What is Compulsive Skin Picking? 

You’ve always been the one with ragged cuticles. Any hangnail or scab or skin bump makes you want to mess with it, and before you know it, you’ve picked at it until it’s “better,” which can mean that it’s sore or bleeding. What is Compulsive Skin Picking? 

Compulsive skin picking, or excoriation, is a condition that happens in about 3 to 8% percent of the population—which makes it almost as common as generalized anxiety. But many don’t think about it as a serious mental health condition. And it can be. Here’s what to know about this condition, including when to reach out for professional help.

What is Skin Picking?

Lots of people might occasionally pop pimples, or pick at a hangnail during a long, boring work meeting. But excoriation, also known as dermatillomania, is a mental health issue where you compulsively pick at, squeeze or scratch areas of your skin, often causing physical damage that leads to feelings of shame. 

The most common target areas for skin picking are the head, scalp and face (including your lips), and your arms, especially around the fingers and nails, like your cuticles. 

But, truly, the focus of skin picking can be anywhere, says Nicholas Farrell, PhD, a licensed clinical therapist and Regional Clinical Director at NOCD. He specializes in the treatment of patients with obsessive-compulsive disorder (OCD) and excoriation, and notes that there is really a wide variety of triggers for this behavior.

When Does Skin Picking Become a Problem?

If you’re not familiar with OCD, it’s a mental health condition that can plague you with unwanted intrusive thoughts, images, urges, sensations, and/or feelings (or obsessions). Everyone has these passing feelings, but with OCD these intrusive thoughts are ego-dystonic—a fancy psychological term that means that your thoughts don’t align with your values, morals, or beliefs. You can’t dismiss these thoughts as being out of alignment with who you are, and instead, you take them very seriously.

These obsessions can cause extreme distress, causing you to perform mental or physical actions (compulsions) to try to relieve your discomfort. 

“No two people are the same, so some might pick in response to anxiety or stress because of its temporarily relieving effects. However, others may pick to fill a void. In other words, there’s a sense of under-stimulation. Skin picking fills a perceived need for gratification or stimulation of some sort in these cases,” says Dr. Farrell. 

He adds that this behavior usually starts young and is highly prevalent in kids: “We often find that the onset tends to be during either late childhood or early adolescence. So for parents, it’s important to look out for skin picking behavior, since kids at this age may not immediately recognize it as an issue themselves.”

Skin Picking Versus OCD

It can sometimes be challenging to figure out if you truly have an excoriation behavioral issue, or you’re just messing with a scab.

This is a subjective call that might require professional help to tease out, says Dr. Farrell, but like most mental health conditions, it’s about the degree to which the condition and behavior impacts your life. He suggests asking yourself two things:

1. Does this behavior take time away from things I’d rather be doing? 
2. Am I actually hurting myself as I do this? Skin picking sometimes comes with unintentional injury that can be severe and do significant damage resulting in scarring—to the point where medical intervention is necessary to bandage or heal wounds.

If those two things are true, it could be excoriation, rather than OCD.

“For folks who repetitively pick their skin, there is a strong compulsive quality to it, which can make it seem like it must be OCD,” says Dr. Farrell. “However, skin picking isn’t technically considered OCD, since the condition involves compulsions that are specifically done in response to distress, fears, or unwanted thoughts related to the obsessions you feel. It’s a nuanced line. And they can be related.” 

Making matters more difficult to diagnose, he says, is that in many cases skin picking can happen without you being fully aware of it. You may be getting ready in the morning in the bathroom and suddenly realize your cheek is bleeding. Point being that if you do it without knowing it, you may not realize it’s an issue that could benefit from professional help.

“And for other people, there can be a lot of embarrassment around skin picking,” says Dr. Farrell. “I’ve worked with people who have given up on career dreams and goals because the belief was, Oh, this is something I have. This is my cross to bear, and I don’t get to have the life I imagined I could.”

Is Skin-Picking Behavior Genetic?

Do you pick your skin because your mom picked hers? Is it something you learned by watching, or is it something you’re born worth? The answer is, experts don’t really know for sure. “Like many mental health conditions, excoriation disorder is often seen in families where there are already cases. But since there has never been a specific gene—or genes—linked to skin picking, it’s hard to say definitively that it’s inheritable,” says Dr. Farrell. “But what we know anecdotally about genetic vulnerability is that excoriation disorder tends to run in families, and that’s, of course, true for a lot of mental health conditions.”

What Are the Treatment Options for Skin Picking?

The good news is that skin picking is treatable with the right strategy. The gold standard treatment if you don’t have OCD is Habitual Reversal Training.

Habitual Reversal Training (HRT)

HRT is a type of treatment that includes a few steps: awareness training, competing response training, stimulus control, and social support. 

• Awareness Training

With this first step, says Dr Farrell, “We help clients become more cognizant of the circumstances or urges that tend to lead up to a skin picking episode. Because a lot of times what’s uncanny is people with this condition or a similar body-focused, repetitive behavioral condition—like hair pulling—is that it’s occurring almost beneath a level of conscious awareness. I’ll hear things like, ‘I didn’t realize what was happening until all of a sudden there was a pile of hair, or bits of skin on the bathroom counter, and it was almost as though I was in a trance-like state.’ That’s where awareness training comes in.”

• Competing Response Training

After you’re aware of your triggers, Dr. Farrell says that competing response training can further your progress. The goal here is simply to do something else with your hands.

“When HRT was first developed back in the 1970s, the prevailing thought was that a competing response had to physically incapacitate someone from doing a behavior. If it was skin picking, I might have to clasp my hands together, or better yet, I could sit with my hands underneath my buttocks. And if I’m doing that, I can’t pick my skin. But more contemporarily, we’ve learned from research that you don’t necessarily need to incapacitate that part of your body to have a positive treatment outcome. Whatever the competing response is, we want it to be something that makes it increasingly difficult for you to carry out the behavior.”

Dr. Farrell recommends things like knitting or using a fidget spinner—both great competitive behaviors and ways to keep your hands busy. And they’re helpful in achieving the ultimate goal: to break the connection between the trigger and the behavior of skin-picking.

“The whole reason we use competing response training,” he adds, “is to give you an opportunity to learn. Okay, I can feel that unpleasant sensation or that urge to want to pick at my skin, but I can ride it out. I can endure it, I don’t have to give into it. And then the feeling gradually fades and goes away.”

• Stimulus Control

When treating skin picking, your therapist may also help manage triggers by using a strategy called stimulus control. This works through awareness training by identifying the potential triggers that may be lurking in your environment. 

“You might recognize that, wow, a lot of my skin picking occurs when I’m in a particular bathroom in my house where I have a high-resolution mirror or very intense lighting,” says Dr. Farrell. “If that’s the case, then what can we do to modify that environment so it becomes less conducive to skin picking? Can we temporarily remove the mirror from that bathroom? Can we reduce the glare of the lighting? Can we remove a bulb from the light fixture?”

• Social Support

Like many behavioral health conditions, it takes a village to treat skin picking optimally. Social support is another helpful part of treatment. Adults can empower the loved ones around them to recognize the signs and gently intervene with a suggested competing response. 

And since skin picking often occurs in young kids, it’s essential that parents and guardians of affected kids become knowledgeable HRT coaches themselves.

“This is as straightforward as really being educated on the key components of HRT, so you can guide your child,” says Dr. Farrell. “Mom and dad could learn to notice the warning signs, and use a competing response strategy before the skin picking starts. It can make a huge change over time.”

Exposure and response prevention (ERP)

However, for cases where skin picking might actually be a sign of OCD, a type of therapy called ERP might be the better option. 

Here’s how it works: A trained therapist who specializes in OCD will take the time to understand your symptoms and create a custom ERP therapy plan specifically for you. Then, you’ll work together to rank your fears or triggers based on how stressful they seem. To begin with, your therapist may ask you to face a fear that brings on only a mild amount of distress. For example, you might be asked to think about something mildly upsetting without picking your fingers. The fear thoughts will likely come up, but instead of responding with a compulsion, you’ll learn to tolerate the discomfort. By making this conscious choice and seeing that nothing bad occurs, your brain eventually gets the message that there was nothing to fear in the first place.

As your therapy progresses, you’ll tackle triggers that elicit a bit more distress, to conquer bigger fears. With an ERP therapist guiding you, you’ll practice confronting your fears in your everyday life, too, instead of just the controlled setting of therapy. 

Most of the time something amazing happens as a result of this therapy: You won’t be riddled with distress from intrusive thoughts, images, feelings, sensations, and/or urges. Your need to engage in compulsions goes away. And you can live a life free of the shame and embarrassment that skin picking can cause.