Picking Apart the Habit of Skin Picking

Feb 7

Skin picking affects roughly 2-5% of the population, mostly affecting women. I’m one of them.

It is something that I have struggled with since childhood and has stayed with me to adulthood. I would spend countless time picking at my face and my arms, really, anywhere that may have anything that resembled acne. And I thought it was normal, that everyone picked at their skin.

Now, as an esthetician with my own practice, I see it regularly in my treatment room. And what I notice most isn’t just the picking itself, but the shame, judgment, and lack of understanding surrounding it.

The Two Types of Skin Picking

There are two types of skin picking I’ll address here: Acne Excoriée and Excoriation (Dermatillomania).

Acne Excoriée is a subtype of acne where in the presence of acne lesions compulsive picking follows. The picking can include obsessive picking, scratching, or touching of the lesion leading to scarring, scabbing and even disrupting the skin barrier.
Excoriation, also known as Dermatillomania, is a skin picking disorder where skin is picked, even if there is no presence of acne lesions. This can occur anywhere from the face, limbs, nail beds, cuticles, etc.

Acne Excoriée is a subtype of Dermatillomania, however not everyone who struggles with Dermatillomania experiences acne excoriée.

Both have been linked to mental health disorders, most prominently OCD, and can increase during bouts of stress, depression and anxiety.

Why Skin Picking Impacts Healing

As mentioned earlier, skin picking can lead to other skin issues like scarring, persistent scabbing and the risk of disrupting the skin barrier. Let’s address the process of healing to understand why.

There are four steps to wound healing:

Coagulation: Fluid (typically blood) coagulates to form a scab to protect the wounded area.
Inflammation: An inflammatory response occurs where the body sends white blood cells to manage bacteria and clean house.
Proliferation: Your skin rebuilds itself by increasing collagen, and other structural proteins, to help fill the wound while new vessels are grown to supply nutrients to the area.
Maturation: The healed wound now takes its time strengthening its newly formed proteins and vessels.

Consistent picking interrupts this process, and often restarting it entirely, making proper healing nearly impossible.

PIE, PIH, and Healing Marks

Post-inflammatory Erythema (PIE) and Post-inflammatory Hyperpigmentation (PIH) are part of the final stages of healing.

PIE is a vascular response where the capillaries near the skin's surface become damaged or dilated. PIE is identified by red or pink marks.

PIH is a pigment reaction to inflammation where an excessive amount of melanin is produced and settles in the epidermis or dermis. PIH is identified by brown marks.

PIE and PIH is a normal step in skin healing and will diminish over time, however skin-picking can prolong, or even worsen, these responses.

Types of Scarring

There are a few different types of scarring, but I’m going to talk about the types most common with skin picking.

Atrophic, also called ice pick scars or pitted scarring, is common in lesion-type skin conditions, such as acne or chickenpox. They present as small ditches in the skin.
Flat scarring starts off slightly raised, then flattens out as it heals.
Keloid scarring is raised, overgrown scar tissue that develops outside of the wounded area.
Hypertrophic scarring, also called raised scarring, is raised and stays within the wounded area. They may flatten over time, but never completely flattens out.
Hypopigmentation is the type of scarring where the skin loses pigmentation altogether. Once skin loses its pigment, it’s gone.

Scarring is part of the healing process, showing where the skin stitched itself back together. Like PIE and PIH, this occurs in the final stages of healing. Because consistent picking can disrupt the healing process, the risk of exacerbated scarring can increase.

Unlike PIE and PIH, scarring does not eventually go away. They may become less noticeable over time, but they typically leave a lasting imprint. There are treatments to ease scarring, such as microneedling, laser treatment, injections and scar-revision surgery. These treatments should only be done by licensed, skilled professionals.

Skin Picking vs. Extractions

There is a difference between skin picking and professional extractions, however one can lead to the other if done improperly.

Extractions involve a controlled technique to remove the impaction from acne lesions in a safe manner. This technique reduces risk of scarring and helps the acne lesion heal faster.

You may be familiar with Dr. Pimple Popper, who paved the way for viral pimple popping videos. While she is a licensed physician trained to extract severe lesions like cysts, estheticians are trained to safely extract less severe acne lesions, such as pustules and non-inflamed acne lesions.

Extractions differ from skin picking by these three main components:

The skin is prepped by cleaning it and softening the surrounding skin and trapped debris for easier removal.
The tools used are prepped and used correctly.
The technique of extraction is to remove the impaction with as little damage as possible.

Skin picking typically involves repeated touching, picking, pinching and scratching the skin, usually leaving an open wound.

The Slippery Slope of At-Home Extractions

At home extractions can easily lead to skin picking if you are not mindful… trust me, I experience this myself.

In my treatment room I am mindful and grounded with what I can and cannot extract, and I have to remind myself that sometimes it’s okay to walk away from a stubborn lesion. If this is the case, then I need to bring myself back to the facts:

Is the skin prepped? When skin is dehydrated and impaired, extractions will be harder to perform.
Is there too much inflammation where I need to step away and check on it later? Sometimes letting an area settle down will allow the impaction to extract easier, it just needs a minute to settle.
Am I extracting something that may not be ready to extract? Sometimes, us estheticians have to settle on defeat and let our other tools do the heavy lifting and that’s okay.

When I taught extraction techniques to esthetics students, I always said:

“As exciting as it may be, you're not digging for gold. Calm down.”

As a picker, it’s easier to have this discipline when working on someone else's skin, but at home and with my own skin, this discipline is much harder.

When Picking Becomes a Problem

Everyone picks at their skin occasionally, and that’s normal. But when the urge becomes obsessive, compulsive, or damaging, it’s time to pay attention.

Not every esthetician agrees with my approach, but I do teach some acne clients harm-reduction techniques for picking, what I lovingly call Proper Picking Habits.

Some may believe this is a gateway to more picking, and I understand that concern, but if a client is going to pick, I would rather them know ways to do it that causes less harm to their skin. I get it, I’m a picker too. And being an esthetician who has trained in the art of picking (JK, extractions) has saved my skin from a lot of damage. Until I’m stressed.. then logic flies out the window and I forget I’m an esthetician.

We’re human. It happens.

My Professional Advice to the Picker Reading This

First and foremost…
If your picking is becoming damaging, obsessive and compulsive, I always suggest seeking medical and professional help – like, speaking to your primary care doctor about ways to manage anxiety and stress, or seeking out a therapist to talk to.

Check in on your needs:

Are you getting enough sleep?
Are you managing your stress?
How is your work/life balance?

Mental wellbeing is a key component in healthy skin, and overall living a healthy life. I know, we live in a fast-paced world that is distracting and stressful. Give yourself grace and take a minute to check in with yourself: What do you need right now?

Secondly…
Find an esthetician to help you find a solid homecare plan to support your skin needs. Regular facials are also a good way to manage breakouts.

Lastly, two pro tips for the acne-prone…

Ice your face. Whenever you get the urge to pick at your pimple, ice your skin. Icing is so good for reducing inflammation and calming your skin.
Use spot treatments or pimple patches. This will help cover the pimple to reduce touchy fingers, AND do active work to heal it.

My Final Words to my Readers (this time around)

If skin picking were just about willpower, most of us would have “stopped by now.” But it’s not. It’s about habits, stress, nervous systems, and being human in a world that asks a lot of us.

Your skin doesn’t need perfection. Your skin needs consistency, care, and compassion, just like you. Healing happens when we take a beat, ask ourselves the question we don’t want to ask (what do I need), and start giving ourselves what we need.

Sources:

International OCD Foundation. (n.d.). Skin picking disorder. https://iocdf.org/about-ocd/related-disorders/skin-picking-disorder/

Rodrìguez-de-la-Fuente, L., et al. (2020). Excoriation (skin-picking) disorder: A systematic review. Frontiers in Psychiatry., 11, 811. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7115927/

Lim, D. (n.d.). Picking acne vs. acne excoriée. https://drdavinlim.com/picking-acne-acne-excoriee/

CityMD. (n.d.). Healing step-by-step: The 4 wound healing stages. https://www.citymd.com/health-and-wellness/healing-step-by-step-4-wound-healing-stages

Cleveland Clinic. (2023). Scars. https://my.clevelandclinic.org/health/diseases/11030-scars

Face Reality Acne Expert Certification Training. (n.d.). Face Reality Education Program. (Internal training course)

Valerie Hansel