Lip Picking

Lip picking is another form of compulsive skin picking that targets the lips or inside of the mouth. Behaviors such as peeling, biting, or chewing the skin on lips or biting and chewing on the inside of the mouth and cheeks can result in significant damage. While everyone can find it hard to resist pulling or biting off a bit of peeled skin on their lips, people with disordered picking behaviors go beyond that. Driven by stress, boredom, or worry, they can cause so much harm to their lips that ordinary activities, such as eating or kissing, feel unpleasant or even painful.

How common is this? 

Lip picking is a body-focused repetitive behavior included in the larger category of skin picking disorder. There is limited data on lip picking and biting specifically, although just as prevalence data about compulsive skin picking is often underreported, it is likely that lip picking is as well. The lips can be one target amongst other skin picking targets such as the face, which makes quantification difficult.

However, a 2012 study evaluated the prevalence of cheek biting, which included lip picking, in a sample of 718 college students and found that of those with skin picking disorder, 46.7% reported targeting the lips and cheeks. In the control group, 31.9% of the sample reported cheek biting and lip picking. To qualify as a reportable behavior, the biting or picking of the lips and inside the cheeks needed to result in damage such as bleeding or scarring. This study shows that people with compulsive skin picking are more likely to engage in lip or cheek behaviors, but also that there are those in the general population who do it as well.

As with other body-focused repetitive behaviors, lip picking may be more common than researchers realize. This means that people who struggle with these behaviors are not alone.

What causes it?

Causation of body-focused repetitive behaviors is difficult and research does not have the answers. Like compulsive skin picking, lip picking is more likely to occur in families with a history of obsessive-compulsive disorder or body-focused repetitive behaviors. Lip picking is also associated with stress and anxiety, with clinical samples citing those as triggers. While stress and anxiety do not cause lip picking, lip picking behavior often increases in severity with increases in stress. Some people report picking without realizing it, which suggests the behavior may be related to attempts to regulate emotion. However, each person’s behaviors are different.

In other cases, lip picking results from physical conditions. For example, chapped lips can be a temptation to peel the skin and efforts to help the healing process by removing dead tissue can result in a cascade of compulsive behaviors. Cold sores or fever blisters may also start the process of picking. While those behaviors may start benign, sometimes they can turn into something worse.

Disordered lip picking behaviors often begin during childhood around puberty, suggesting that some aspect of the condition may be hormone-related.

Bad habit or disorder?

Determining whether lip picking and cheek biting is a bad habit or a disorder depends on the degree of damage and behavior patterns. Similar to other forms of compulsive skin picking, behaviors vary. They can occur outside of awareness as an automatic behavior, or with full awareness and intent. Either scope of behaviors can also be used as a way to manage strong feelings or tension.

Lip picking falls under the diagnostic category of compulsive skin picking, or excoriation disorder and identified as a qualifier. Bad habits differ from disorder in that disorders result in significant damage, and people tend to attempt quitting the behaviors many times without success.

According to diagnostics, lip picking becomes disordered when:

1. Behaviors cause significant injuries
2. Repeated efforts to stop do not work  
3. Engaging in the behaviors negatively affects multiple areas of life

Complications

Co-morbid Disorders

Lip picking and cheek biting tend to occur with other body-focused repetitive behaviors.

• Other compulsive skin picking behaviors
• Anxiety
• Depression
• Social anxiety
• Obsessive-compulsive disorder

Physical Complications

Lip picking and cheek biting result in multiple physical complications.

• Bleeding
• Inflammation, pain, redness
• Wound infections
• Lesions inside the cheeks that do not heal
• Increased risk of secondary infections
• Increased risk of cellulitis, abscesses that require hospitalization

Impact on Quality of Life

Lip picking results in multiple quality of life issues, including appearance and stigma. People make judgments of others based on appearance, and those who compulsively pick at their lips often have red, swollen, or injured lips, which leads to shame and embarrassment. Because of the effects on appearance, many people with lip picking problems isolate themselves from others to hide the effects. The tendency toward isolation often interferes with school or work as well as social activities and relationships.

Due to the injuries of the lips or cheeks, pain and inflammation can make regular activities such as eating and drinking very difficult. Relational touching such as hugging or kissing may also be difficult, if not impossible.

People with lip picking injuries may also experience negative reactions from employers, coworkers, customers, family, and friends because people tend to associate lip injuries with disease.

What treatment options are available?

Treatment of compulsive lip picking and cheek biting follows the same protocols as other skin picking disorders and body-focused repetitive behaviors. Before treatment initiation, however, a thorough medical and mental health assessment will help determine the most effective treatment interventions. The assessment process will also help identify triggers and other psychological issues that contribute to picking behaviors.

Following the assessment, health providers may suggest several treatment options, including behavioral, pharmacological, and mechanical. 

Behavioral

Behavioral treatments focus on increasing awareness of behaviors and learning a healthy alternative. Assessment will help determine whether behaviors are automatic or focused. Either pattern of behaviors requires training for improved self-awareness and trigger identifying. Self-awareness helps a person detach the behaviors from their identity. As awareness builds, therapies like habit reversal training and cognitive behavioral therapy help a person build new habits and coping skills.

An additional part of behavioral treatment is addressing other co-occurring mental health disorders that affect behaviors. Since behaviors tend to worsen with stress, anxiety, and depression, it is essential to work on managing those disorders as well.

Pharmacological

Currently, there are no approved medications for body-focused repetitive behaviors. At times, pharmacological treatment can help reduce the symptoms of stress, anxiety, and depression that contribute to behaviors. With the successful management of those symptoms, people often find it easier to manage picking behaviors.

There is one pharmacological treatment that showed some promise. N-acetyl cysteine (NAC) demonstrated limited effectiveness when tested with other body-focused repetitive behaviors. However, in the randomized, double-blind placebo-controlled trial, which means it was a thorough, well-constructive study, showed that NAC was no more effective than a placebo. Use caution and discretion when using pharmaceuticals since some of them can worsen picking behaviors.  

Mechanical

There are not many mechanical solutions for lip picking or cheek biting. However, if a person primarily uses the hands to pick at the lips, awareness wearables such as the Keen from HabitAware can increase awareness of behaviors. When the hands reach towards the mouth, for example, the Keen will vibrate and make the person aware of hand placement. Then, the person can choose from picking or engaging in a healthier activity.

Other times dental or oral appliances can make picking or biting less convenient. However, these are not well-researched and would require consultation from a dentist or orthodontist.

Compulsive lip picking and cheek biting, in its disordered form, causes significant impairment. However, with thorough assessment from a qualified professional and proper selection of treatment modalities, the behaviors can be managed. While some people grow out of the behaviors, others need more direct intervention. Recovery is possible.