New Insights on Skin Picking and Appearance-Related Concerns

Most of us have at some time probably had a bothersome skin blemish or pimple that we’ve picked, pinched, or squeezed. For most people, it’s a benign cosmetic behavior and quickly forgotten. For others, skin picking can become a repetitive behavior that causes emotional distress and injury to the skin. When that happens, the picking becomes problematic and may be a sign of skin picking disorder.

Skin picking, clinically known as Excoriation Disorder, is a body-focused repetitive behavior (BFRB) characterized by the repetitive picking of the skin causing injury to the skin. It is classified as an Obsessive Compulsive Related Disorder (OCRD) along with OCD, hair pulling (trichotillomania), hoarding, and body dysmorphic disorder. Skin picking and other BFRBs are not the same as OCD but share similar qualities including repetitive behaviors that reduce anxiety. Despite frequent attempts to reduce or stop picking, they are unable to do so, resulting in emotional distress and impaired interpersonal functioning, often related to the visible damage to their skin (open wounds, scarring, etc.)

We also know that skin picking is highly heterogenous. People experience skin picking in many different ways and with varying severity. Anecdotal and experiential evidence suggests that people living with skin picking disorder struggle with their appearance. They report that it affects their self-esteem and their ability to connect with others.  They sometimes go to great lengths to conceal their skin damage and sometimes even avoid social interactions altogether.  

Not everyone who has skin blemishes or imperfections (real or perceived) responds in the same way. Is it possible that there is something different in the relationship between appearance and skin picking disorder? 

Skin Picking and Appearance

Unlike some other disorders, skin picking leaves visible skin damage that can sometimes be quite severe. Past qualitative research has found that people with living with skin picking are quite sensitive to their appearance and how it may be perceived by others:  

• One of the over-riding themes often found is that of worrying about people looking at and judging them, creating distress over how their picking may be seen. As a result of that distress, people will often go to great lengths to hide their skin damage.

• Social interactions seemed to increase feelings of shame, embarrassment, and disgust.
• Participants reported feeling self-conscious about their damaged skin which led to social avoidance and attempts to conceal their skin.  Some worried that others would think they were infectious or lacked self-control.
• Some people reported feeling misunderstood leading to frustration and a reluctance to seek help. They also reported relief when they felt understood by others.

People with skin picking disorder seem to be especially sensitive to their appearance and the perceptions of others.

While there has been some research regarding appearance and body image related to skin picking and to dermatological conditions, there has been little research to explore the differences that may exist between these groups and as compared to individuals without skin issues. Is there something unique about their situation compared to people with a dermatological condition or those with no skin issues? Are there unique mental health concerns?

Looking Closer

A new study takes a closer look at the possible differences between people with a skin picking disorder, a dermatological disorder (like acne) and people without skin issues. They looked at four groups along parameters of appearance concerns and mental health outcomes: skin picking only (SP), dermatological condition only (DC), individuals with both SP and DC (SP/DC), and a skin-healthy (SH) control group.

Their findings suggest that individuals with SP were significantly more affected by appearance and mental health concerns than individuals with dermatological conditions only or skin-healthy controls. Except for appearance concerns, the two groups with SP were not significantly different from each other. Results suggested that both SP groups (SP and SP/DC) were more susceptible to body-image concerns. The SP/DC group showed the strongest impairments in almost all variables and higher scores for possible symptoms of body dysmorphic disorder. The study authors concluded that appearance concerns might possibly arise from or be aggravated by existing skin conditions in individuals with PSP.

Findings also suggest that SP alone seems to account for a significant impairment regarding appearance, including dysmorphic concerns and appearance-based rejection sensitivity. This result is in keeping with other research showing that the severity of skin picking is positively correlated with appearance variables such as impaired body image appearance concerns even when controlling for depressive symptoms. Interestingly, individuals in the DC group, while having concerns about appearance, did not seem to experience as much fear of rejection or significant impairment in their interpersonal relationships.

With regard to mental health, both the skin-healthy and DC groups were found to experience mild depressive symptoms. The SP groups were found to have more moderate symptoms of depression. These findings underscore the distressing nature of skin picking and the increased risk for other mental health issues.

So what do these findings mean for someone living with skin picking?

The Takeaway

Findings like these and other studies support the idea that skin picking goes beyond the act of picking. Skin picking is a complex disorder that has both behavioral and cognitive/emotional underpinnings. It is both dermatological and psychological in nature. Treatment may be less either/or and more of both/and.

Skin picking is commonly seen in dermatological settings as well as psychiatric settings. Individuals with a dermatological condition may struggle with appearance-related or mental health issues as well. Dermatological treatment with therapeutic support may be helpful for these individuals.

For people with psychodermatological conditions like skin picking disorder, a dermatologist is often their first stop. They too may need both dermatological care as well as therapeutic services. The emerging specialty of psychodermatology offers hope for specialized care for people with skin picking whether it’s primarily dermatological or psychiatric in nature.

There is much more to learn about skin picking and it’s complexities. Ongoing research brings hope for a better understanding of the disorder and more effective, individualized treatments.

References

1. Anderson, S., Clarke, V., & Thomas, Z. (2022). The problem with picking: Permittance, escape and shame in problematic skin picking. Psychology and Psychotherapy: Theory, Research and Practice, 96(1), 83-100. https://bpspsychub.onlinelibrary.wiley.com/doi/10.1111/papt.12427

2. Schmidt, J., Gallinat, C., & Martin, A. (2023). Appearance-related concerns in individuals with pathological skin picking—a comparison with individuals with dermatological conditions and skin-healthy controls. Frontiers in Medicine, 10. https://www.frontiersin.org/articles/10.3389/fmed.2023.1075743/full

3. Gallinat, C., Stürmlinger, L. L., Schaber, S., & Bauer, S. (2021). Pathological Skin Picking: Phenomenology and Associations with Emotions, Self-Esteem, Body Image, and Subjective Physical Well-Being. Frontiers in psychiatry, 12, 732717. https://pubmed.ncbi.nlm.nih.gov/34721107/