hyperphagia, and an increased obesity risk. In one study, 97% of patients with Prader-Willi syndrome engaged in skin picking.11
