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Skin picking can be a troubling, visible mark of pandemic stress

Reports of skin picking have increased during the coronavirus pandemic, mental health experts and dermatologists say. It can be exacerbated by stress, anxiety and boredom.
Reports of skin picking have increased during the coronavirus pandemic, mental health experts and dermatologists say. It can be exacerbated by stress, anxiety and boredom. (iStock)
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For as long as I can remember, I’ve picked at the skin on my fingers. Growing up, my family did everything they could think of to curb the destructive behavior, which flared up whenever I was stressed or anxious. They made sure my nails were trimmed short, covered my fingers with bandages or silicone caps, and gently swatted at my hands or scolded me when they caught me in the act. But nothing worked.

Picking has become my go-to response to stress, and sometimes I don’t even realize I’m doing it until I’ve gone too far and parts of my fingers are raw or bleeding. During the coronavirus pandemic, which has exacted a psychological toll on many Americans, myself included, I haven’t been able to stop attacking my fingers.

Theresa Nguyen, a self-described “hardcore skin picker” and chief program officer at Mental Health America, can relate; “2020 was the first time I started picking my face, which was so alarming, because it was like the next level of stress,” she said. “I’m like, ‘Okay, I’m so stressed I’m now unable to stop picking at places that are very hard to hide.’ ”

Do wearable stress-relief gadgets work? I tried some to find out.

Much of the pandemic’s effect on skin picking and other body-focused repetitive behaviors (BFRBs), such as hair pulling, has been anecdotal. A July survey of a small sample of people who self-reported diagnoses of BFRBs suggested both skin-picking and hair-pulling problems increased during the pandemic, according to findings published in the peer-reviewed Journal of the American Academy of Dermatology. Meanwhile, some dermatologists and mental health experts say they’ve seen a rise in people reporting new or worsening behaviors.

Jon Grant, a professor of psychiatry at the University of Chicago who specializes in skin picking and hair pulling, said he’s seen “at least a 100 percent increase” in new patients in the past year. The TLC Foundation for Body-Focused Repetitive Behaviors reported that the number of people who received direct support through its services went from about 1,000 in past years to 10,000 in 2020.

“We do know that the anxiety will exacerbate it in some people. Other people, boredom exacerbates it,” Grant said. The pandemic created some unusual conditions: People spent more time isolated at home; may have overly worried about their health, finances and loved ones; and may have been less concerned about being seen by others. “All of those variables increased the picking behavior for many, many people,” Grant said.

Here’s what he and other experts say you need to know about skin picking and how to seek help.

Pulling your hair or picking at skin can be signs of serious disorders

It's not just a 'bad habit'

Everyone engages in occasional self-grooming behaviors, such as nibbling on a jagged fingernail or picking at a blemish or scab. But “the issue with skin-picking disorder is it is done at a level of frequency and intensity where people are actually causing harm to their body, and they feel unable to control the amount of the behavior,” Grant said. “It’s almost like the off switch doesn’t kick in the same way.”

The disorder, also known as excoriation disorder or dermatillomania, is characterized by recurrent picking that causes skin lesions and significant distress or impairment in day-to-day functioning, as well as unsuccessful attempts to stop, said Katharine Phillips, a psychiatrist at Weill Cornell Medicine and New York-Presbyterian Hospital. People will pick any areas of the body they can reach, most often targeting spots on their hands, feet, arms, legs, upper back and face.

Recent research estimates that at least 2 percent of Americans are living with skin-picking disorder, and that slightly more than 3 percent will be affected during their lifetime. These figures, however, probably underestimate the prevalence of cases, said Grant, who co-authored the paper. Psychiatrists and primary-care providers aren’t always well-educated on skin-picking disorder, he said, and mental health assessments rarely screen for it.

Many sufferers are also hesitant to bring up their struggles with skin picking, because it’s often labeled as a “bad habit,” Grant said. “Calling it a habit in the vernacular suggests that it is a simple little behavior that anybody should be able to stop, and that is absurd and such a horrible mischaracterization of this behavior.”

Phillips added: “People are not intending to harm themselves. There’s an impulse or drive to pick, and it’s hard to control.” Sometimes the person picking doesn’t even realize they’re doing it, she said.

There can be serious negative consequences

Untreated skin picking can have serious consequences on a person’s physical and mental health as well as their quality of life, experts said.

“As you scratch and pick the skin, you’re permanently injuring the skin,” said Adam Friedman, chair of the dermatology department at George Washington University. Once scars form, “the stress of that disfigurement perpetuates disease as well.”

Nguyen said she had multiple wounds from picking during 2020, including one on her face. She has received medical care to prevent serious infections.

Beyond concerns about physical health, skin scratching and picking “has a social ostracism associated with it,” which can cause significant disruptions in people’s daily lives, Friedman said.

For Nguyen and others who pick their skin, shame is a familiar feeling. “We are deeply aware of how disgusting we must look to other people,” she said.

Don't rely on 'DIY' care

People struggling with skin picking shouldn’t delay seeking professional care, said Ronda Farah, an assistant professor of dermatology at the University of Minnesota.

Friedman agreed. “This is not a DIY situation,” he said.

One reason is that “diagnoses of skin picking are very difficult,” Farah said. “We don’t normally just look at somebody. We usually have to rule out many things before we just call it skin picking.” She added that sometimes a biopsy is needed to determine whether trauma to the skin is caused by external or internal factors.

Another reason is that being correctly diagnosed by a mental health professional is important for getting the appropriate treatment, Phillips said.

Skin pickers should prioritize working with a provider who is knowledgeable about the disorder and its treatment options, Grant said. Otherwise, they risk being in therapy for months and thinking: “ ‘Wow, I’m not getting any better. It’s me. I’m defective. I’m untreatable,’ ” he said. “And it could be that the therapy is not appropriate.”

Treatment can help

According to Phillips, the “first-line treatment” is habit-reversal training, which is a behavioral approach that includes self-monitoring and awareness practices. You start by becoming more aware of when you pick and what your triggers are, then you develop behaviors, known as “competing responses,” that keep you from picking until you feel the urge subside, she said. Some examples include sitting on your hands, clenching your hands into fists or playing with fidget toys. “Basically doing something else with your hands,” she said.

Additionally, some people have benefited from emotion regulation training, which can help improve impulse control.

Experts also suggested trying to modify your environment to reduce your triggers — removing things you might use to pick your skin, for example — or covering areas you like to pick with specialized bandages, such as Hydro Seal Band-Aids or DuoDERM wound dressings.

No drugs have been approved by the Food and Drug Administration for the treatment of skin picking, but experts said certain medications, including common antidepressants, have been used with some success. There is also promise for an over-the-counter dietary supplement called N-acetylcysteine, which is an antioxidant. One small randomized clinical trial, which Grant was involved with, showed that participants who received the supplement had “significant reductions in skin-picking symptoms” compared with those in the placebo group.

“I would just be cautious about ever saying one size fits all,” Grant said. “It’s a very complex and heterogeneous behavior.”

Compassion is critical

Experts emphasized that instead of trying to solve the problem on their own, skin pickers and their loved ones should approach the situation with empathy.

Family and friends should “always want to be supportive rather than critical,” Phillips said. “It’s not helpful to tell them to just stop doing that.” Instead, Grant said, loved ones should try to be “a sounding board” for frustration or sadness that pickers may feel, then act as a resource to guide them toward help.

People who pick should also refrain from judging themselves, Nguyen said. “Sometimes my first step is having personal compassion,” she said. “Take a step back and take an accounting of how stressful life is and all the things that are on your table.

“We can feel really stressed out,” she added, “but we don’t often give ourselves credit for how much we’re carrying around.”