How to Stop Picking Skin: Barriers, a Competing Response and Aftercare

About this tool

How to stop picking skin is a question many people ask quietly, and it has a worked answer. Repeated picking that damages the skin, that has survived repeated attempts to stop, and that causes distress or gets in the way of daily life is recognized in the American Psychiatric Association's DSM-5-TR as excoriation disorder, also called skin picking disorder or dermatillomania. It sits in the obsessive-compulsive and related disorders chapter alongside hair pulling. Grant and Chamberlain surveyed 10,169 US adults in 2020 and found that 2.1 percent met criteria for current skin picking disorder and 3.1 percent for the disorder at some point in life.

Picking splits into two styles, and the plan depends on which one you mostly do. Focused picking is deliberate: you go to the mirror, you are working on something specific, and there is often a sense of relief or satisfaction when a bump is finally gone. Automatic picking runs in the background while you read, drive, work or watch something, and you discover it afterward from the evidence under your nails. Most people do both, in different places and at different times of day, which is why the first section of the worksheet below asks about times and places rather than motives.

Mansueto and colleagues set out a comprehensive behavioral model for hair pulling in 1999, usually shortened to ComB, and clinicians apply the same map to picking, which is a useful map even outside therapy. It organizes what keeps picking going into domains: sensory, meaning the roughness or texture your fingers hunt for; cognitive, the rules and permissions in your head such as just this one; affective, the tension, boredom or relief around the episode; motor, the movements and postures involved; and place, the rooms, mirrors, lighting and times of day where picking actually happens. A plan that touches two or three of these domains usually outperforms one that only tries harder.

Habit reversal, the method Azrin and Nunn introduced in 1973, is the behavioral core, and for skin picking it has direct support. Teng, Woods and Twohig randomized 25 adults with chronic skin picking in 2006 to habit reversal or to a wait-list, and reported reductions in picking in the treated group. Schuck, Keijsers and Rinck ran a larger comparison in 2011 with 34 adults assigned to four sessions of cognitive behavior therapy or a waiting list, and found the treated group improved more on picking severity, psychosocial impact, picking-related beliefs and skin damage, with gains holding at a two-month follow-up. Both trials are small, and both were conducted with motivated volunteers.

The honest summary of the evidence is that the best supported approach rests on a narrow base. Lee, Mpavaenda and Fineberg reviewed randomized trials of habit reversal across the obsessive-compulsive related disorders in 2019 and found only two in excoriation, with reporting quality they judged questionable against standard criteria, and concluded that a gap remains in the literature. That does not argue for doing nothing. It argues for working the plan for two weeks and reading your own counted results, rather than expecting a published success rate to apply to you.

Barriers, the stimulus control half, do the work while you are not paying attention. Pick your worst setting first and make picking inconvenient there. Cover or step away from the magnifying mirror, since magnification and bright light turn ordinary skin into a list of jobs. Put a timer on bathroom time. Keep tweezers, pins and extraction tools out of the house or at least out of that room. Keep nails filed short and smooth, and try tape, a plaster or thin gloves on the two fingers that do the most work during your highest-risk hour. Fewer tools means fewer episodes.

The competing response is what replaces the behavior in the moment. When you catch a hand traveling to your face, hold a position that cannot coexist with picking for about a minute: loose fists resting on your thighs, palms pressed flat together, hands under cool running water, or hand cream worked slowly into both hands. The one minute matters because urges rise and fall rather than building forever, and holding still through the peak teaches you that directly. Choose something you would actually do in public, since picking does not wait for privacy.

Aftercare is where most plans quietly fail, because the inspection is the first link in the chain. Decide now what you do with damaged skin: clean it gently, cover it, and change the dressing once a day at a fixed time, which is ordinary wound care and is different from the inspecting that starts an episode. Apply cream without a mirror. Look for signs of infection, such as spreading redness, heat, swelling or pus, and see a clinician if they appear. A covered wound that is not reopened heals faster and scars less, and a dressing is also a physical barrier. If an active skin condition keeps producing targets, treating that condition with a dermatologist removes work from the plan rather than adding to it.

Shame is the part that keeps this going for years. People cover marks with makeup and clothing, avoid photographs, swimming and bright rooms, give vague explanations about an allergy, and arrive at a first appointment having told no one at all. Secrecy has a practical cost: it removes the support that habit reversal relies on, and it makes every lapse feel like proof of something about your character rather than a Tuesday evening with a bright bathroom light. Working on that is a lane of its own, and the How to Deal With Shame guide is a reasonable place to start alongside this plan.

Two kinds of appointment deserve naming. Medically, infection is the one to act on: spreading redness, warmth, swelling, pus, a wound that is not healing, fever, or scarring you want assessed, and a dermatologist can also treat the acne or eczema underneath. Psychologically, the markers are time lost to it, distress, avoidance, and attempts to stop that have failed over years. Grant and Chamberlain also found high rates of co-occurring conditions, so a broader look is often useful: the Dermatillomania Test (Skin Picking) screen is specific to picking, and the BFRB Test (Hair Pulling, Skin Picking, Nail Biting) screen covers picking, pulling and biting together.

The worksheet below is our own design, informed by the habit reversal and ComB literature cited here rather than copied from any published or copyrighted instrument, and it is educational rather than treatment. Keep the review concrete: count episodes for one day before you start and one day two weeks later, note how many areas are healing, and record which single barrier actually interrupted a real episode. Keep that one, drop the rest. A short plan that stays in place beats a long plan you abandon after the first bad week.

Reviewed by Michael Callans, MSW
Checked that the focused and automatic distinction, the ComB domains and the habit reversal steps match the cited sources, that trial sizes are stated plainly, and that infection and scarring are sent to a dermatologist rather than handled on the page.

References

1. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 5th ed, text revision. American Psychiatric Association Publishing; 2022.
2. Grant JE, Chamberlain SR. Prevalence of skin picking (excoriation) disorder. Journal of Psychiatric Research. 2020;130:57-60. https://doi.org/10.1016/j.jpsychires.2020.06.033
3. Teng EJ, Woods DW, Twohig MP. Habit reversal as a treatment for chronic skin picking: a pilot investigation. Behavior Modification. 2006;30:411-422. https://doi.org/10.1177/0145445504265707
4. Schuck K, Keijsers GPJ, Rinck M. The effects of brief cognitive-behaviour therapy for pathological skin picking: a randomized comparison to wait-list control. Behav Res Ther. 2011;49(1):11-17. https://doi.org/10.1016/j.brat.2010.09.005
5. Mansueto CS, Golomb RG, Thomas AM, Stemberger RMT. A comprehensive model for behavioral treatment of trichotillomania. Cognitive and Behavioral Practice. 1999;6(1):23-43.
6. Lee MT, Mpavaenda DN, Fineberg NA. Habit reversal therapy in obsessive compulsive related disorders: a systematic review of the evidence and CONSORT evaluation of randomized controlled trials. Frontiers in Behavioral Neuroscience. 2019;13:79. https://doi.org/10.3389/fnbeh.2019.00079
7. Azrin NH, Nunn RG. Habit-reversal: a method of eliminating nervous habits and tics. Behav Res Ther. 1973;11(4):619-628. https://doi.org/10.1016/0005-7967(73)90119-8

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