Scalp Picking

Scalp picking is another subcategory of skin picking disorder where a person picks at the skin of the scalp and hairline. Behaviors can include persistent scratching, pulling, or picking that ends up causing skin damage and bald spots.

How common is this? 

Skin picking disorder affects 1-6% of the population, often beginning in early adolescence. Since scalp picking is a subcategory of compulsive skin picking, prevalence numbers are difficult to discern. Most research studies that assess for skin picking disorder do not differentiate by targeted area.

What causes it?

The cause for compulsive skin picking disorders remains unknown, yet research shows a genetic correlation. Body-focused repetitive behaviors tend to run in families, and they tend to begin in early adolescence, usually coinciding with the onset of puberty.

Other things correlate with skin picking, however. Those who target the scalp, often pick at perceived imperfections supported by the thought that picking at the imperfection will get rid of it. However, the picking tends to create wounds which scab over, thereby creating another imperfection at which to pick. Other times, a physical cause such as a skin disorder, creates discomfort or irritation that makes a person want to pick. Keep in mind that scalp picking differs from compulsive hair pulling, however, in that the target is the skin on the scalp, not the hair strands.

In other cases, picking at the scalp serves a purpose by either the need to feel pain or as a way to relieve pain. Although the tension release or the distraction of picking may address the pain in the short-term, the long-term effects cause even more distress.

Bad habit or disorder?

Compulsive scalp picking falls under the diagnostic category of compulsive skin picking (excoriation disorder) as a qualifier. Behaviors vary in presentation with some occurring with full awareness and intent while other times picking occurs when people are less aware. For example, automatic picking may occur when someone is bored or zoned out. Regardless of the behavioral pattern, determining the difference between a bad habit and a disorder relies on several criteria.

1. Picking results in repeated injury
2. Attempts to stop failed multiple times
3. Creates difficulties in other areas of life

Complications

Co-morbid Disorders

Scalp picking rarely occurs on its own and tends to co-occur with other mental health conditions such as:

• Depression
• Anxiety and stress
• Obsessive-compulsive disorder
• Body dysmorphic disorder
• Other body-focused repetitive behaviors

Physical Complications

Scalp picking results in several physical impairments:

• Open wounds and scab formation
• Inflammation, pain, redness
• Hair loss due to damaged hair follicles
• Increased risk of infections
• Permanent skin damage and scarring
• Permanent bald spots

Impact on Quality of Life

People with compulsive scalp picking experience primary and secondary quality of life impairments.

Picking at the scalp requires the hands, which means a person stops other activities to engage in it. Therefore, frequent disrupted activities may result in increased stress or anxiety related to completing tasks.

For those who pick automatically, there is a risk of engaging in the behaviors in front of others, which can cause embarrassment and social problems.

The inability to control the behaviors often leads people to believe they are weak, which leads to embarrassment, guilt, and shame. 

For those who experience physical complications of scalp picking such as open wounds, scabs, scars, and hair loss, the issues surrounding appearance creates personal discomfort as well as unwanted questions or stigma from others. 

Secondary quality of life impairment includes spending extra time or money on first aid, cosmetics, medical care, and hair replacement treatments to cover up the injuries related to scalp picking.

Scalp picking may also interfere with a person’s school, work, or social relationships due to adverse reactions from employers, coworkers, customers, friends, or family. 

How to Stop Scalp Picking?

Treatment for scalp picking is like other body-focused repetitive behaviors. A medical assessment by a dermatologist is essential to determine the best treatment options for damaged skin. A thorough mental health assessment will determine behavioral patterns and other psychological issues related to picking. Accurate assessment by qualified professionals ensures consideration for the most effective treatment methods.

Treatment options may include behavioral, pharmacological, and mechanical. 

Behavioral

The most effective treatment interventions, according to the research, include behavioral treatments that focus on increasing awareness of triggers and behavior patterns. As self-awareness improves, the person learns to make choices about behaviors. Also, addressing mental health triggers such as strong emotions, anxiety, or beliefs about imperfections can also relieve the compulsive urges to pick. Cognitive-behavioral therapies such as habit reversal therapy, acceptance and commitment therapy, and dialectical behavior therapy all show positive results for managing picking behaviors.

Pharmacological

The only pharmacological agent that shows some effectiveness for managing body-focused repetitive behaviors is N-acetyl cysteine (NAC). Even with some positive results, there are no randomized, double-blind, placebo-controlled trials that show any more effective than placebos. In other words, the highest quality research studies do not indicate that NAC is any better than placebo. Sometimes, however, medications are used to manage other mental health issues such as anxiety or depression, which results in reduced behaviors.

Mechanical

Mechanical therapies make picking more difficult and inconvenient by placing a barrier between the hands and the scalp. Sometimes, the presence of an obstacle is enough to make the person aware of the behavior to make it easier to choose a healthier behavior. Techniques such as wearing gloves or head coverings can help. Wearables that improve habit awareness such as the Keen from HabitAware, also increase awareness by alerting the wearer of hand position. Again, this enables the wearer to make a conscious choice about picking.

Scalp picking causes significant problems not only with the effects of picking at the skin but also emotionally and socially. Damage to the skin on the scalp can also result in hair loss or bald spots which may be permanent. A complete physical and mental health assessment by a qualified professional will not only determine the severity of the picking behaviors but will also help determine the most effective treatment options. Picking behaviors may or may not go away on their own, but with evidence-based intervention, recovery is possible.