Picky, picky: Itching not part of scratching disorder

Scratching posts are made for cats, but I think many humans would benefit from having one as well. Some people want to scratch out other people’s eyes (e.g. Nancy Grace–>Casey Anthony, gay people–>Michele Bachmann). Most of us scratch our heads at things like the government’s approach to the national deficit, the price of gasoline, and the future of the cast of Glee!

But what happens to people with a scratching and picking problem?

Pathologic skin picking (PSP) is a disorder in which a person deliberately damages the skin (and usually underlying tissue) by picking, scratching, rubbing, digging, and/or squeezing. Also known as dermatillomania or neurodermatitis, PSP involves a preoccupation with picking at the skin with fingernails, fingers, or teeth. Objects to pick at the skin are also used, such as tweezers, scissors, and pins. Ouch!

PSP is not due to an itchy medical condition such as eczema, psoriasis, or scabies. The person with PSP just can’t resist the impulse to pick/scratch. There is a kind of arousal or tension to pick, followed by a feeling satisfaction or relief while doing the harmful act. There may not be a feeling of regret afterwards, because often the person doesn’t have insight into the self-destructive behavior.

Picking episodes usually last 6-10 minutes, though the behavior can go for hours each day. Usually it happens in the evening, especially while looking in the mirror. Let’s face it: we all pick at pimples because we want to get rid of them before they grow to be the size of Mt. Vesuvius. But people with PSP will squeeze, pick, and scratch to make the molehill into the mountain– or into a crater by making it into an ulcer.

Others will mutilate their skin while watching TV, talking on the phone, reading, or lying in bed. Even the ability to function socially can be compromised due to the feeling of distress and need to “go at it.”

Up to five percent of Americans have PSP, and many hide their self-induced skin lesions with long clothing. Eight times more women than men have this disorder, and it occurs mostly in 15-45 year olds. Picking can be a characteristic of other psychiatric disorders like obsessive-compulsive disorder, impulse control disorder, depression, anxiety, bipolarity, eating disorders, drug and alcohol dependencies, and body dysmorphic disorder. Picking problems are often seen in those with trichotillomania (hair plucking) and onychophagia (nail biting).

Infections and ulcers can be serious complications of PSP. Scarring to disfigurement can occur and create great distress. I’ve seen people look like they ran naked though a briar patch because their entire body was scratched, bleeding, crusty, scabbed, and/or ulcerated. Topical or oral antibiotics are used for infections, although sometimes surgery is needed to drain abscesses or remove dead/infected deep tissue. In extreme cases, a person can lose part of the nose, ear, or even a toe from complications.

A psychologist and/or psychiatrist can help a person with PSP. Antidepressants (sertraline, citalopram, Cymbalta) are often used to help victims stop scratching. Cognitive and behavioral therapy can be effective to minimize and hopefully stop the behavior of skin picking.

Pick and scratch is not a lottery game. There are definitely no winners! Hopefully a cure will someday be found for this dermatologically disastrous disorder.
Dr. Hook cracks a joke or two, but he’s a respected physician with an interesting website, drjohnhong.com. Email him with your questions!