Skinpick Guide

.
com
The complete guide to Excoriation Disorder

(Compulsive Skin Picking - CSP)
By Skinpick.com
© skinpick.com
ISBN 978-1-105-33167-1
Last update: December 2017
Third Edition
No part of this publication may be reproduced, stored in or introduced into a retrieval

system, or transmitted, in any form or by any means (electronic, mechanical, photocopying,
recording or otherwise) without prior written permission of the publisher. Requests for
permission should be directed to [email protected].
TABLE OF CONTENTS
GENERAL INFORMATION ......................................................................................... 3

What is Compulsive Skin Picking (CSP)? ................................................................... 3
Symptoms ................................................................................................................... 4
Who Develops CSP .................................................................................................... 6
Descriptions of Picking Episodes ............................................................................ 8
Body Areas Affected .................................................................................................... 10
Face .......................................................................................................................... 10
Scalp ......................................................................................................................... 11
Lips and Cheeks ...................................................................................................... 13
Arms, Legs, Chest, and Back ................................................................................. 14
Nose.......................................................................................................................... 15
Cuticles and Nails ................................................................................................... 16
Causes of Compulsive Skin Picking .......................................................................... 18
Psychological ........................................................................................................... 18
Neurological ............................................................................................................ 19
Medical ..................................................................................................................... 20
Childhood Environment ......................................................................................... 21
Heredity ................................................................................................................... 22
Compulsive Skin Picking Triggers ............................................................................ 23
UNDERSTANDING COMPULSIVE BEHAVIORS ................................................. 26
Psychodermatology ..................................................................................................... 27
CSP & Obsessive-Compulsive Behavior ................................................................... 27
CSP & Impulse Control Disorder............................................................................... 28
CSP & Body Dysmorphic Disorder ........................................................................... 29
CSP & Addiction ......................................................................................................... 30
CSP & Self-Harm ........................................................................................................ 31
TREATMENT OPTIONS............................................................................................. 32
Will Power Does Not Work ........................................................................................ 32
Healing Mind and Spirit ............................................................................................. 33
Cognitive Therapy ................................................................................................... 34
Substitution Therapy ............................................................................................... 35
Behavioral Therapy ................................................................................................. 37
Existential Therapy ................................................................................................. 38
Hypnosis .................................................................................................................. 39
Habit Reversal ......................................................................................................... 40
Group Therapy......................................................................................................... 41
Healing the Body......................................................................................................... 42
Dermatology ............................................................................................................ 42
Neurology ................................................................................................................ 44
Choosing the Best Therapist ...................................................................................... 45
Psychiatrist ............................................................................................................... 46
Psychotherapist ....................................................................................................... 46
Psychodermatologist ............................................................................................... 47
Coping Strategies ........................................................................................................ 48
Self Acceptance ........................................................................................................ 48
Relationships ........................................................................................................... 49
Social Disclosures .................................................................................................... 50
Therapeutic Disclosures ......................................................................................... 51
RECOGNIZING CSP IN OTHERS ............................................................................ 53
CSP in Your Children .................................................................................................. 53
CSP in Others .............................................................................................................. 55
Recognizing CSP ..................................................................................................... 55
Discussing CSP ....................................................................................................... 56
APPENDIX: TOOLS AND PROGRAMS .................................................................... 58
Chapter
1
GENERAL INFORMATION
What is Compulsive Skin Picking (CSP)?

We've all done it. Everybody has. You lean into the mirror in the morning as
you're brushing your teeth, preparing for another busy day, and there it is - a
tiny, pink, fresh pimple you've never seen before.
The urge to pick at it is almost irresistible. Most of us would poke and prod a
bit, maybe even give it a gentle squeeze and then go on about the day's business
as if nothing out of the ordinary happened. And, really, nothing out of the
ordinary did happen.
Some of us, however, would not go on about the day's business as if nothing
out of the ordinary happened. Instead, we'd stop everything and poke, prod,
pick, and squeeze as if our lives depended on it. We would be entirely unable
to stop ourselves. We would no more be able to allow a tiny, pink, fresh
pimple to remain on our faces, unabused, than we could jump to the moon and
back.
That little pimple would draw us in as if spellbound. It would capture our

every thought, stir our emotions, and maybe even change the course of our
day. We would tease and torture it until that tiny little pink spot became a big,
gaping, bloody crater that causes both pain and embarrassment.
Sometimes those little blemishes get the better of us to the extent we skip class,
call in sick from work, or reschedule the day's appointments because we've
abused our faces so badly we don't want to be seen in public. We hide at home
behind closed doors instead.
And we don't just hide idly behind those closed doors. Oh, no. We are quite
likely to devote the better part of the day to poking and prodding some more.
After all, if there's one little pimple trying to make its way into the world, there
are likely to be more to follow. We'll hang around in front of the mirror all
Copyright © 2017 SkinPick.com 3

day, intently engaged in a search and destroy mission. And, by golly, if we can't
find exactly what we're looking for, we'll just pick on anything that tempts us.
It's that spellbinding, irresistible, uncontrollable urge to pick, poke, and prod to
the point of pain and disfigurement that is the impulse control disorder known
as excoriation disorder, compulsive skin picking, or CSP. Doctors call it
Dermatillomania but they often don't call it anything at all. That's because
most of us quite simply don't discuss it with our doctors. After all, we go to
the doctor because we are sick or broken, not because we have a nasty habit.
But CSP is not a nasty habit. It's a very confusing and complex psychological
syndrome that demands attention. It demands the attention of the picker as
well as his or her family, friends, and physician. In many cases, the sufferer
knows the picking must stop and may even desperately wish he or she had the
will power to quite simply stop picking. It just seems impossible to bring that
knowledge, that desire, to fruition.
CSP is not pretty and the results of it certainly don't look very healthy, either.
But that's really not the worst of it. The worst part of CSP is that it is an
outward, visible, sign of something very sad and traumatic happening inside,
out of sight and often very well hidden, even from the picker him- or herself.
It's this inner turmoil that fuels the compulsion to pick. It's the inner turmoil
where the real danger lurks.
It's almost impossible for a CSP sufferer to identify and heal alone, without the
help of supportive friends and family members. Some CSP sufferers need
medication and other therapies, too.
Left untreated, CSP often leads to scarring and emotional pain. In extreme
cases, it can even lead to more adverse outcomes.
Symptoms
A brief, concise description of the symptoms of CSP is virtually impossible.

The disorder comes in many variations. Dermatillomania, meaning the
uncontrollable picking of the skin, is only one medical term used to describe
the disorder. Sufferers experience the disorder to different degrees, with
different triggers, and different coping mechanisms.

One of the most common triggers for picking is acne vulgaris, or common
acne. Almost everybody gets a pimple or two during adolescence but someone
experiencing inner turmoil and conflict may attach undue physical or emotional
significance to those pimples, focusing too much attention on them and
beginning a regimen of picking, hiding, and searching for more that can spiral
out of control and remain a problem for many years.
Acne vulgaris is not a problem so much as a rite of passage. There is a strong

likelihood that the condition will resolve itself, with no lasting evidence, once
hormone levels have balanced themselves naturally once again and the person
has matured emotionally.
Some people, however, find that the common pimple is a gateway into a life-
long compulsion to inflict harm to ourselves. We do so without thought,
almost as if hypnotized by the blemishes, and we don't stop until there is very
real physical damage done. And in too many cases, we don't stop because we
quite simply can't stop.
We obsess over our complexions. We buy mirrors that are lighted and
magnified so we can see even the tiniest spots at the moment of their birth.
We schedule our lives around time at the mirror, picking, and time to hide the
damage in order to face the world. Many of us leave home in the morning
anxious to get home in the evening so we can pick some more.
Pimples are not the only targets of CSP sufferers. Pickers are a crafty lot.
Ingrown hairs, nicks and other minor wounds to the skin, fever blisters or cold
sores, and scabs can be the source of release for the compulsion to pick.
For obvious reason, the parts of the body that bear witness to the compulsion
are those easiest to reach - the face, head, neck, chest, shoulders, arms and legs.
These are also the most difficult to hide, especially the face and neck.
Adjacent disorders to CSP are apparent as Onychophagia (nail and cuticle

biting or picking) and Trichotillomania (hair pulling).
As with so many variations of CSP, excessive nail and cuticle biting is a self-
perpetuating cycle, breaking which is very difficult. In this CSP related
disorder, the sufferer will bite the nails so short they bleed and form scabs as
they heal. The scabs and any hard or jagged skin around the nails, including the
cuticles, then become fair game for picking, which, of course, forms more
tempting scabs and damaged skin around the nail.

Everyone stops to scratch their head from time to time. And we lose some
hair every day. But when the scratching becomes so intense that bald spots are
created, there is an underlying problem that probably has little to do with the
hair. Excessive pulling and twirling of the hair is also a CSP related symptom –
called trichotillomania - and both these activities can and do lead to obvious
bald spots, too.
It isn't just the hair on the scalp that is a target. Some people pull the hairs
from their eyelashes and brows until they are gone entirely. Others pull on
pubic hair and still others target the hairs on their arms and legs.
One very puzzling aspect of CSP is the events that induce to the picking.
During times of stress, most people experience weakened resolve. For
someone with CSP, this may be when the urge to pick is escalated.
We may be anxious about a date or job interview, wanting to look our very best
for either occasion. Yet we simply cannot refrain from picking and causing
unsightly wounds where they will be most noticed. The damage done by the
picking escalates the event-related anxiety, which just makes us want to pick
more, or harder, or deeper.
Other people can handle the stress-provoking events with no problem but pick
when they are most relaxed, such as reading or watching television. In fact,
these CSP patients aren't even aware of the picking, biting, or pulling until a
companion points it out, or until they feel pain.
Whether the picking is provoked by stress or relaxation, a trusted companion is

invaluable in achieving the internal peace needed to reach a point of acceptance
so the healing process can begin.
Who Develops CSP
It's estimated that in the United States (US) roughly 17 million people age 18 or
older suffer from some form of acne. Not everyone seeks medical treatment
for acne, however, instead resorting to over-the-counter remedies and other
self-medicating treatments.
Of those who do seek medical intervention, it is estimated that about 2% of

them are considered CSP patients. Most people with CSP are female. In fact,

CSP is diagnosed in women eight times more often than in men.
People of all ages have been diagnosed with the disorder but most people start
picking during their teenage years, when dramatic hormonal changes trigger
acne, tender emotions, and often-conflicting thoughts about the adult body
emerging from that of the child.
There is a higher ratio of CSP patients in college than in the population at large.
It is believed that the confluence of reaching sexual maturity, moving away
from home, and the stress of college life all work together to exacerbate any
minor picking urges and underlying psychological or traumatic issues that lead
to the behavioral expression of anxiety disorders in general. As many as 4% of
college students suffer from CSP.
Many people develop the disorder during their teen years but continue the
behaviors for decades. A recent survey revealed that 79% of people with CSP
are between the ages of 15 and 50. As much as 84% of them had been picking
for at least several years.
CSP has a tendency to run in families. Whether this is genetic, learned

behavior, or the collective experience of similar traumas is not clearly
understood at this time. There are many personal accounts, however, of one
family member acknowledging his or her CSP behaviors to a family member
only to have the relative confess to similar behaviors.
Some drugs affect the health of the skin. Taking them on a regular basis may
cause outbreaks of acne or make the skin seem to itch and tingle, aggravating
any tendencies to pick and prod at the skin. Many such drugs are prescription
medications but methamphetamine and opium derivatives, such as heroin and
codeine, produce similar effects on the skin. Abrupt withdrawal from both
prescription and recreational drugs can also trigger outbreaks as well as a state
of nervous tension caused by absence of the drug.
Because CSP is often overlooked or undervalued as a real and true

psychological condition in and of itself, it is often underreported during
medical examinations. Even when reported, it is likely to be considered an
aggravated form of acne and not something that requires more thorough
treatment measures.

Descriptions of Picking Episodes
The compulsion to pick at one's body to the point of pain and disfigurement is
a very private one. Some pickers claim they'd find it easier to admit to
alcoholism than to CSP.
Due to the very intimate nature of the condition, there are few documented
reports of picking episodes except in anecdotal form. One of the few well-
documented cases, however, is both highly revealing and highly publicized.
Most people remember the shockingly grisly murders of Nicole Brown

Simpson and Ronald Goldman in Brentwood, California, during the summer of
1994. Mrs. Simpson's ex-husband, the one-time football hero and actor, OJ
Simpson, was accused in both criminal and civil courts for the murders.
Transcripts of Simpson's depositions revealed that his former wife had a

problem with picking at her skin during times of stress. Indeed, looking back
at close-up photos of her now, it's easy to see beyond her natural beauty to the
bumps and scars on her face that could only be partially concealed by
cosmetics.
Simpson is on record as saying that every time he and his wife would have a
fight, she'd end up in the bathroom picking at her pimples for hours. That she
did it almost every night. When asked if he considered this routine to be out of
the ordinary, he attributed it to just a girl thing.
We know now that it was so very much more than that. Mrs. Simpson had
been the victim of long-term and repeated abuse at the hands of her husband.
He tormented her with physical and verbal abuse that included threats of death.
While the revelation of Mrs. Simpson's CSP behaviors only serves to deepen
the poignancy surrounding her short and troubled life, it came as a relief to
many CSP sufferers who felt doomed to a life of suffering alone and helpless.
Until that time, it was almost impossible to define or even describe the
uncontrollable urge to act on these overwhelming compulsions.
Once it was revealed that someone as rich, famous, and remarkably beautiful as
Nicole Brown Simpson lived with the same fears and doubts felt by so many
CSP sufferers, conversation became easier. Now we knew there had been
someone else out there who understood us. Perhaps, with even more open and

honest conversation, we could find other kindred spirits in whom we could
find acceptance and solace.
Perhaps the best source of first-person accounts can be gleaned from chat
rooms and forums on internet sites that are devoted to CSP. Many of the
revelations here are familiar to those of us who have CSP. Others are quite
shocking, even to those of us who consider ourselves such long-time survivors
that nothing surprises us.
In one very telling account, a girl confides to her sister, only to have her sister
advising her focusing on just one spot and making that a friend. Leave the
others to heal.
Another declares a picking episode as a success when the contents of a blemish

can be squeezed out in one fell swoop.
Many testimonials describe how easy it is to avoid picking in public where

others might see but find it inescapable behavior within the privacy of their
own homes.
There are many confessions of covering first one, and then all, mirrors in the
home in order avoid picking, as if not seeing the spot or examining the face will
make the urge to pick go away. Even this failed to satisfy the craving of one
lady who wrote that she then discovered the highly reflective nature of compact
discs, which enabled her to continue picking in spite of the covered mirrors.
One woman claims to prefer taking the stairs, where there are fewer people and
everyone is moving quickly in different directions, rather than the elevator,
where she'd be still and in confinement long enough for others to notice the
results of her picking.
Sometimes fingernails aren't tool enough to get the job done effectively.
Instead, safety pins, needles, and other sharp objects are used to get deeper,
where the fingernails can't go.
One truly insidious aspect of CSP is that it comes in many guises, offering
enough ways or reasons to pick that almost anyone with the urge can find an
opportunity. One writer likens pores to dominoes - there is no just one.
Instead one just leads to another and another and another.

Body Areas Affected
The skin is the largest organ in the human body. It is also the very most visible
organ. The skin provides a great deal of insight into the health of the inner
body and the emotional state of a person.
The skin is an organ of defense. It defends us from outside environmental

elements that would be detrimental to our health if not for the protective
barrier provided by the skin.
The skin is an organ of protection. It protects our internal organs - muscles,

bloodstream, bones, everything - from harmful outside forces and is vital to
maintaining proper body temperature.
The skin is representative of our identity. Just one look at a person's skin and it
is fairly easy to trace ancestry back many thousands of years. The skin
identifies our age, with the youngest skin being smooth and soft and older skin
being less resilient but more revealing.
The skin is a fascinating gateway from our inner life to our outer life and these
two worlds can often seem so juxtaposed that it's difficult to think they are
separated by a barrier as thin as the skin.
The skin communicates things between our inner and outer worlds that we are
sometimes unable to put into words. The conflict between these two worlds,
these two selves, is one reason the skin is the target of the emotional turmoil
associated with CSP disorders.
We often use our skin to "say" things we cannot or to reveal things we haven't
yet discovered, even about ourselves. This is one reason why the compulsion
to pick at the skin can become so overwhelming and uncontrollable. We must
communicate but have no more effective means of expression.
Many people afflicted by the CSP disorder target one specific part of the body,
such as the face or scalp. Most pickers are more opportunistic and will pick
just about anywhere they can reach even though there's likely to be a zone of
greatest concentration.
Face

The face is by far the most popular area to demonstrate CSP behaviors.
Surveys show that 54% of people with CSP acknowledge picking at their faces
in one manner or another.
Since acne is often cited as the trigger that led to the onset of the condition, it
stands to reason that the face sees the most action. The biology of facial skin
leaves it most prone to acne outbreaks and we are most likely to put our efforts
where they are the most effective.
Whether this is a tragic coincidence or a telling cry for help, our faces are the
part of our bodies that we can hide the least. Cosmetics help cover the
evidence of picking but even the heaviest make-up doesn't always hide the
damage done. Picking at the face may be a matter of convenience, too, since
almost everyone can physically reach his or her face.
Our faces are very important to communications, too. Some researchers of

body language claim our actual words convey very little effective
communication while our bodies are the real messengers. Posture, tone of
voice, hand gestures, and many other elements of communication are involved
with relaying a message from one person to the next but it's facial expression
that matters most.
Perhaps we have an underlying understanding of the significance our faces play

in interpersonal relationships and we subconsciously choose to abuse this part
of our bodies the most when we are caught up in the self-perpetuating cycle of
CSP behaviors.
Scalp
According to a recent study, 36% of people with CSP said they pick at their
scalp. The reasons for targeting this part of the body to release the anxieties
associated with the disorder are likely to be as varied as the unique individuals
who participated in the study.
Perhaps it’s the assumed hidden nature of the scalp that leads people to act out
their compulsions here. After all, the scalp is hidden under a mass of hair in
most cases. Men, of course, receive less coverage since they often cut their hair
short and some experience normal male-pattern baldness in the later years of
their lives. But then again, men are less prone to develop the habit of picking

at their scalps in an obsessive-compulsive way.
No matter how thick and luxuriant the hair, however, enough picking and even
the healthiest hair thins out. Sometimes, too, the picking is so focused and
intense that sores develop on the scalp, making for a much more unsightly, and
unhealthy, condition than mere thin spots.
In many cases, the picker herself won’t acknowledge the condition but her
hairdresser is usually aware of the situation. After all, hairdressers get a better
view of our heads than we can. Sometimes our scalp picking presents
problems to the hairdresser that puts him or her in an uncomfortable situation
that calls for making a decision that is likely to be unpleasant, perhaps even
unprofitable, to the hairdresser but the reputable ones will choose the health of
their client over the few dollars a hair salon appointment will bring.
In one such case, a woman came to a new hairdresser to cut, color, and perm
her hair. The hairdresser worked from a small resort town that had quiet
winters but a busy summer tourist season. The woman said she wanted a new
look to enjoy during her summer vacation away from the city.
As the hairdresser shampooed the new client’s hair, she became aware of some
large black crusty spots dotted throughout the woman’s head. They were
obviously the sign of injury and were undoubtedly painful. She knew that,
regardless of the source of the sores, the harsh chemical treatments the client
had asked for would be extremely painful and might even cause more harm.
She discussed her discovery with the client and tried to persuade her to choose
a new hairstyle that could be obtained without the chemical dyes and curling
agents the client’s original request involved.
The client became insulted by the hairdresser’s concerns and suggestions. She
refused all further treatment and left the salon, without paying for her
shampoo.
Since the resort town was small and all the locals known to each other, the
tourists were easy to spot. The hairdresser soon encountered the woman,
sporting her new summer hairstyle, fresh color and curls included.
The hairdresser was saddened by both the poor woman who refused to accept
the fact that she felt the need to endure what must have been pretty intense
chemically induced pain, all for looks, and saddened, too, that a colleague had

been willing to operate under questionable ethical standards and cater to this
client’s self-destructive wishes.
Lips and Cheeks
Unless we’re actively shopping for or applying lipstick, most people take the
lips for granted. After all, they’re rather small and there’s very little we can do
about them. They are, of course, highly valued when we eat, speak, and
especially when kissing a loved one. We wouldn’t enjoy these activities nearly
as much as we do without healthy lips.
Lips, however, are pretty vulnerable body organs. They have no ability to
produce melanin, which gives us a nice tanned look after a day in the sun.
Melanin is the body’s defense against the damaging rays from the sun and
tanning is actually a protective reaction that protects us from harm.
Lips contain no oil glands, either. They cannot produce the protective layer of
oil that keeps the body’s moisture within, where it’s needed. Most of us have
become painfully aware of the lack of moisture in the lips after a day in the sun,
the cold, or the wind.
When exposure to the elements leaves us with a case of dry, chapped lips, most
people apply moisturizing balms and drink plenty of water to restore moisture
from within.
Someone with a predisposition to pick may not be quite so patient. They may
pick at the dry, rough edges until their peeling lips become painfully sore. Of
course, the sore spots give new reason to pick and the cycle begins.
Outside elements are not the only cause for damage to the sensitive lips. Cold
sore, fever blisters, and any injuries to the lip area can be enough to trigger the
urge to pick uncontrollably. Once the compulsive picking begins in earnest,
the lips often stay sore, thereby giving rise to something to pick at.
Some people are able to leave their lips alone but develop a tendency to chew
on the insides of their cheeks. They may find themselves unaware of the
constant gripping of the cheeks between the teeth and the damage that can be
inflicted by doing so.
One young lady discovered she was doing this when her mother admonished

her several times to stop pursing her lips so. The girl never pursed her lips so
she took her mother’s words as typical conversation from a domineering
mother to whose standards the girl would never live up.
After a few times of hearing it, though, it dawned on her that each time her
mother complained of her pursing her lips, she was actually clenching the
insides of her checks between her teeth, although she had never before been
aware of the behavior.
The unconscious clenching of the teeth, whether delicate cheek tissue is

between them or not, is a sign of chronic but unexpressed stress. The
discovery of this rather hidden exhibit of obsessive-compulsive behaviors may
signal the need to discover the source of the underlying stress, which provokes
the behavior in the first place.
Arms, Legs, Chest, and Back
Most people can easily reach their arms, legs, and chest. Sometimes a little
more maneuvering is required to reach all areas of the back but the shoulder
area is often reachable. And often picked obsessively.
Perhaps it is the very accessibility of these parts of the body that makes them
such common targets for obsessive-compulsive skin picking behaviors. 36% of
people with CSP pick the skin on their arms and 29% pick the skin on their
legs.
Each person who suffers from CSP is different and their disorder will be
manifested in different areas for different reasons, as different as the
individuals are themselves. But many of the people who pick these particular
areas do it because it’s reachable but also because it’s pretty easy to hide these
parts under clothing, thereby hiding away the secret.
Hormones do indeed play a role in developing the CSP disorder in the first
place. It’s when our hormones are going through major shifts that the picking,
in general, begins for so many of us.
And those hormones, as we all know, often play havoc with out complexions,
causing acne outbreaks with intensity we’ve never before known. Those
hormonal surges cause acne outbreaks on the shoulders, chest, and upper arms
for many people. Acne is not limited to the face.

Acne isn’t the only reason a person might develop CSP. The story of two
teenage girls illustrates the point.
The two girls were at the age when wearing makeup, plucking their eyebrows,
and shaving their legs became important. It was the same time boys became
important, too.
Sitting around one hot summer day, wearing shorts and discussing the shaving
mishaps they’d suffered as they were learning to maneuver their fathers’
shaving razors, they began to question why they plucked their eyebrows but not
the hair on their legs. Plucking doesn’t cut and cause bleeding the way razors
do.
They got tweezers and began to explore the idea. One girl played around for
the day but the other girl grew obsessive about plucking the hairs on her legs.
She continued to use the razor but she supplemented with the tweezers, too.
Soon her plucking accelerated to gouging when ingrown hairs and other very
normal imperfections appeared on her legs. Gouging led to sores which led to
scabs which led to picking which led to more sores and on and on until an ugly
cycle had developed.
Her legs were often so spotted with sores she’d wear long pants during the
hottest days of the summer when everyone else was enjoying short pants and
skirts. If anyone ever questioned her about all the sores on her legs, she’d
attribute them to poison ivy or a close encounter with a cactus, something that
could happen to anybody.
The tweezers plucking continued until she was grown and the hosiery that
became a part of her professional wardrobe aggravated the condition so she
had to abandon the behavior.
Nose
We’ve all heard it a thousand times – don’t pick your nose in public. It’s really
rude. We’ve probably said it ourselves more times than we can count, too.
But sometimes an itchy nose needs a little discreet attention, no matter where
we happen to be. Most people have acquired the techniques to relieve the

distress without too much public offense or to graciously excuse ourselves in
order to find a private moment of self-care.
Some people, however, just can’t help themselves. They seem to always be
picking at or digging in their noses. There doesn’t even need to be a real
irritant, the kind that would send most people to the nearest secluded mirror.
When excessive nose picking develops into a CSP-related disorder, there

needn’t be a visible reason to pick one’s nose. The very act of the picking is
what brings the relief these people are seeking.
Some people are quite aware of their nose picking. They can be very actively
engaged in the behavior, examining closely anything they find, maybe even
playing with it before disposing of it, whatever it happens to be. Some people
even eat what they pick.
Others pick their noses without being aware of the action. Their thoughts may
be immersed in a movie, a good book, or perhaps they are focused intently on
solving a problem, doing some work, or anything, really, that requires some
focus on something other than themselves.
It doesn’t make any difference whether or not the nose picking is a consciously
done activity or one done without active awareness, excessive nose picking can
be a sign of a deeper problem and, as with all other forms of picking, too much
of it can lead to injury which leads to something to pick. And once again, the
cycle repeats.
Cuticles and Nails
No matter how diligent we are about protecting them, our poor busy hands
have a rough life. They’re often our favorite tools. We use them for all kinds
of things – waving hello, talking, touching, scratching an itch, petting the dog,
opening any number of containers. The list is endless. Injury is inevitable.
Our hands, especially the ends of them, our fingertips and nails, often become
injured over the course of a typical day. The injuries are usually not severe and
almost none of them require medical attention. Usually the worst thing that
happens is that we develop a tender spot that has to be favored a day or two.
Someone with a tendency toward obsessive-compulsive behaviors, however,

may do more than favor the little cuts, nicks, and dings that the rest of us can
take in stride. This person will, instead, pick at the wound, making it slow to
heal.
Of course, the slower it is to heal, the more there is to pick. Hangnails can be
especially tempting. A ragged spot along the cuticle will drive some people to
distraction. They will pick, maybe even chew, on the spot until the hangnail is
no more.
But often the hangnail that is no more is replaced by a bigger injury, one caused
by the picking and chewing. This, of course, means there’s more work to do
and the self-perpetuating cycle begins.
And we’ve all chipped a nail during the normal course of a day, too. A ragged
nail can make most people stop just about everything to tend to it. After all,
nails in such disrepair seem to catch on everything in reach, snag our clothing,
scratch our skin, and continue to become more and more distracting until the
damage has been repaired and the nail is smooth, and more functional, once
again.
Some people rely on their teeth to fix these minor repairs and almost
everybody has used their teeth to fix the problem when no better tools are
available. This isn’t always the best fix for the problem but it will often do the
job until a better solution is available.
Some people don’t seem to know when to stop and will continue chewing or
picking at their nails long after the ragged part has been removed or smoothed
over. They will chew until there is no free nail left and the nail bed is left
bleeding.
And once the nail bed is left bleeding, sores and scabs will develop as a part of
the body’s natural repair system. If we let it.
Someone with a CSP disorder manifested in cuticle and nail chewing or picking
will pick at anything they can feel. Pain and bleeding are not a problem. They
may even be a relief, in some truly severe cases of the disorder.
Just like so many other behaviors involved with the disorder, some people
chew and pick their nails and cuticles without seeming to be aware of their
actions while others do it when their minds are occupied elsewhere.

Causes of Compulsive Skin Picking
Compulsive skin picking is a very complex disorder. It affects different people

in different ways and it is triggered, or caused, by a number of different stimuli
as well.
Psychological
It’s possible that a very stressful episode in an otherwise healthy person’s life
can be the trigger that turns an innocent behavior, such as picking at a pimple
the morning before the prom, into a lingering disorder that requires
professional intervention. There could be any number of psychological reasons
why the ill-timed pimple became the catalyst.
Prom night, and its equivalents, can be thought of as a rite of passage, a turning
point that marks the passage from childhood into young adulthood. Many
people avidly look forward to the event as the beginning of freedom but a
person with apprehensions of the future may look with dread to the event and
everything it symbolizes.
This can be especially true when comfort with one’s own sexuality is involved.
The fear of being unattractive to the opposite sex can be as problematic as the
fear of being found attractive. Issues of sexuality can seem especially
overwhelming when there is a history of sexual indignities or improprieties.
Dress-up events such as prom night are very competitive, too. Not everyone
cares to compete with others, especially when the competition involves
something we have very little control over, such as our looks. Every girl wants
to be the belle of the ball and it’s often difficult to remember that beauty is in
the eye of the beholder. It’s impossible to produce a definitive candidate to
bear the title “fairest of them all.”
Even though we know this to be true, we nevertheless feel the opportunity to

judge and be judged that surrounds such events. Finding that pimple can bring
blessed relief albeit in a somewhat self-defeating way.
For example, we can convince ourselves that the pimple itself is stopping us
from needing to look our very best. We may have the feeling of being off the
hook, so to speak. Now we can relax and not worry so much because, no

matter how we apply our make-up, style our hair, or coordinate our outfit, the
pimple will be the first thing everyone notices anyway. We can relax, knowing
the pressure’s off us personally because the pimple has marred our beauty,
whether or not we feel truly beautiful about ourselves.
Once we relax and enjoy the prom without worrying too much about not being
the prettiest girl in the ballroom, thanks to that nasty blemish we spent the day
picking at, we may find that we’re resorting to the picking every time a stress-
provoking event comes into our lives. The picking becomes the scapegoat
upon which we place the responsibility of our imperfections, our humanness.
Neurological
In some cases, it’s not so much the psychology as it is the neurology behind the
compulsion to pick at our skin. Self-doubt can be overcome with training but
neurological damage presents a different situation altogether.
There is any number of neurological events that might lead to a compulsion to

pick at our skin. In fact, the incessant picking may be one of the first
symptoms of a more sinister underlying condition that requires immediate
medical attention.
Many people who are diagnosed as suffering from any of the disorders
associated with the spectrum of autism are found to have an overwhelming
urge to pick at their skin. Picking is also associated with attention deficit
hyperactivity disorders (ADHD), which is becoming more common in
children.
The brain is perhaps the least understood organ of the human body and the
way our body, including our thoughts and behaviors, responds to and from the
signals of the brain are the subject of intense studies on many fronts. The
brain is both powerful and delicate. A seemingly small imbalance in chemical
or electrical activities in the brain can lead to serious repercussions that
reverberate throughout our lives.
Prolonged exposure to stress, head injury, and hormone imbalances can all
generate chaos in our autonomic nervous systems, giving rise to some very
startling behaviors as a result, including the compulsion to pick at our skin even
past the point of self harm.

Medical
Neurological disorders can generate symptoms associated with compulsive skin

picking but there are other medical issues that can do the same.
Chemical imbalances caused by improper diet will eventually affect the skin and
may first appear as dry, itchy skin that feels better when scratched.
Unfortunately, if the chemical imbalance isn’t corrected, the urge to scratch is
likely to linger. Scratching can be sweet relief under most circumstances but
when it’s caused by something other than a typical temporary stimulus, it can
be maddening.
When excessive scratching damages the skin, the condition may escalate to
include picking at the sore spots the scratching causes. When the urge to
scratch is left untreated, the desire to pick at the sore skin can escalate to the
point where the cycle of compulsive skin picking takes over.
Certain drugs are known to cause the urge to scratch. In many cases, too, a
person can complete an entire course of pharmaceutical treatment with no
adverse effects but experience the extreme urge to scratch and pick at the skin
during the withdrawal phase of treatment.
Opiates and their derivatives are especially notorious for causing skin
sensations that lead to picking. Codeine is one such opiate derivative that can
produce skin-related reactions to such severe extent that many people avoid it
as if it were a severe allergy.
Street drugs as well as pharmaceuticals can cause the same problems, especially
when they are from the same base ingredient, such as codeine and heroin.
Users of heroin almost always have permanent scars on their arms and legs,
some of which came from injecting the drugs but even those who use it in a
different format experience the feeling of something crawling in and on their
skin and pick uncontrollably trying to make the feeling stop.
Chronic skin conditions, such as eczema and psoriasis, can make controlling
compulsive skin picking seem like a never-ending battle against one’s own skin.
These medical conditions leave the skin feeling dry, often scaly and crusty. The
urge to scratch and pick can seem like good medical treatment until the long-
term, cyclical nature of the compulsion is examined.

Once these dermatological disorders have led to permanent damage to the skin,
it can be very difficult to refrain from inflicting further damage. It almost
seems as if there’s no real reason to even try to have healthy skin. Like fighting
a losing battle so what’s the use in fighting it, anyway.
People with these issues of dermatology must remain diligent about the health
of their skin. Constant self-examination and scrutiny of every blemish is
required. Keeping such a close and mindful eye on one’s imperfections can
sometimes cloud the difference between healthy grooming and destructive
behaviors.
It is important to remember that the very real dermatological conditions are a

medical condition and not a curse. No further form of punishment, especially
the self-inflicted kind, is needed.
Childhood Environment
The psychological trauma of growing up in a home run by a domineering or

overly critical parent can trigger the spectrum of disorders associated with
compulsive skin picking.
A parent who is a perfectionist may instill feelings of insecurity on their very

normal but perfectly fine child. Not understanding why he or she seems to
never live up to parental standards, the child may begin picking at every minor
blemish or imperfection within reach just to affirm the feelings of inadequacy
faced when living in the shadow of a perfect parent.
Displays of affection, such as cuddling, hugs, and endearing words, are

important for developing a healthy self-image during childhood.
Unfortunately, not every parent offers these loving gestures as often or as
lavishly as every child needs them. An overly rigid or critical parent is more
likely to damage the burgeoning self-image of the child instead of toughening it
up, which is frequently the excuse cited for such unloving parental behaviors.
Unfortunately, the need to be overly critical, aloof, perfectionistic, and even

bullying are parental traits passed on from one generation to the next. It’s
often easy to judge an irrational parent as being unfair or cruel but the case is
very likely to be that the parent was raised in the same manner and endured the
same emotional hardships they’re now inflicting upon their own children.

These parents don’t mean to intentionally cause harm but they often don’t
know a better way to relate to their children.
In some truly heartbreaking situations, violence and sexual abuse may be

inflicted upon a child in the home environment. The pain from these
experiences can be so extreme the child will resort to compulsive behaviors as a
matter of survival.
Some people identified as compulsive skin pickers will say they do so as a way
to control the pain of an emotional unstable family environment. They know
pain comes from outside, the other family members, and they have no way to
predict or control that. But they can control some of the pain by self-
mutilating behaviors associated with compulsive skin picking. The power to
start or stop the pain, depending upon how the child treats him- or herself, is
seen as a sad measure of control over his or her own inevitable pain.
There is another side to compulsive skin picking as a means of taking control

of one’s own pain. In these cases, the child is emotionally crippled or so
inhibited she is unable to express her frustrations and pain. It remains locked
up inside although growing in intensity with every insult, blow, or indignity.
People diagnosed with CSP under these circumstances often describe the
picking as a means of relief from the pain and pressure built up inside, almost
in the way a volcano will release a periodic plume of smoke or ash between
full-blown eruptions.
Heredity
The nurture-versus-nature debate permeates the community of doctors and

scientists studying human behavior in all its peculiar and amusing forms.
Sometimes the dividing line between the two influences is so small it can be
better described as blurred, at best.
Children often mimic their parents. After all, we have no better teacher for our
children than ourselves.
There is no doubt that compulsive skin picking runs in families. Sometimes

one family member does it and everyone knows he or she does. It’s no real
secret. It’s more likely thought of as just a bad habit or a quirk associated with
a specific family member.

In these families, it might even be considered a private source of amusement
among family members that the daughter picks her face the same way her
mother does. Or her sister, her aunt, or her brother.
Other times, the compulsion is played out in private and kept hidden from
other family members. When and if the picker confesses the compulsion to
another family member, it’s not terribly unusual to get a similar confession in
return.
Whether the familial connection is one initiated by genetic predisposition to the

compulsion or learned habit remains open to debate. The study of genetics is
still in the pioneering stages and it seems that with every mystery solved, others
arise.
It is true that we learn from our parents and they learned from theirs. It stands
to reason that when a child experiences a traumatized childhood at the hands
of a parent who is unaffectionate, cold, demanding, and perhaps even
physically or sexually abusive, this is also the way the child will come to parent
his or her own children a generation later.
If a harsh childhood environment generated compulsive behaviors such as skin

picking in a child, it’s fairly easy to expect that child to grow up and have
children that develop the same compulsive behaviors, too. Whether it’s a result
of genetics or of family environment is almost impossible to determine unless
an underlying medical condition can be documented.
Compulsive Skin Picking Triggers

Everyone will experience compulsive skin picking disorders in a unique way.
No two people will be exactly the same in the way they exhibit the compulsion
and they will differ in the reasons why they slip into these behaviors in the first
place.
There are, however, a few generalized triggers that most compulsive skin
pickers can identify with.
We live in an ever-stressful world. As we grow up and mature, life takes on

stress in different forms in different stages of life. We learn to cope with these
new stressors the best we can as we are presented with them but sometimes the

stress seems endless. Sometimes we feel as if we have little, or no, control over
the stress in our lives at all.
And it’s little wonder stress overwhelms us sometimes. We live in an age of

technological marvels that are often touted as a means to making life easier
when the truth is that they usually make life faster, louder, more crowded, more
expensive, and more frenzied in general.
Sometimes it seems as if the stress generated by simple, everyday living is

increasing at a much faster pace than we can evolve the mechanisms with
which to cope in the face of the never-ending onslaught of stressing factors.
Many compulsive skin pickers describe stress as the most irresistible triggers
they face in trying to control their self-defeating behaviors. And they will often
say they understand that their failure to refrain from the picking behaviors
during times of stress is its own stress-related trigger.
Boredom is often described as a really difficult trigger to tame, too. Boredom

often leads to thoughts of hopelessness, helplessness, frustration, and
depression. It’s very difficult to maintain a healthy self-image, and the
affirming lifestyle to go with it, when chronic boredom brings feelings of
despair, gloom, and doom.
Anxiety is another commonly identified trigger for people suffering from

compulsive skin picking disorders. It seems little wonder that the two are
identified together since they both tend to be self-repeating situations.
With anxiety, the more one worries about something, the more one can find
something to worry about. With compulsive skin picking, the more one picks
and damages the skin, the more one can find to pick.
And then, of course, the more one damages the skin, the more one worries
about others finding out or worries about the damage the picking causes.
Anxiety and compulsive skin picking seem to enjoy a very symbiotic, although
very self-destructive, association.
In many cases, the combination of anxiety and compulsive skin picking escalate
to the point of paranoia. The desire to hide the evidence of the skin damage is
so great, the anxiety that is provoked becomes so powerful, that paranoia takes
over and life becomes truly out of control.

After all, the secrets that must remain hidden the most are the ones most
difficult to hide. Compulsive skin picking, and all other forms of self-
mutilation, present no exceptions.
When paranoia influences our every effort to hide the compulsion to pick, the
compulsion to pick can be impossible to resist.
These particular triggers are common in the lives of most compulsive skin
pickers but they do not by any means present all reasons all people indulge in
the behaviors. Some people may never be affected by some, or even all, of
them but will more likely experience a combination of one or more of them,
perhaps in conjunction with outside influences not mentioned here. Again,
every person develops the compulsion for the disorder due to his or her own
unique physical or mental circumstances and each one will respond to different
triggers.
To better understand your specific symptoms, causes and triggers, consider this
online program: skinpick.com/online-therapy-program

Chapter
2
UNDERSTANDING COMPULSIVE
BEHAVIORS
Compulsive behaviors represent a truly broad scope of behaviors that are done
to relieve stress, disguise stress, and produce emotional relief from many
sources. We all develop our own coping skills over a lifetime and most of us
go through life dealing with stress in a way that may leave us exhausted, cranky,
and perhaps suffering from the pain of a headache but we seldom suffer lasting
damage from our coping skills.
Compulsive disorders are a bit different. These behaviors are much more
impulsive than effective and the pain of a stress-induced headache is minor in
comparison to the lasting effects of a compulsive disorder.
Some of the better-known compulsive behaviors include excessive washing of

the hands and repeated checking for locked doors.
The compulsion to wash ones hands excessively throughout the day is often
started with good reason but when the washing becomes ritualistic and
disruptive to the flow of a day’s activities, there is a problem behind the need
for extreme cleanliness that needs to be addressed.
The same applies to someone who must check every door repeatedly each
night before going to bed. It’s a wise idea to make sure one’s home is secure
before retiring for the night but when the need to check the locks again and
again leads to loss of sleep, there is more at play than a desire for security.
Good grooming and care of our skin is vital to a healthy life. Without
awareness of the changes our bodies undergo each day, we wouldn’t be able to
spot threatening symptoms that may signal impending illness. But when we
spend hours each day diligently examining every inch of skin, picking at every
imperfection we find along the way, this ritualistic behavior becomes a
problem, too.

The behavior itself is often a sign of an underlying emotional or physical
condition that warrants medical attention. Impulsive picking at the skin should
never be considered merely an unsightly habit or a sign of poor hygiene.
Psychodermatology
In recent years, the medical specialties dermatology and psychology have
teamed up to address the needs of a growing number of patients who seek
medical advice from one or the other but who get little, if any, long-term relief
of symptoms.
Some practitioners in each of these medical specialties have recognized that

treating disorders such as compulsive skin picking is both psychological and
dermatological. Without tackling the problem from both fronts, relief is only
transient at best.
In fact, some estimates state that as high as 30% to 60% of all patients seeking
medical treatment for skin conditions have emotional issues that must be
addressed in order to effectively treat the skin. Not every dermatologist or
psychologist acknowledges, or even recognizes, a connection but a growing
number of them do.
Compulsive skin picking is related to anxiety disorder. Oftentimes, an

untreated anxiety disorder will lead to chronic depression, which is a true and
very real psychological condition. When chronic depression goes untreated, it
can turn into acute, or clinical, depression, which can become dangerous and
debilitating. Most people who attempt suicide suffer from depression.
The following pages describe a few psychological conditions closely associated

with compulsive skin picking. If the descriptions sound familiar but your
doctor won’t take your concerns seriously, it is probably in your best interest to
consult another, more receptive, physician if at all possible.
CSP & Obsessive-Compulsive Behavior
Obsessive-compulsive behaviors are those that a person feels compelled to

perform to an excessive, perhaps destructive, degree even when the person

knows the behavior will bring little relief or comfort. This type of behavior is
classified as falling within the spectrum of obsessive-compulsive disorder
(OCD), which is a diagnosis that covers many ritualistic behaviors, including
compulsive skin picking.
When skin picking reaches the compulsive stage, the patient cannot stop the
picking even when he or she knows the desired outcome of the action is
impossible. To deny or delay the picking only leads to obsessive thinking about
the offending blemish or imperfection and all other thoughts and healthy
activities become abandoned or delayed in order to address the compulsion to
pick.
Many a compulsive skin picker thinks nothing of devoting hours each day to
thorough examination of all parts of the target zone. Responsibilities become
neglected, family and friends forgotten, until the picker has satisfied,
temporarily, the compulsion to pick.
Some compulsive skin pickers establish schedules that are followed with
precision. They build their entire day around the schedule that allows for the
picking.
Others aren’t so regimented. They may become distracted during the course of
the day by the discovery of a new imperfection and stop everything until they
are satisfied with the job, usually a destructive one.
One compulsive skin picker describes the situation like dominoes lined up and
standing on end. Knock one over and, one by one, they all fall in succession.
Finding one blemish that requires immediate, compulsive, attention means
reviewing older wounds and searching diligently for more that might have gone
as-yet undiscovered.
CSP & Impulse Control Disorder

In impulse control disorders, the main symptom is the tendency to act on
impulse even though the action in question is known to be detrimental to the
health or well being of the patient.
One of the more common impulse control disorders is Kleptomania, which

induces some to steal an object that isn’t needed at all. Most kleptomaniacs
steal for the thrill of the activity and the risk of getting caught. In many cases,

the person stealing has more than enough money on hand to purchase the
stolen items but chooses the thrill instead, even though satisfying the thrill
leads to criminal activity.
Other forms of impulse control disorder are pyromania, or starting fires for the
excitement generated; pathological gambling; and intermittent explosive
disorder, which is the clinical term for hotheaded behaviors.
Although skin picking and hair pulling don’t fall under the umbrella of impulse
control disorders, they share similar characteristics.
When acting out these impulsive behaviors, insignificant short-term gain is

achieved at the risk of much larger loss that usually comes with very long-term
consequences.
Impulse control disorders often begin between the ages of 7 and 15, which
coincides rather closely with the time many people begin compulsive skin
picking behaviors.
CSP & Body Dysmorphic Disorder
Ask anybody, everybody, if there is something they’d change about their

appearance if it were possible and almost everybody will answer affirmatively.
There‘s nothing disturbing to want to be a little taller or shorter, a little thinner
or curvier, blonde, brunette, whatever.
When someone is so disturbed by his or her own appearance, or any small part
of it, that he or she feels disfigured or deformed because of it, it’s likely that
body dysmorphic disorder (BDD) is present.
The obsession that can develop over a perceived unsightly appearance can
escalate to the degree of becoming debilitating and destructive. The time and
effort spent of hiding or improving the appearance can become so time
consuming that the disorder is classified as an obsessive-compulsive disorder.
BDD is often viewed as an exaggerated sense of vanity but it is actually the

opposite. The person suffering from the disorder does not devote countless
hours to grooming because they are proud of their appearance. Instead, they
absolutely loathe the sight of themselves and go to extreme measures to change
it.

TV talk shows and tabloids frequently exploit the stories of people who have
made a lifestyle out of having cosmetic surgeries. They’ve had dozens of
surgeries and eagerly admit to being ready for more. The chances that these
people are suffering from BDD are great.
In some very extreme cases, people with BDD even resort to attempting
cosmetic surgeries on themselves, with disastrous results.
An estimated 1% to 2% of the population suffers from BDD and it seems to

be equally prevalent between women and men.
In a study of more than 500 patients with BDD, 73% of them said their
concerns focus on their skin. Hair and nose account for 56% and 37% of
responses, respectively. Many people with the disorder identify more than one
area of concern.
CSP & Addiction

The most common associations with addictions include drugs and alcohol but
an addiction can be associated with a behavior just as easily as with a substance.
A more concise definition of the term is any specific activity that generates a
recurring compulsion to indulge even though the person is fully aware of
detrimental consequences to physical and mental health or social relationships.
Addictions in general are identified as either physical dependence or

psychological. Physical dependence involves a substance, usually a drug or
alcohol, which produces physical withdrawal symptoms when the substance is
not available.
Psychological addiction describes an uncontrollable, compulsive urge to repeat

behaviors that are known to be destructive.
In many cases, both physical and psychological addictive behaviors are present
in the same patient.
Compulsive skin pickers do, in fact, create a lot of physical harm for
themselves. In many cases, CSP is identified by the excessive scar tissue that
has developed over years of destructive addictive picking of the skin or scalp.

The root cause for addiction has yet to be identified definitively. Indeed, the
medical community is in disagreement as to the actual reality of the term.
Some physicians describe addiction as a very real diagnosis while others
consider it merely a term used to persecute. Whether the condition is physical,
psychological, or social in under debate as well.
Nevertheless, the CSP patient does usually exhibit addictive behavior in that he
or she finds it almost impossible to refrain from picking even though the
outcome is known to be, expected to be, short lived and destructive.
CSP & Self-Harm
Masochism is described as a taste for suffering, deriving pleasure from abuse.

There is no limit on where the pain and suffering come from and, in the case of
a compulsive skin picker, the source, sadly enough, is in the mirror.
CSP is a form of masochism frequently referred to as self-harm. Some

physicians describe it as self-injury and self-injurious behavior but, by any
name, it means a person is doing something, consistently and repetitively, to
cause actual physical injury to him- or herself.
One of the more highly publicized forms of self-harming behaviors is cutting,

whereby the person uses knives, scissors, razors, or whatever tool of choice to
repeatedly cut the skin. When asked, the cutter usually attributes the behavior
to relief from overwhelming feelings of numbness or as a release of emotional
pain welling up dangerously inside.
These same reasons are often cited among skin pickers. And just as it is in
cutting, skin picking as self-harming behavior develops in response to any
number of reasons that are as varied as the practitioners of these behaviors
themselves.
Some people experience life as emptiness, with no depth or meaning. When

there is nothing to feel, the compulsive skin picker will generate physical pain
since pain is one of the most unavoidably felt sensations in life. Happiness, joy,
and a sense of belonging are too difficult to define for someone living in this
state of anguish but actual, physical pain is very, very real. It’s the realness of it
that makes it attractive. It reminds the picker that he or she is, in fact, still
alive.

Chapter
3
TREATMENT OPTIONS
Will Power Does Not Work
The compulsion to pick at one’s skin often comes as a surprise to the person
doing the picking. It’s often become a deeply ingrained behavior before the
picker is even aware of how much time and attention is focused on the activity.
By this time, it’s quite likely that the picker has actually structured daily
activities around the behavior.
Everyday grooming may take much longer for the skin picker than other family
members because so much time is devoted to the behavior. And once the
episode of picking is complete, the need to cover up the destruction comes
along. This cycle is often repeated morning and night and often at intervals
throughout the day.
A compulsive skin picker may even have subconsciously adopted a wardrobe

designed to hide the evidence of the behavior. Where scalp picking is present,
hairstyles are often designed to hide bald and sore spots. Caps, hats, and
scarves may become a signature accessory although for camouflage instead of
fashion statement.
Compulsive skin picking is not a habit. It is a behavior. It is this very

important distinction between the two that makes will power entirely useless in
controlling, and eventually stopping, the compulsion to pick at one’s skin.
Habits can be broken and so can the compulsion to pick. Some of the same
techniques that work with breaking a habit can be helpful in retraining a
compulsive skin picker, too. Cognition, substitution, hypnosis, and reversal
training all help break bad habits and they all have their place in recovery from
compulsive skin picking, too. With a habit, the force of will power can end the
habit.

The difference is that habits are a result of training; compulsive skin picking is a
behavior in response to something deeper which must be addressed,
conquered, in order to heal. We seldom have the need to heal from a habit.
In order to end the painful and disfiguring behavior of picking one’s skin,
outside assistance is almost always required. This is not the case with habits.
Habits are routine occurrences, of course. That’s what makes them a habit in
the first place. But a habit isn’t a way of life.
Compulsive skin picking is a way of life. It’s a lifestyle that incorporates time
devoted to the activity, wardrobe and hairstyles designed to accommodate it,
lies and secrets spun to deny it. These things don’t happen with mere habit.
Moreover, CSP isn’t just a behavior, it's a compulsive behavior, which means
that we can't control it, and picking has life of its own, which is driven by
unconscious factors. It's these factors we ultimately need to target in order to
heal. We cannot just decide to stop picking, cause decisions are made on
conscious level (that's where will power operates), and CSP just isn't rooted in
that domain.
Healing Mind and Spirit

The actions we take in daily living are influenced by what’s going on in our
minds and our spirits. It’s the inside that fuels the outside. In a case of
compulsive skin picking, it’s the inside thoughts, emotions, and pain that drives
the outside need to pick.
Once we can accept that the problem on the outside, affecting our skin and our
actions, actually comes from within, even though its true origin may be so
deeply buried we can’t easily grasp it, the road to recovery begins.
Once we’ve accepted that our compulsion to pick is much more than skin
deep, we become more open to the healing qualities behind a number of highly
effective therapies. There have been many therapeutic regimens devised to
soothe and heal compulsive behaviors, including the compulsion to pick at the
skin and scalp.
And just as each person experiencing the disorder does so for intensely
personal, totally unique reasons, we will each respond to the different therapies

in different ways. Some of them, or even one of them, may be the key to
recovery for one person but have no effect on the next person. Some therapies
may work a little bit but others may have greater effect.
Do not discount the value of any therapies and do not give up if results don’t
come immediately. It took many years to develop the behavior and it will take
a while to overcome it.
If the first therapy tried doesn’t prove as beneficial as desired, be patient. Give
it time to work. If, after an honest effort, the therapy doesn’t prove promising
or effective, try something different.
But don’t give up. There are many options and it may be that one is better
suited to your own needs than another or that perhaps a combination of
therapies is the answer for you.
And don’t be surprised if, when the appropriate course of treatment comes
your way, issues involving the rest of your life improve, too. Many of these
therapies involve measures that are beneficial to everyone who is interested in
developing a healthy lifestyle that includes peace, happiness, and a generalized,
lasting feeling of well being.
Cognitive Therapy
The 1960s was a time of cultural revolution in the United States, a cultural
revolution felt around the world. Many traditional beliefs and values of society
were questioned, tested, and sometimes modified. The field of psychotherapy
enjoyed a revolutionary turn of its own.
Aaron T. Beck was just one psychiatrist who had become disillusioned with the
traditional approach to psychotherapy, wherein lengthy forays into one’s distant
past were employed as a means of finding the root of current psychological ills.
He, instead, advocated a practice that focused on errors in thinking, regardless
of their source, and then set out to amend those errors.
Beck’s work was based on the scientific concept of cognition, or the

perception, interpretation, and attribution of meaning. The practice soon
became known as cognitive therapy.

In cognitive therapy, the patient learns to identify his or her own errors in
thinking. Once identified, they can be acknowledged without guilt or blame
and then explored so as to find the errors, correct them, and alter sad, or bad,
thoughts into happier, more productive thinking.
Cognitive therapy is useful in healing the compulsive skin picking disorder in

that many people suffering from the disorder think they don’t deserve any
better. They think they deserve to feel pain or look unattractive for any
number of reasons.
One particular characteristic of thinking where CSP is involved is with “always

and never” thinking. I always say the wrong thing. I never get chosen.
Everybody thinks I’m stupid. Nobody likes me.
One observation to be gleaned from cognitive thinking is that there are

currently almost seven billion humans on the planet. By employing “always
and never” thinking, that allows just one person, the picker, to voice the beliefs
of all the other seven billion planetary co-habitants and to do so collectively.
This is, quite simply, impossible.
It’s almost impossible to find any two people who agree on most things most
of the time. To put everybody and nobody into the picture is where the error
in thinking occurs.
And no one “always” or “never” does something. Extenuating circumstances

vary widely and unpredictably. Always and never are both impossibilities.
Cognitive therapy uses these concepts to explore the beliefs of each patient
until a more generous way of thinking becomes comfortable.
Substitution Therapy
Substitution therapy is pretty self-explanatory. One undesirable behavior is

substituted for another behavior that produces a more favorable outcome. In
this particular form of therapy, the compulsion is treated a bit like a habit in
that the desirable substituted behavior must be repeated until it becomes a
habit itself.

The key to recovery is to find the appropriate substitute behavior that will
produce beneficial results that outweigh the emotional release achieved by the
compulsive behavior.
Take for example the story of the nail-biting bride-to-be. She’d been a
compulsive nail-biter all her life. Some of her most humiliating memories
involved her beloved second-grade schoolteacher discreetly and gently coming
to her desk and whispering into her ear that pretty girls don’t bite their nails.
Now, many years later, she’d just become engaged to her very own Prince
Charming. They were an attractive couple and were planning a fairy-tale
wedding.
The bride’s only concern was with the wedding photography. The latest trend
in wedding photography was a close-up shot of the bride’s hand, sporting her
new wedding ring. She knew her gnarled, ragged, bloody fingertips would be a
bitter distraction from the beautiful wedding ring she and her beloved fiancé
had selected.
She made her mind up to end the nail-biting once and for all and made a very
conscious and deliberate effort to have beautiful hands, all the way to the
fingertips, by her wedding day.
Each evening, she planned the clothes she would wear the next day. She also
selected a shade of nail polish that would complement the outfit. Then, as she
watched TV, she removed the day’s nail polish, massaged her nail beds with
oils, smoothed the rough nails and cuticles, and painted two coats of fresh
polish so her hands would be ready for tomorrow.
At first she felt ridiculous working so hard to make her tiny, tattered nails so
colorful. She’d always tried to hide them before but it was fruitless to try to
hide the bright, vibrant colors she’d chosen. She soon accepted the fact that
her nails, and her compulsion to bite them, were in a period of transition and
she could survive it.
By the time the wedding, and the photographer, came around, her hands were
as lovely as the rest of the wedding. And nail biting has never been an issue for
her since.
For the rest of us, nail biting might not be the problem. Even so, there is a
viable substitute important enough to each of us to help to end the compulsion

to pick. Substitution alone may not be the final solution but it is something
that can be easily practiced alongside any other therapies we choose to use.
Behavioral Therapy
Another approach to overcoming the compulsion to pick one’s skin is

behavioral therapy, often associated with cognitive therapy. In fact, a blending
of the two therapies is common and is referred to as Cognitive Behavioral
Therapy, or CBT.
In cognitive therapy, one learns to recognize, acknowledge, and accept the

troubling behavior, which, in our case, is compulsive skin picking. Behavior
therapy can be thought to advance the therapy a bit by programming ourselves
to expect a certain type of response when we indulge in our compulsion.
In essence, behavior therapy provides a means of rewarding good behavior

choices while producing nasty consequences for poor choices.
One rather classic example of behavior therapy is that of Ivan Pavlov and his
dogs. To simplify a complex series of experiments, Pavlov routinely rang a bell
before feeding the dogs he’d prepared for experimentation. Before long, the
dogs would begin salivating in anticipation of food at the mere sound of the
bell. Eventually he only rang the bell, without any evidence or promise of
food, and the dogs salivated nevertheless.
In many cases, our compulsions are the bell and we are the salivary glands. We
see a tiny red spot on the chin, a jagged fingernail, or some other very small,
benign blemish that really doesn’t warrant much attention and yet it captivates
us. We can’t leave it alone or forget about, letting nature take its course, any
more than Pavlov’s dogs could control their own salivation in response to the
bell.
In behavioral therapy, we learn to reverse the control mechanism. Instead of

becoming the response to the stimulus, we program ourselves to take control
of it.
It’s quite true that most of us develop our obsessive-compulsive behaviors as a

response, sometimes even a defense mechanism to internal trauma and unrest.
Some forms of therapy delve deeply into that emotional miasma to root out the

cause, as if exposing it to daylight and debate will diminish its power. And it
often does just that.
But behavioral therapy can work in conjunction with that internal search.
Many people even report effective treatment using behavioral therapy alone,
while leaving the internal trauma to fade into distant, harmless memory.
Existential Therapy
Some of us are the most alone in a crowded room. We feel invisible, unable to
communicate effectively, unworthy of existence. Our lives have no meaning,
no purpose, and sometimes there seems to be no truly valid reason to go on.
When these thoughts, this self-image, is associated with our compulsion to pick
at our skin, we may be likely candidates for existential therapy. This form of
therapy is built upon the concept that we are all, at best, entirely alone.
By being truly alone, we lead lives that are meaningless, by conventional

standards. We are alone, we’re isolated. Our lives have no meaning, no value,
and no values.
Existential therapy embraces this aloneness as if wiping clean the slate of a

graffiti-filled past. Once we accept that we, like everyone else, are alone and
living a life without meaning, we become free to build the life we’d really enjoy
living. We build our own meaning to life. When there is nothing to begin with,
we have everything to work with.
It’s impossible to live without the presence of anxiety from time to time.
When we dwell on our anxieties, they become traps that prevent us from
growing in a more mature, creative, or satisfying way. When the feelings of
entrapment become strong enough, some people resort to behaviors that
escalate into compulsive disorders, such as skin picking.
In existential therapy, we will be guided to constructively acknowledge and

confront the anxiety-causing issues in our lives. And we will be instructed
through the process of understanding that we are alone and that our lives,
everybody’s lives, are essentially meaningless. Once we reach the point of truly
accepting that, we can accept that our anxieties are meaningless, too.

From that point forward, existential therapy becomes a celebration of freedom.
It helps us to explore, design, and create a life filled with only the things we
enjoy and desire most. We no longer feel compelled to live by the standards
and value systems of others. After all, they’re meaningless.
We gain the freedom to say good-bye to all the wrongs committed against us in
the past. They were committed or perpetuated by people who are alone and
who live lives without meaning, just as we do.
Existential therapy teaches us how to make peace with the past but to focus on
the present and the future, which we and we alone have control over. With the
creative freedom comes responsibility of tailoring a life that looks and feels like
the one we’ve always dreamed of.
Like most forms of psychological therapy, existential therapy shows a new way
of thinking. In this case, it takes the aloneness, which we fear, and turns it into
the foundation from which we build a life that is free. And happy.
Hypnosis
“Hypnosis is a state of inner absorption, concentration and focused attention.”

That’s the description offered by the American Society of Clinical Hypnosis.
For those of us with a compulsive disorder such as skin picking, that

description sounds pretty familiar. Perhaps it’s this very close similarity that
makes hypnosis, in the form of hypnotherapy, an attractive avenue of relief
from the disorder.
Once considered a process best left to the circus sideshow or the magician’s
bag of tricks, hypnosis has gained a firm foothold in the realm of traditional
measures, especially since modern scientific technologies bring us visual and
chemical markers of the brain at work, including the hypnotized brain at work.
Hypnotherapies include programs for breaking unhealthy habits such as

smoking and overeating, overcoming phobias, and even treatments for
depression and post-traumatic stress disorders. There’s even
hypnodermatology, a specialized field of hypnotherapies devoted entirely to the
disorders of the skin.

Some people suffering from CSP indulge in their skin picking behaviors
without awareness, doing it during periods of calm relaxation. This type of
person is most likely to exhibit the behaviors when engaged in a spellbinding
movie or book or perhaps a pleasant conversation with loved ones. In fact, it’s
often the loved ones who identify the behaviors in their companions.
Other people experience the disorder in the opposite way. They resort to the
picking in response to anger, agitation, and other anxiety-provoking situations.
The higher the level of stress, the more intense the picking.
It’s perhaps this type of person who is more likely to benefit from hypnosis as
therapy for the disorder. The very word “hypnosis” comes from the Greek
word for sleep – Hypnos. In current usage, the word is used to mean the sleep
of the nervous system.
The objective of hypnotherapy is to provide a mechanism for relaxation during

times of stress. By easing the level of anxiety, the level of compulsion to pick is
expected to be minimized in return.
There are many forms of hypnotherapy. As with other therapies, if one form
of it doesn’t seem to be producing the desired results, try a different method.
Each method is designed to produce a different result by working in a different
way. There is no one-size-fits-all form of hypnosis.
A therapist trained in hypnosis is required to achieve maximum benefit but

there is no reason at all to expect that, once the most appropriate form of
hypnotherapy has been identified and the basics are mastered, the patient will
not be able to engage in a highly beneficial form of self-hypnosis anywhere,
anytime it’s needed.
Habit Reversal
Habit reversal training is another rather blended form of therapy against

repetitive disorders such as compulsive skin picking. One key component of
habit reversal is that the patient learns to train him- or herself to recognize
what is called a premonitory urge.
The premonitory urge is defined as the awareness that is felt just before the
compulsion to act upon the undesirable behavior begins. The patient is trained

to identify the premonitory urge and apply a competing response against it
instead of the more familiar compulsive behavior.
To be most effective, the awareness and response phases of habit reversal

training are supplemented by relaxation techniques as well as some generalized
training measures designed to make coping with compulsive skin picking as
painless as possible.
Group Therapy
One of the most tragic aspects of compulsive skin picking, and many similar
disorders, is that the person suffering from the disorder often feels alone,
isolated. There is little effort made to reach out to someone else for help or
comfort because it’s often difficult to understand that others may be
experiencing the very same type of compulsive behaviors, too.
Kindred spirits are blessings in many facets of life and this is certainly true with
compulsive disorders. We are often scorned and ridiculed by the way we look
or the seasonally inappropriate clothing we wear to hide the evidence of our
disorder. Even when we manage to hide effectively, we often feel like freaks,
expecting to be shunned if ever our secret is uncovered.
It’s the kindred spirits that make group therapy sessions so beneficial. We find
we aren’t alone and that there is no need to be isolated from the rest of the
world. We can let our hair down and roll our sleeves up in group therapy
sessions. We’ve got little or nothing to hide here.
In group therapy, a counselor or therapist mediates the session in which every

attending member is allowed to voice any thoughts, concerns, questions, or
other commentary on the subject matter, in our case compulsive skin picking.
We are allowed the opportunity to voice our fears, tell our stories, ask for
guidance in a controlled, relaxed environment where everyone is experiencing
similar issues and no one is there to criticize, compare, or ridicule.
In addition to the comfort to freely discuss our symptoms, thoughts, and

emotions, we discover coping skills that our fellow group members have
developed in their own battles against compulsive skin picking. We can
exchange phone numbers for therapists we were impressed with and warn
others of those who are best avoided.

We can relate our own adventures in finding the best therapies for our disorder
and welcome the recommendations of others. We can compare notes, share
tears, and enjoy a little laughter in the company of understanding companions
from time to time, too.
There are many different forms of therapy proven to be effective in the fight
against compulsive skin picking. Some of them work better for one person
than the next. Some of them seem effective individually but others may work
best as a multi-layered regimen.
Even within the given therapies, there are subspecialties that address one
specific issue, aspect, or methodology more so than the next. There is no one
answer for anyone.
Please don’t be discouraged if the first method of therapy tried doesn’t prove
to be the final solution. There are many ways to tailor the therapy to better suit
individual situations and there are many alternatives to explore, too.
Healing the Body
Until the reasons behind the compulsion to pick are addressed, it is basically
impossible to heal the ravaged skin itself. As long as the emotional turmoil
runs unchecked, there will be more picking, more destruction.
However, once the internal conflict begins to abate, it’s time to help the
physical healing process of the skin itself. Once progress becomes evident in
both the emotions and on the skin, the process of healing becomes self-
perpetuating. A quieter mind leads to healthier skin, which, in turn, leads back
to augmenting the quieter mind. The compulsion to pick led us in a vicious
cycle of destruction. The healing leads us into a joyous cycle of health.
Dermatology
The field of dermatology may be the first step to healing the body during the
recovery from the compulsive skin picking disorder. There are a number of
ways this can be accomplished. Some of them can be done at home without
medical intervention. Some cases, however, are likely to require the assistance
of a dermatologist to get the physical healing process off to a better start.

When working at home, learn to pamper your skin. It’s been through plenty.
It’s a living organ, just as all the internal organs are and it needs the proper
nourishment to function at its best.
Proper nourishment of the skin starts with ample moisture. Use moisturizers
often and always apply sunscreen before spending time outdoors. Waiting until
you are outdoors, enjoying the glorious sunshine, is the wrong time to apply it.
It’s too late by this point. Sunscreen requires about 20 minutes after
application to become its most effective so always allow at least this much time
between application and sun exposure.
The most beneficial way to apply moisturizer is to do so immediately following

a bath or shower. Lavish the wet skin with a rich lotion or cream and allow it
to soak in as the water from the shower or bath evaporates. The layers of the
skin are never so plumped full of nourishing moisture as they are immediately
following bathing and the application of the moisturizer will provide a barrier
that will prevent this precious liquid from evaporating too rapidly, leaving the
skin dry and brittle.
Hot water is never a good thing for skin care. Excess heat causes the pores to
open wide, releasing unhealthy levels of moisture that your skin needs. And
the longer the skin is exposed to the heat, the dryer the skin will be afterward.
Instead of excess heat, learn to enjoy bathing in water that is as close to body
temperature as possible. Warm is fine but the warmer the water, the shorter
duration the bathing should be.
Avoid harsh chemicals, including soaps and detergents intended for the body,
the hair, the clothes, and bedding you will be exposed to. Whenever possible,
choose products that have little or no added fragrance or color. All chemicals
can be irritants and your skin has seen enough irritation. Give it a break now
and choose gentle cleansing methods for everything that comes in contact with
it.
Pampering your skin at home may be enough for many compulsive skin pickers
to see quick improvements in the quality and health of their skin. And treating
ourselves to a spa treatment, even when it’s the do-it-yourself spa we enjoy at
home, can be as soothing inside as it is outside.

There may be times, however, when professional assistance is required. See a
qualified dermatologist for specific advice. Prescription medications might be
necessary. Fortunately, the dermatologist enjoys an entire arsenal of drugs that
can combat the effects of even the most long-term skin-picking disorders.
When healing seems slow, there might be an underlying infection hindering the
process. An antibiotic medication can be prescribed in such cases. Topical
antibiotics applied directly to the point of injury often do the trick, especially
when slow healing is in a specific or isolated spot. When infection is more
system wide, an oral antibiotic is probably in order.
Most dermatologists will prescribe a mild antibiotic to begin with. If the

healing process remains slow, more potent medications are available. Some of
them are known to produce serious side effects, however, so careful
monitoring and meticulous attention to dosage is critical.
Hydrocortisone ointments, creams, and lotions can reduce inflammation and

speed healing, too, especially where no sign of infection is detected. It is never
a good idea to take an antibiotic except in the presence of bacterial infection so,
when no infection is present, try a topical hydrocortisone treatment to speed
healing.
Medical regulations vary from country to country but, in many locales,

medications containing mild doses of hydrocortisone can be gotten without a
physician’s prescription. If this is the situation in your area, start with a mild
dosage and seek medical advice if not satisfied with the results. Prescriptions
are usually available for hydrocortisone in larger doses.
Neurology
In almost every case, compulsive skin picking is an outward manifestation of

something amiss inside. In many cases, the inner problem is one of struggle
with emotions, thoughts, self-image, value. In other cases, the picking is an
outward symptom of an inner conflict of an organic nature. The picking is a
part of a neurological condition that requires a different form of treatment
altogether.
When neurology is an issue, it is vitally important to identify the underlying

medical condition and seek the appropriate treatment. Psychotherapeutic

measures may ease the symptoms but it’s likely to be short-lived if the
underlying neurological concerns are missed or left unaddressed.
The list of possible neurological complications that manifest themselves in

compulsive skin picking are too numerous to list. All neurological issues
require immediate medical attention. If you suspect there may be a
neurological link to your compulsion to pick your skin, please seek immediate
medical counsel.
Choosing the Best Therapist
Sometimes the list of treatment options seems long and foreign enough to be
daunting. Don’t let it frighten you. And don’t give up.
Instead, strive to find a therapist who is qualified to treat people with

compulsive skin picking disorder or related disorders and with whom you feel
comfortable (a good option to consider are SkinPick’s experts). Many of us
developed this disorder in the first place because we have difficulties relating to
others. At times, there may be no one in our lives who is more important to us
than our therapist so it’s vitally important to employ someone who provides
comfort, wisdom, understanding, and a sense of trust.
And just as with forms of therapies, if the first therapist doesn’t seem to be the
best fit after a session or two, it’s entirely OK to find another one. Therapists
are like plumbers, lawyers, and bookkeepers. If he or she isn’t getting the job
done to your liking, fire them and hire another.
Here is a brief description of the kinds of medical personnel you might want to
consider as your therapeutic partner against CSP. It’s impossible to provide a
narrowly defined field of professionals as there are so many therapies and
subspecialties even within the individual methods. And the medical profession
itself differs from one country to the other. If it’s any consolation at all, take
comfort in the fact that people in every country around the globe suffer from
CSP. It’s not limited to you so don’t be ashamed or feel as if you are alone.
This is certainly not the case.

Psychiatrist
A doctor of psychiatry, or psychiatrist, is a physician who specializes in the

medicine behind mental disorders. He or she is trained to evaluate and
diagnose medical conditions that cause mental distress of all natures.
A psychiatrist is trained to conduct laboratory tests that may include

electroencephalograms (EEGs), blood analysis, and computerized scans of
various sorts. As a licensed physician, a psychiatrist can prescribe medications,
too, and many of them become involved with psychoanalysis, cognitive
behavior, and other similar therapeutic courses of treatment.
Within the field of psychiatry, there are many subspecialties. The field of
human emotion and mental processes is so complex that it would be almost
impossible to be effective to all people under all circumstances. With this need
for specialization in mind, some psychiatrists work only with children, or only
with adults or the elderly. The specialty might be cancer patients, diabetics,
victims of injury or war. Or obsessive-compulsive disorders.
In many areas, it’s possible to schedule a consulting session before delving full
force into a course of testing and treatment. The physician understands that
any therapy involving affairs of the heart and emotions is only effective when
the patient is comfortable with his or her physician. They will almost always
allow an initial appointment to become acquainted.
Psychotherapist
A psychotherapist will generally lack the medical background of a psychiatrist.

Where the psychiatrist focuses on the metabolic evidence supplied in
laboratory and diagnostic tests, a psychotherapist focuses instead in building a
sense of personal well being and establishing more comfortable and effective
interpersonal relationships.
Sometimes during a course of therapy, a psychotherapist may identify the need

for prescription medications to supplement the relational therapies already
underway. Many psychotherapists are licensed for the behavioral therapies but
must refer patients to a psychiatrist for prescription medications. In such a
case, the two doctors work together to monitor all symptoms of the patient and
devise the best plan for combined therapies.

Psychotherapy is based upon achieving a deeper understanding of why certain
triggers in our everyday living cause us to feel the need to do things that might
not be in our best interest, such as compulsively picking at our skin. There is a
great deal of conversation involved in psychotherapy and, from time to time, a
psychotherapist may determine that it is in the patient’s best interest to include
various family members in the therapy sessions as well. This is never done
without consent of the primary patient and the sessions with family members
may take place in the presence of the patient or they may be private. Different
patients, and their unique circumstances, determine the preferred course of
treatment.
As with all physicians, health and well being are best achieved when there is a
comfortable relationship of trust and mutual respect between therapist and
patient. When beginning treatment, ask for an introductory session to meet the
therapist. Chances are you’ll be spending a great deal of time in heart-to-heart
conversation with this person and a level of comfort is crucial.
Psychodermatologist
In recent years, a growing number of dermatologists and psychotherapists have

come to accept the fact that many patients of dermatology seek medical
treatment because their skin is providing evidence of psychological distress.
One form of such distress is compulsive skin picking.
The understanding of the link between the skin and the mental state is
relatively new, meaning there are few physicians trained to treat both
dermatology and psychological disorders. The few who do meet the
qualifications are ideal candidates for treatment but they may enjoy very full
schedules, with little opportunity to take on new patients. If possible, be
patient, try to relax, and wait for an opening.
If no opening is in sight, look for either a psychologist or a dermatologist who

understands and accepts the link between the two specialties. After all, the
skin, the heart, the mind are all a part of one intricate but important system –
you! The good thing is that you probably aren’t the first patient either
physician has seen who is experiencing compulsive disorders.

Coping Strategies
Self Acceptance
One of the very most important steps to take in treating CSP is to accept the
fact that it exists in your life. It doesn’t mean there’s something wrong with
you, that you’re dirty, or that you are a freak in any sense of the word. It just
means you have a medical condition that requires some attention.
Acceptance is the first phase of the attention you’ll need to address. Don’t
chastise yourself for the injuries you’ve created. Focus, instead, on the healing
you will create now. Think of your CSP with the same gentle compassion
you’d think of someone else if he or she had asthma, anemia, or any other
chronic medical condition that required diligence and care.
Understand that there may indeed be some underlying turmoil in your

emotional world that has driven you to become overly attentive to the
condition of your skin. Accept that but don’t dwell on it. If it seems
impossible not to dwell on it, discuss it with your therapist. In many cases,
inner demons don’t have to be defined and confronted in order to gain the
upper hand over them. Sometimes the best thing to do about them is to simply
accept them as part of your psyche, then forget about them and move on.
Once you really come to terms with the existence of CSP in your life, it is likely
to become easier to cope with it. Now, every time you find yourself in the
midst of a picking session or being lured into one, you’ll know that what you
are doing is something that can be identified, named, and treated. After a
while, the awareness of it will come as often as the urge to pick. And the
refusal to pick, to be lured into the behavior, the thrill of the pain, is a giant
step in eliminating the disorder.
The disorder may have seemed mysterious at times, causing shame, prompting
lies, or even driven you to hide from others. Once you accept the behavior as a
medical disorder, you can stop all those things. No chronic medical condition
improves with secrecy. It requires time and treatment. And that means
discussing your condition with others.

Relationships
The people who love you the most are the first people you should tell. If
you’ve already consulted a physician of any nature about your CSP, let your
family know. This will give credence to your disclosure and is likely to generate
offers of support.
It’s also likely that your family already knows you pick to the point of
destruction. Even when we think we are very secretive about it, hiding all the
evidence, it’s hard to remain that private around the people with whom you
share a home. Your disclosure may be the opportunity for them to
acknowledge their own picking behaviors. Many people find that when they
reveal their secret, other family members come forward with similar stories. Or
know someone in the extended family who shares the compulsion.
No one likes to learn that a loved one is tormented by a lingering psychological

condition. Your disclosure will probably be followed by an outpouring of love
and compassion that may seem foreign to you. In times past, you may have
not allowed yourself to be accepted by the people most important to you. You
may have felt undeserving or inadequate to receive their affections. This sense
of diminished stature may even be a driving force behind the development of
the compulsion to pick in the first place.
If this is the case, acknowledge the discomfort but embrace the love. You
deserve it. You do deserve it but it’s quite possible you’ve been the force
restricting it in the past, distancing yourself from it although you craved it.
Learn to enjoy the love and affection you receive from the people important to
you. Feelings of acceptance just might dim the desire to pick.
Many people consider the revelation of a psychological disorder as an action

that reveals vulnerabilities. It does. But everyone has weak spots in their
psyches. Revealing them can have a diminishing effect on them, making them
seem less significant in the light of day. People who love you accept this just as
readily as you accept their vulnerabilities.
Sometimes, however, people come into our lives who aren’t quite so
compassionate. They are frequently insulting and derisive, preferring poison
arrows to Cupid’s loving arrows. If you’ve got one of these types in your life,
other issues may need to be addressed as well.

People who are mean and nasty-spirited are usually hurting inside. They are
often filled with self-doubt and suffer from very low esteem. Their only way of
protecting their own vulnerabilities is to showcase yours. Bullies and abusers
of all sorts fall into this category. And it’s important to remember some of the
most vile and hurtful abuse is verbal, not physical.
If you’ve got one of these people in your life, it may be a good time to
reconsider relationships. When you reveal your CSP, you also reveal the
strength of character required to deal with it. Your newfound strength is a
threat to them and they will try to sabotage your every gain. This type of
person is often very cunning, often undermining your own vulnerable self-
esteem in ways that seem empowering, but only for a little while. After all, if
you get better, you may not bother with their taunts. You may replace them
with more pleasant people and they’ll be just as lonely as they’re afraid they
deserve to be.
You’ll never change this personality type. You’ll never change the personality
and behaviors of anyone but yourself. And changing something as big as CSP
is all the changing anyone needs to deal with at one time. Distance yourself
from these people. Re-evaluate relationships. Poisoned relationships such as
this may be behind your compulsion to pick in the first place. Think of
yourself first and reconsider how important this sad person is to you.
Social Disclosures
Picking one’s skin to the point of injury is a very intimate act. We often do it
thinking no one knows. This is often not true but what often is true is that
most people don’t associate the behavior with a true medical disorder. Most
people consider it merely a bad habit but you know the difference.
You know that it’s so much more than a bad habit. It’s more like a driving
need, a tour de force that engulfs your every action, your schedule, your
thoughts. But now you’ve learned that there is a way to conquer this behavior,
to learn to cope with it, accept it as part of your life, and perhaps even
eliminate it altogether.
Confronting it, coming face to face with it, is important when learning how to
live with it. And confronting it means sharing its existence in your life. Sharing
it with your family but also sharing it with your friends, coworkers, and others
in your social circle.

There’s no need for grand announcements or formal proclamations. You
know the people in your life. You already know how to relate to them
effectively. You’ll know to whom and how your message will be best
addressed.
Don’t be surprised if your revelation isn’t met with gasps and sobs. CSP is very
misunderstood, if not entirely unknown to most people so it’s likely it will be
something entirely new to the people in your life. You may get curious
questions but you may also get asked what you’re doing to overcome the
disorder. It could be that you’ve revealed your disorder to someone suffering
from a similar condition and they’re relieved to learn that it’s something with a
name in medical literature. Often a diagnosis is all that’s necessary to bring a
great sense of relief.
And there will be people who just don’t get it. They’ll think it’s just one of
those silly little things that makes you so unique. Don’t let them irritate you by
undermining the significance of your medical condition. Humor them instead
and know you can relax and be yourself around these people. And be
prepared. Now that you’ve revealed you have an almost irresistible urge to pick
at your skin way past the point of routine maintenance, they’re likely to reveal
to you some of the quirky things they do, too.
You’ll find all sorts of reactions when you tell people about your CSP. You
don’t need to broadcast it far and wide but talking about it openly is a healthy
way to come to terms with it. Holding it inside, maintaining the secret, will
only cause further harm. Most secrets grow in significance, becoming harder
and harder to keep, the longer they are left unspoken. Don’t do this to
yourself. Discuss it freely and don’t get hurt or annoyed when others just don’t
seem to understand. It’s your understanding, not theirs, that is beneficial.
Therapeutic Disclosures
If you’ve reached a certain degree of acceptance of your CSP disorder but feel
the issue is a little too daunting to tackle alone, it’s perfectly acceptable to
consult a physician for some professional assistance.
Some prescription medications may be the quickest way to see measurable

results in overcoming the disorder and that can only be gotten from a
physician. It could also be that you will benefit from some coaching in the

skills needed to live a more fulfilled and free lifestyle. A therapist familiar with
obsessive-compulsive disorders can help you with that.
When seeking medical advice, remember that full disclosure is required. If you
tell your doctor that you’ve come down with a wild acne outbreak, a nasty
encounter with a swarm of mosquitoes, or that you have no idea where those
sores on your head came from, you only diminish the benefits of the
relationship between physician and patient. Let your doctor know that you did
these things to yourself, you know it isn’t a healthy thing to do, and that you
are now ready and in need of some professional help.
People are complex organisms and all sorts of medical maladies arise every day.
Physicians are prepared for that. They’ve heard or seen just about anything the
human body can deliver. They can deal with medical issues the rest of us can
hardly imagine and they do it with dignity and grace. Let your doctor know
exactly what and when you do and let him or her know how you feel about
doing it. It’s only when the big picture is revealed that the healing can begin in
earnest.
Your physician is your partner in the process of healing. Rely on him or her
and follow their advice. Know that there are different treatment options, some
of which work better for some people than for others. If the first round of
treatments isn’t achieving the desired effects, try something new. Try a
combination of therapies, too, because some deal with the physical aspects of
the disease and some work with the emotional impact of the disorder.

Chapter
4
RECOGNIZING CSP IN OTHERS
By the very act of reading this book thus far, a connection to CSP must be
present in the lives of the readers. Some readers will suffer from the disorder
themselves but others are reading because of the diagnosis of someone
important in their lives. The more public awareness there is for the disorder,
the more likely a greater number of people will get relief from the symptoms.
Readers who do have the disorder, as well as those who do not, are likely
nevertheless to know of someone somewhere who might have it. Suspicions
might exist but a means of approach is uncertain. For anyone concerned about
the health of another, it’s the nature of the relationship that presents the best
method of opening an avenue for conversation.
CSP in Your Children
The first inklings of a future compulsion for skin picking usually occur during
childhood. The hormonal changes of adolescence often give rise to the acne
that leads to the picking. At this point in time, the maturing body can lead to
feelings of self-doubt and inferiority. These two emotions, combined with the
availability of pimples, can prove to be a temptation almost impossible to
ignore.
Another very critical stage of childhood is when a child enters college and must
learn to face the world somewhat independently. By now the child may be a
little more comfortable in his or her more grown-up body but college
represents a pretty dramatic change in lifestyle for most students and, again,
those feelings of self-doubt and inferiority can run deep.
These two stages of childhood represent the most common times for
developing CSP. These stages are not, however, the sole stages of vulnerability.

It can strike any child at any age. The key to keeping a developing habit from
becoming an emerging compulsion is quick response.
Compulsive behaviors are similar in many aspects to an addiction. And an

addiction that is allowed to grow over many years’ time is much harder to break
than one recognized and treated at the earliest stage possible. Compulsive
behaviors, including skin picking, are easiest to treat in the early stages, too.
The longer a person with CSP continues the behavior, the more deeply rooted
in the personality the behavior becomes. The more deeply rooted, the more
difficult the treatment required to end the cycle of self-destruction.
Compulsive behaviors are mysterious to many people, hard to understand and

difficult to explain. Children who develop CSP don’t always know why they
feel the overwhelming need to pick at their skin or their scalp but they do know
that they are almost powerless when it comes to preventing it. Because
compulsive behaviors are so complex, involving both the body and the mind,
children can become quickly ingrained with the habit of picking and never feel
the need to question the reasons why this is so.
It’s important for parents to understand CSP, especially when it is suspected in

one’s own child. It’s also critically important for parents to understand that
what looks like a bad habit might actually be a medical disorder. Medical
evaluation may be required to discern the difference.
When CSP is diagnosed, it becomes important for parental involvement in the

way of support and guidance. Parents may never understand exactly what’s
going on inside the head of their child with CSP but many parents think that
anyway at one point or another over the childhood of most of their children.
Probing questions, shame, and threats of punishment will be more likely to
have a negative effect on treatment than a positive effect.
Instead, parents should strive for a trusting relationship with the child that
involves free and easy communication and mutual respect. It’s also important
that any siblings present be equally as respectful of the child with CSP. Sibling
rivalries can be brutal and they affect each child differently. The child with
CSP may need a little more comfort and encouragement as he or she learns
how to break through the cycle of injurious behaviors associated with CSP.
With the diagnosis for CSP comes an added sense of vulnerability. Love,
affection, and comfort are needed now more than ever and taunts, ridicule, and

insults are likely to become incredibly damaging to the child in recovery. If
family dynamics aren’t as warm and respectable as they could be, it might be a
beneficial idea to look into family counseling sessions to work out any
communication difficulties.
CSP in Others
Parents are in the ideal situation to recognize and discuss CSP symptoms with
their children. Parents can also take the action required to get treatment and
monitor the child through the treatment period. Unfortunately, not every
parent is aware of CSP and many people grow up with the disorder without
being aware of its existence.
These people need comfort and support, too, but usually don’t even know they
have an issue for which there is a medical name. If you suspect someone in
your social or professional circle might be at risk of developing the disorder, or
may have already done so, some kind and gentle words of acknowledgement
may be just what the person needs to begin to take charge of the disorder and
overcome it.
Recognizing CSP
As complex an organism as the human body is, there are many symptoms of
one disease or disorder that mimic those of others. In fact, similar symptoms
often lead to missed diagnoses when even the most competent of physicians
metes them out. It is entirely unfair to suspect that everyone who appears to
have a problem picking at his or her skin is sure to have the compulsive nature
of CSP as an underlying issue.
When the appearance of CSP is present, it is advised that some insights into the
emotional state of the individual be assessed, too. CSP is often related to issues
of self-esteem, body image, and self-confidence. When someone you know
exhibits any of these characteristics and they seem to pick at their skin or scalp
to an unhealthy or unattractive degree, it very well could be a compulsion and
not just an unsightly habit. However, some people with issues of self-worth
never pick at their skin and some people who do seem extraordinarily self-
confident do experience the disorder.

Only a professional can give a precise diagnosis of the disorder but a little
friendly conversation from a concerned friend or coworker may provide the
impetus for the person to seek medical attention and begin the process of
healing.
Discussing CSP
People suffering from CSP do so in ways as private as they can make them.
Before diagnosis and treatment, it is unlikely anyone will describe the very
intimate ways they injure themselves. Instead, they are often convinced it is,
truly, a secret and that no one knows.
If you suspect CSP in someone close to you, the secret is out. It’s just that the
person with the disorder usually doesn’t understand that others suspect. He or
she is very unlikely to bring up the subject in the normal course of
conversation. If you care enough about the person to worry for their health, it
might expedite treatment if you were to gently mention it in a private
conversation.
The dynamics of every relationship are different so there is no absolute right or

wrong way to express concern. The natural flow of communication between
the two of you will present the best opportunity for sharing. It will be
important to you to be ready when that moment occurs.
Leave accusations, judgments, and derision out of the conversation. The

person with CSP probably has a mind full of those ugly thoughts already and
doesn’t need to hear yours. Instead, try to provide some supportive and
constructive words of acceptance and sympathy.
And don’t preach. Don’t play the role of the wise sage who knows everything
and decides what’s best for others. The truth of the matter is that you honestly
and truly don’t know. You don’t know why anyone would develop this
disorder in the first place. You can’t know because everybody is different and
has different issues to confront in their singularly unique lives.
This is a good time to be a listener and a provider. Offer the suggestion of

awareness of a disorder that responds to medical treatment. If the suggestion
gets a response, be prepared with contact information for websites that offer
advice on CSP and for local resources if you know of them.

Be patient. The person with CSP is probably going to be reluctant to discuss
the disorder with you. He or she may be aware of the problem and may
actually be in treatment but it’s possible they’ve never heard of the disorder.
Nevertheless, just hearing you mention the reality of the disorder to them in an
unthreatening way will get them curious. It may take a while for the person to
bring the subject up again but be patient. Everyone craves acceptance and
finding a new ally in any battle is a welcome relief.
If treatment has already been started, the person with CSP will probably be
grateful to know there is someone out there with whom progress can be
shared. Encouraging words during a time of trial can be as good as gold. And
the person already in the treatment phase is probably learning new ways to
communicate and express feelings. Sharing the progress with others is great
practice.
If, however, no treatment is underway, it could be that the person doesn’t

know the situation is any more serious than an undesirable habit. Your
knowledge of CSP may shed new light on a perplexing situation, hinting at
relief where there had been no hope of relief without your concern.
Compulsive skin picking is a form of self abuse, personal denial of the worth of
the individual. It is a very real psychological disorder and there are some very
real and effective treatment options that can dramatically reduce the severity of
the disorder, identify any co-conditions that might need immediate medical
intervention, and perhaps put an end to the picking forever.

Appendix
A
APPENDIX: TOOLS AND PROGRAMS
Some more info & tools you will find useful:
- An explanation of how CBT (cognitive behavioral therapy) is used for

compulsive skin picking treatment – click here
- An online test to check the severity of your symptoms
- A free App to monitor your picking – download here
- An online therapy program for compulsive picking lead by experts on

Excoriation Disorder treatment – learn more and enroll here

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The complete guide to Excoriation Disorder

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GENERAL INFORMATION ......................................................................................... 3

What is Compulsive Skin Picking (CSP)?

That little pimple would draw us in as if spellbound. It would capture our

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A brief, concise description of the symptoms of CSP is virtually impossible.

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Acne vulgaris is not a problem so much as a rite of passage. There is a strong

Adjacent disorders to CSP are apparent as Onychophagia (nail and cuticle

Copyright © 2017 SkinPick.com 5

Whether the picking is provoked by stress or relaxation, a trusted companion is

Who Develops CSP

Of those who do seek medical intervention, it is estimated that about 2% of

Copyright © 2017 SkinPick.com 6

CSP has a tendency to run in families. Whether this is genetic, learned

Because CSP is often overlooked or undervalued as a real and true

Copyright © 2017 SkinPick.com 7

Most people remember the shockingly grisly murders of Nicole Brown

Transcripts of Simpson's depositions revealed that his former wife had a

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Another declares a picking episode as a success when the contents of a blemish

Many testimonials describe how easy it is to avoid picking in public where

Copyright © 2017 SkinPick.com 9

The skin is an organ of defense. It defends us from outside environmental

The skin is an organ of protection. It protects our internal organs - muscles,

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Our faces are very important to communications, too. Some researchers of

Perhaps we have an underlying understanding of the significance our faces play

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Lips and Cheeks

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The unconscious clenching of the teeth, whether delicate cheek tissue is

Arms, Legs, Chest, and Back

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When excessive nose picking develops into a CSP-related disorder, there

Cuticles and Nails

Someone with a tendency toward obsessive-compulsive behaviors, however,

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Compulsive skin picking is a very complex disorder. It affects different people

Even though we know this to be true, we nevertheless feel the opportunity to

Copyright © 2017 SkinPick.com 18

There is any number of neurological events that might lead to a compulsion to

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Neurological disorders can generate symptoms associated with compulsive skin

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It is important to remember that the very real dermatological conditions are a

The psychological trauma of growing up in a home run by a domineering or

A parent who is a perfectionist may instill feelings of insecurity on their very

Displays of affection, such as cuddling, hugs, and endearing words, are

Unfortunately, the need to be overly critical, aloof, perfectionistic, and even

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In some truly heartbreaking situations, violence and sexual abuse may be

There is another side to compulsive skin picking as a means of taking control

The nurture-versus-nature debate permeates the community of doctors and

There is no doubt that compulsive skin picking runs in families. Sometimes