Evidence-Based Reviews

Captive of the mirror: ‘I pick at my face all day, every day’

Current Psychiatry. 2003 December;2(12):45-52

References

1. Arnold LM, Auchenbach MB, McElroy SL. Psychogenic excoriation: clinical features, proposed diagnostic criteria, epidemiology and approaches to treatment. CNS Drugs 2001;15:351-9.

2. Wilhelm S, Keuthen NJ, Deckersbach T, et al. Self-injurious skin picking: clinical characteristics and comorbidity. J Clin Psychiatry 1999;60:454-9.

3. Gupta MA, Gupta AK, Haberman HF. Neurotic excoriations: a review and some new perspectives. Compr Psychiatry 1986;27:381-6.

4. Keuthen NJ, Deckersbach T, Wilhelm S, et al. Repetitive skinpicking in a student population and comparison with a sample of self-injurious skin-pickers. Psychosomatics 2000;41:210-15.

5. Phillips KA, Taub SL. Skin picking as a symptom of body dysmorphic disorder. Psychopharmacol Bull 1995;31:279-88.

6. Phillips KA, Diaz S. Gender differences in body dysmorphic disorder. J Nerv Ment Dis 1997;185:570-7

7. Arnold LM, McElroy SL, Mutasim DF, et al. Characteristics of 34 adults with psychogenic excoriation. J Clin Psychiatry 1998;59:509-14.

8. O’Sullivan RL, Phillips KA, Keuthen NJ, Wilhelm S. Near fatal skin picking from delusional body dysmorphic disorder responsive to fluvoxamine. Psychosomatics 1999;40:79-81.

9. Kalivas J, Kalivas L, Gilman D, Hayden CT. Sertraline in the treatment of neurotic excoriations and related disorders [letter]. Arch Dermatol 1996;132:589-90.

10. Stein DJ, Hollander E. Dermatology and conditions related to obsessive-compulsive disorder. J Am Acad Dermatol 1992;26:237-42.

11. Dykens E, Shah B. Psychiatric disorders in Prader-Willi syndrome: epidemiology and management. CNS Drugs 2003;17:167-78.

12. Bishop ER. Monosymptomatic hypochondriacal syndromes in dermatology. J Am Acad Dermatol 1983;9:152-8.

13. Koblenzer CS. Dermatitis artefacta: clinical features and approaches to treatment. Am J Clin Dermatol 2000;1:47-55.

14. Stein DJ, Hutt CS, Spitz JL, Hollander E. Compulsive picking and obsessive-compulsive disorder. Psychosomatics 1993;34:177-80.

15. Stout RJ. Fluoxetine for the treatment of compulsive facial picking [letter]. Am J Psychiatry 1990;147:370.-

16. Seedat S, Stein DJ, Harvey BH. Inositol in the treatment of trichotillomania and compulsive skin picking [letter]. J Clin Psychiatry 2001;62:60-1.

17. Gupta MA, Gupta AK. Olanzapine is effective in the management of some self-induced dermatoses: three case reports. Cutis 2000;66:143-6.

18. Duke EE. Clinical experience with pimozide: emphasis on its use in postherpetic neuralgia. J Am Acad Dermatol 1983;8:845-50.

19. Harris BA, Sherertz EF, Flowers FP. Improvement of chronic neurotic excoriations with oral doxepin therapy. Int J Dermatol 1987;26:541-3.

20. Lienemann J, Walker FD. Reversal of self-abusive behavior with naltrexone [letter]. J Clin Psychopharmacol 1989;9:448-9.

21. Arnold LM, Mutasim DF, Dwight MM, et al. An open clinical trial of fluvoxamine treatment of psychogenic excoriation. J Clin Psychopharmacol 1999;19:15-18.

22. Hendrickx B, Van Moffaert M, Spiers R, Von Frenckell R. The treatment of psychocutaneous disorders: a new approach. Curr Ther Res Clin Exp 1991;49:111-19.

23. Simeon D, Stein DJ, Gross S, et al. A double-blind trial of fluoxetine in pathologic skin picking. J Clin Psychiatry 1997;58:341-7.

24. Bloch MR, Elliott M, Thompson H, Koran LM. Fluoxetine in pathologic skin-picking: open-label and double-blind results. Psychosomatics 2001;42:314-19.

25. Kent A, Drummond LM. Acne excoriee—a case report of treatment using habit-reversal. Clin Exp Dermatol 1989;14:163-4.

26. Rosenbaum MS, Ayllon T. The behavioral treatment of neurodermatitis through habit-reversal. Behav Res Ther 1981;19:313-18.

27. Twohig MP, Woods DW. Habit reversal as a treatment for chronic skin picking in typically developing adult male siblings. J App Behav Analysis 2001;34:217-20.

28. Deckersbach T, Wilhelm S, Keuthen NJ, et al. Cognitive-behavior therapy for self-injurious skin picking. Behav Modif 2002;26:361-77.

29. Fruensgaard K. Psychotherapy and neurotic excoriations. Int J Dermatol 1991;30:262-5.

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? atopic dermatitis scabies Prader-Willi syndrome Psychiatric disorder? body dysmorphic disorder obsessive-compulsive disorder delusional disorder dermatitis artefacta Impulse control disorder, not otherwise specified?
Step 2: Assess picking severity Treat comorbid mood or anxiety disorders Treat skin picking if: patient is preoccupied with picking picking causes distress or dysfunction picking is causing skin lesions/disfigurement
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

Step 1: Assess reasons for skin picking
Dermatologic or medical disorder?

atopic dermatitis
scabies
Prader-Willi syndrome

Psychiatric disorder?

body dysmorphic disorder
obsessive-compulsive disorder
delusional disorder
dermatitis artefacta

Impulse control disorder, not otherwise specified?

Step 2: Assess picking severity
Treat comorbid mood or anxiety disorders
Treat skin picking if:

patient is preoccupied with picking
picking causes distress or dysfunction
picking is causing skin lesions/disfigurement

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 reports^5,14-15 and two double-blind studies^23-24
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