Face Picking

Face picking is a subcategory of compulsive skin picking (excoriation disorder) where the person targets the face. Face picking is not a sign of poor hygiene, nor does indicate an acne problem. In many cases, the person targets a barely visible spot on the face, and the hyperfocus on that one spot leads a person to pick until the barely visible spot becomes a bleeding would. Picking at the face leads not only to physical skin damage but also to emotional and social difficulties.

How common is this? 

Face picking is considered part of the general classification of skin picking disorders with the prevalence estimated at 1.4% - 6% depending upon the population surveyed. Many of those estimates do not ask on which part of the body the picking behaviors target, but anecdotal evidence suggests face picking is very common.

Bad habit or disorder?

Picking at one’s face is not always a disorder. For example, many people pick at blemishes on the skin. Picking often begins to manage acne, eczema, psoriasis, or other skin conditions, yet other times it serves to make the person ugly or unworthy of attention. Regardless of the reasons someone gets started, when picking at the face takes up substantial time and results in repeated skin injuries, it is time to get help.

There are multiple types of picking behaviors ranging from intentional to unintentional. Those who pick intentionally usually seek gratification related to eliminating a perceived blemish or feel the urge to pick at anything that feels irregular on the face. People with automatic picking behaviors may do so while they are zoned out, bored, or concentrating heavily on something else.

As a subtype of compulsive skin picking (excoriation disorder), the diagnosis of face picking as a disordered behavior requires the following criteria:

1. Significant time is spent picking
2. Picking results in repeated injury
3. Multiple unsuccessful attempts to stop the behavior 
4. Quality of life adversely affected

Complications

Co-morbid Disorders

Face picking often occurs with other disorders.

• Anxiety or social anxiety
• Trauma history
• Depression
• Body dysmorphic disorder
• Obsessive-compulsive disorder
• Other body-focused repetitive behaviors

Physical Complications

Face picking results in physical damage to the skin. Once the skin barrier breaks, wounds form, and a scab develops. Scab development is vital for healing because below the scab, the body repairs skin and blood cells while killing infection with a heavy dose of white blood cells. However, scabs on the face often become targets for additional picking. Picking off the scab destroys the protective barrier and opens the wound to infection. Multiple layers of wounding increases the risk of scar formation, which is difficult to correct. Furthermore, the fingers and fingernails, which are often used to pick at the face, contain high levels of bacteria. When people use tools such as unsterilized tweezers, pinchers, or sharp objects, these can also cause infection. If a person picks a scab off, the bacteria from the fingers and tools enter the wound.

• Damage to multiple layers of skin
• Ineffective wound healing
• Bleeding sores
• Increased risk of infection
• Increased pain, swelling, inflammation
• Scarring

Impact on Quality of Life

People with compulsive face picking not only experience the physical consequences but emotional and social consequences.

People who pick at their face often have low self-esteem, accompanied by shame and guilt. The effects of their behaviors are visible to others, which leads to increased judgment or questions. They understand that their behaviors are not good for them but feel helpless to stop. Furthermore, because they understand people may judge them by appearance, they feel even more self-conscious about appearance. People make assumptions about those who look different, and our cultural aspiration of beauty at all costs puts additional pressure of people with compulsive face picking to hide the results of their behaviors. Therefore, people who compulsively pick at their face often spend considerable amounts of time and money trying to hide the damage.

Furthermore, the inability to control the behaviors often leads people to believe they are weak, which leads to embarrassment, guilt, and shame. Unhealed wounds on the face inspire unwanted attention. If wounds continually get infected, a fair amount of time can be spent attending medical appointments for follow-up wound care. If infection sets in, hospitalization may be required to manage the condition.

Face picking and its aftermath often cause impairments at school or work. Not only do wounds result in physical discomfort, but they also create awkward situations. Often, people who compulsively pick at their face choose isolation to avoid social judgment.

What treatment options are available?

Face picking treatment is the same as treatment for other body-focused repetitive behaviors. The level of impairment, complications, type of behavior, and co-occurring disorders all impact treatment. Therefore, before choosing an intervention, a thorough assessment by a qualified professional is essential.

Multiple treatment options include behavioral, pharmacological, and mechanical interventions. 

Behavioral

Behavioral treatments involve unlearning behaviors and creating healthier behaviors. An assessment helps improve self-awareness to identify triggers and patterns. Once these are identified, interventions such as acceptance and commitment therapy, dialectical behavioral therapy, and habit reversal therapy help create new behaviors.

Therapy also needs to address other mental health conditions that may affect picking. Often anxiety, depression, trauma, or maladaptive beliefs about appearance correlate with picking behaviors. Therefore, addressing these mental health issues is essential.  

Pharmacological

There are no pharmacological therapies indicated for skin picking disorder. However, for those with co-occurring mental health issues, medications can help manage those and make it easier to make behavioral changes.

Skin conditions also need proper evaluation. For people who begin picking due to acne, eczema, psoriasis, or physical sensations, medications can ease flare-ups and reduce the temptation to pick.

Mechanical

Sometimes creating a physical barrier between the hands and the face can reduce the frequency of picking episodes. One method is to wear gloves or keep the hands busy with fidget toys or other tasks. Dermatological treatment such as pain-relieving ointments that speed up healing to reduce blemishes.

Since face picking involves the hands, wearable habit devices such as the Keen by HabitAware can raise awareness and warn the wearer when the hands come near the face. Then, the person can make an informed choice about picking.

Disordered face picking causes physical, emotional, and social impairments, including judgment from others, which often results in social isolation. A comprehensive assessment should evaluate potential physical as well as mental health triggers, which will inform choices for comprehensive treatment. There are multiple effective treatment modalities, which means recovery is possible.