Picking Scabs

“Pick one scab and leave the others alone. Make the one your friend." As bizarre as these words may seem to some people, others will find a great deal of relief, camaraderie, even wisdom in them. They come from advice one sister gave to another when discussing their mutual compulsions to pick obsessively at the scabs that form on their bodies. 

Scab picking is a form of excoriation, just as picking at the skin is. When picking scabs, however, all scabs are a target, including those from trauma, accident, or resulting from earlier picking episodes. Sometimes picking scabs starts as pure coincidence. If the first behavior occurs when the person is under stress or vulnerable. The picking can have a soothing effect, and then it becomes a self-perpetuating behavior that both relieves anxiety and increases the anxiety because the constant picking is painful. However, this scenario is not the only way picking at scabs begins or continues because every person experiences it differently.

Although occasional scab picking may be harmless, when the severity increases to the point of repeat injury, it may be diagnosed as a body-focused repetitive behavior resulting in significant impairment.

How common is this? 

The exact prevalence of compulsive scab picking is unknown. However, surveys indicate that 90% of Americans pick scabs, and 20% - 35% eat them afterward. When considered as part of the general classification of skin picking disorders, the prevalence hovers from 1.4% - 6% depending upon the population surveyed. Many of those surveys do not differentiate between skin picking and scab picking since scabs are part of the skin. Therefore, despite the limited information, more people likely experience compulsive scab picking than originally thought.

Bad habit or disorder?

Scab picking is like the other body-focused repetitive behaviors in that in some people it is only an occasional bad habit, while in others, it becomes a life-impairing problem. There are also different manifestations of the behaviors. Some people pick at scabs intentionally and with focus. When they do this, they experience gratification, relief, pleasure, or other reaction that reinforces the behavior. Other people pick at scabs without conscious awareness, such as those who run their fingers over their skin and pick at anything that is not smooth.

Diagnostically, scab picking falls within the spectrum of skin picking disorders and is labeled as a specifier when it exists. Therefore, the diagnostic criteria for skin picking disorder, officially known as excoriation disorder, is used for scab picking. To meet criteria for a disorder, the behavior must meet the following criteria:

1. Much time is spent picking
2. Behavior results in repeated injury
3. Multiple failed attempts to stop the behavior 
4. Negatively affects social, occupational, and relational life

Complications

Co-morbid Disorders

Scab picking often occurs with other disorders.

• Trauma history
• Anxiety
• Obsessive-compulsive disorder
• Other body-focused repetitive behaviors

Physical Complications

Scab picking creates increased physical danger. After the skin barrier is broken and a wound forms, the scab is vital for healing. Below the scab, the body repairs skin and blood cells while killing infection with a heavy dose of white blood cells. Therefore, to pick off the scab destroys the protective barrier and opens the wound to infection. Furthermore, the fingers and fingernails, which are often used to pick off the scabs, contain high levels of bacteria. As soon as the scab is off, the bacteria from the fingers enter the wound.

• Ineffective wound healing
• Bleeding sores
• Increased risk of infection
• Increased pain, swelling, inflammation
• Scarring

Impact on Quality of Life

For people with compulsive scab picking either on its own or in conjunction with skin picking disorder, the behaviors interfere with the quality of life in several respects. 

Because so much of daily activity involves the hands, a person who picks at scabs needs to stop other activities to engage in the behavior. Further, attention shifts from whatever a person is doing to the action of packing at a scab. Sometimes this results in frequent starting and stopping of activities as well as disrupting others. 

The inability to control the behaviors often leads people to believe they are weak, which leads to embarrassment, guilt, and shame. Scab picking, in particular, can lead to added embarrassment if unhealed wounds 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.

When experiencing physical complications due to scab picking, often the outward appearance of infection or disease creates personal discomfort as well as unwanted questions or stigma from others. 

Scab picking and skin picking can interfere with work and school either by creating physical discomfort that interferes with functioning or by creating awkward social situations because of unhealed wounds.

What treatment options are available?

Treatment for scab picking follows the same methods as compulsive skin picking. Intervention type depends on the level of impairment, the complications, and the type of behavior. Therefore, a full assessment is a valuable tool for determining treatment options. A medical assessment is important to determine the effects of complications while a psychological or mental health assessment can narrow behavioral treatments to an effective method. 

Like skin picking disorder, there are multiple treatment options available, including behavioral, pharmacological, and mechanical. 

Behavioral

The goal of behavioral treatment is to unlearn habits and create healthier behaviors, which is why assessment is crucial. Treatment for unfocused scab picking will work on improving self-awareness and identifying triggers for the behavior. Once triggers and habits are identified, therapies such as habit reversal training can help a person develop other behaviors. Cognitive-behavioral therapy and acceptance and commitment therapy are other non-pharmacological treatments available through mental health providers. 

Pharmacological

There is not much available for pharmacological treatment of skin picking disorder. For those who pick scabs in response to anxiety, sometimes anti-anxiety medications can ease the conditions leading to the behaviors. For those who pick because the scab and the skin around feels strange, sometimes numbing agents can reduce those sensations.

Mechanical

Mechanical therapies create a barrier between the hands and the scab. One method is to keep wounds and scabs covered at all times, either with bandaging or clothing. Also, change bandages frequently to reduce the risk of infection from dirty bandages. Also, sometimes applying a wound cream such as Neosporin can reduce the pain or sensations associated with scabs and it can help wounds heal faster, thereby reducing the availability of scabs to pick.  

Scab picking can cause significant impairment, physically, emotionally, and socially. A comprehensive assessment can help determine a person's picking habits and triggers which informs the treatment options that may be most effective. Some people grow out of the behaviors, however, early treatment intervention makes recovery possible.