Picking Skin Disorder- What is Dermatillomania?

“My daughter was 11 when she first started wearing her hair loose and covering her ears, even while sleeping. I didn't notice anything unusual until our anniversary dinner a few months later, when I saw a large discoloration on her right earlobe. When I asked, she changed the subject. My husband suggested it might be her eczema flair-up. That night, I examined her discolored patch and was shocked to find it was a scratch—she had been skin-picking for months. I became worried and convinced her to see a skin specialist. Fortunately, we found a good doctor who asked the right questions and suspected a skin-picking disorder while diagnosing eczema. He guided my daughter to acknowledge the issue, not to feel ashamed, and not to underreport it. Now, at 18, after multiple ear piercings to stop her skin picking, she still picks during stressful periods. Despite this, she is aware of her condition and fights her inner demons by engaging in activities like piano, netball, and gym.”

                                                                                                            Neena, mother of an 18-year-old teen

Skin picking, also known as dermatillomania, is a condition in which a person picks or scratches their skin. This causes injury and scarring. Dermatillomania is the same as trichotillomania in that a person engages in the act as a coping mechanism, accompanied by anxiety around the idea of stopping. Both are compulsive disorders, making it difficult to stop.

The disorder can be both physically and mentally harmful and is often underreported because patients feel embarrassed. It is associated with psychological distress resulting from social isolation and concealment behaviors.

Skin specialists often see this as a chronic mental health condition called a Body-Focused Repetitive Behavior (BFRB), even though it originates from psychological factors. It involves a persistent, uncontrollable urge to pick, scratch, or gouge the skin, which can lead to noticeable damage, infections, and scars.

Psychologists helps us understand the key psychological features as lck of control ( Sufferers report an inability to stop despite wanting to, leading to deep frustration), addiction like natue (  The behavior is often likened to an addiction, where the immediate rewarding relief reinforces the habit, even when the person knows it will cause damage), dissociation (  Many experience dissociation during episodes, acting on automatic pilot and not realizing they are picking until they notice pain or bleeding) and body image disturbance. (Dermatillomania is linked to low

self-esteem and a negative body image, particularly for those who hide their skin damage). Also, the emotional cycle of picking involves: before: High tension, anxiety, or craving/impulse, during: A trance-like or meditative state is commonly reported, characterized by a loss of control and a temporary feeling of "switching off", after: The relief or satisfaction is often quickly followed by intense feelings of guilt, shame, embarrassment, and self-loathing.

Psychological Aspects of Dermatillomania:

Skin-picking episodes are often triggered by certain internal feelings or external situations, rather than just skin imperfections. 

• Negative Affect Regulation: Picking is often a way some people try to cope with difficult feelings like anxiety, stress, anger, or sadness. It's a common, though not always healthy, response to these tough emotions. 

• Boredom and Tension: Many people find themselves picking when they feel bored, stuck sitting still, or overwhelmed by feelings of tension or 'restlessness." 

• Sensory and Cognitive Factors: Many people want their skin to feel smooth and even, often paying close attention to perceived imperfections, scabs, or pimples.

Dermatological Aspects of Dermatillomania:

• Lesion Presentation: Dermatologists often observe lesions at various stages of healing, such as scabs, papules, ulcers, and nodules. These lesions are typically situated on the face, scalp, arms, and legs, which are readily accessible. 

• The "Vicious Cycle" and Chronic Nature: The patient engages in skin picking, frequently attempting to 'correct' a perceived imperfection. This behavior results in a wound that forms a scab, leading to additional distress and further instances of picking. 

•  Medical Complications: Severe cases may result in tissue damage that necessitates skin grafting, chronic infections requiring antibiotics, or potentially sepsis. 

Evidence-based Management Approach

A multidisciplinary approach is the most effective. Simply focusing on skin damage with creams or antibiotics won't ultimately stop compulsive behavior, so working together with other specialists can make a real difference. Starting with a visit to a primary care doctor, dermatologist, psychologist, or psychiatrist, the specialists will work in tandem as needed.

• Psychodermatology: Psychological stress can trigger the neuro-endocrine-immune network, directly impacting skin inflammation and barrier function. This involves recognizing the important connection between skin health and mental well-being. 

• Topical Treatment: Dermatologists often recommend using topical antibiotics, corticosteroids to reduce inflammation, and suitable dressings to support wound healing. 

• Referral: Specialists often find it helpful to refer patients for Cognitive Behavioral Therapy (CBT), especially Habit Reversal Training (HRT), which is widely regarded as the most effective way to help. Also, Acceptance and Commitment Therapy (ACT) helps clients accept the urge to pick without acting on it, based on personal values.

• Medication: Some cases are managed with Selective Serotonin Reuptake Inhibitors (SSRIs) or N-acetylcysteine (NAC) to reduce the urge to pick.

There are concurrent psychological conditions, like anxiety disorders (e.g., Generalized Anxiety Disorder), Depression, Obsessive-Compulsive Disorder (OCD), Trichotillomania (Hair-pulling disorder), and Body Dysmorphic Disorder (BDD).

Treatment is available for Dermatillomina. If you have the above symptoms or know someone who does, connect with your primary health care provider, dermatologist, or psychologist. Contact mylifenwellness for further understanding and support.