Standing in front of the mirror, fingers digging painfully into a burgeoning pimple that’s just not ready to come out is a familiar scenario for most of us. We’ve all had our moments of going just a little too far with our grooming habits, either subconsciously when we’re absentmindedly pulling on those split ends, nervously gnawing on our nails, or going overboard on those stray brow hairs after getting a little too up close and personal with the magnifying mirror. But, for Alix, a 31-year-old writer in NYC, that attention turned into a painful, unhealthy fixation.
“My personal picking brand is using sharp, pointed tweezers to get out ingrown hairs and hairs that are deep beneath the skin and nowhere near ready to come out,” she confesses. “I have extremely fair skin and black hair, so every tiny black dot below the surface appears larger than life to me. I think that if I can just get the one I focused on out, I’ll be able to move on, but once I’ve dug into my skin for 20 minutes getting to it and I now have a wound that’ll take a week to heal, I figure I might as well get them all out. It’s a sick cycle, and I can end up trapped in it for hours at a time.”
What Alix is suffering from is a disorder known as dermatillomania, commonly referred to as skin-picking. It’s just one form of body-focused repetitive behaviors—other common ones can include nail biting and hair plucking—and, according to a recent study published in the Journal of the American Academy of Dermatology, people suffering from BFRBs have self-reported that their behaviors have been triggered or increased since the start of COVID-19 pandemic (a time when face-touching, in general, has been strongly discouraged to prevent the spread of the virus). Many dermatologists have also reported seeing more patients demonstrating symptoms of BFRB.
“I have seen an uptick in face picking since the pandemic,” says Dr. Joshua Zeichner, dermatologist and Director of Cosmetic & Clinical Research in Dermatology at Mount Sinai Hospital in New York City. “Working from home and looking at our faces on Zoom all day, we are generally becoming more fixated on facial imperfections. That coupled with the emotional stress of living through a pandemic without the usual channels to relieve stress has been a recipe for disaster for many people.” Adds Dr. Doris Day, an NYC cosmetic dermatologist, “I have seen an increase in hair pulling and cuticle picking. I think it's the fear, uncertainty and anxiety around COVID-19 and the limitations and disruptions in activities of daily living and social life that has contributed to this.”
As we hit the one-year anniversary of the pandemic lockdown, we thought it would be helpful to talk candidly about this oft-ignored condition. Keep reading to hear from real people who are dealing with it and to learn from the experts on what causes BFRBs, how to identify if you have one, and what can be done to manage your symptoms.
What Causes Body-Focused Repetitive Behaviors?
Generally speaking, BFRBs like skin picking are a form of obsessive-compulsive behavior. However, notes psychotherapist and Byrdie's Beauty & Wellness Board member Michele Koury, the two diagnoses don’t always go hand in hand. “The behavior is strongly associated with anxiety and OCD, but most diagnoses operate on a spectrum; so even if you're picking, that doesn't necessarily indicate a classical OCD diagnosis,” she explains. “It may just mean you have tendencies, which are still valid to address with seriousness. On the same token, these behaviors can indicate an untapped diagnosis that may change your life to address.”
How Do I Know If I Have BFRB?
As we mentioned before, the occasional picking or pulling is a normal behavior that many experience. The difference with those who have a body-focused repetitive behavior is the compulsion—the all-consuming need to do it. “It's basically a form of release,” says Koury. “It is much like many other forms of self-harm, self-mutilation, substance abuse, or binging and purging. All of these behaviors are forms of self-soothing, and that is why they can become addictive and damaging. The relief tends to be short-lived and it usually becomes a cycle of behavior.”
For Alix, it can be any number of triggers that gets her to pull out the tweezers. “I do it when I’m bored, procrastinating, stressed and not sleeping well or exercising. It gives me something to focus on intently without having to use my brain at all, and I find that soothing.” That doesn’t mean she doesn’t understand that her behavior is problematic, however. “In my head, I keep making deals with myself, like okay, once you dig out two more hairs, you have to be done, so I do know what I’m doing in the moment and I know I should stop, but it usually takes something jolting me—like a phone alarm going off or a car horn or someone screaming on TV—for me to snap out of it and put the tweezers down,” she says.
While self-diagnosing any type of mental illness is never a good idea, you can be on the lookout for some classic signs of BFRB and use that as a stepping stone to seek help. As Koury explains, “The general rule of thumb in assessing any potentially problematic behavior is to question whether the behavior has become disruptive to your day to day. Are you picking to the point of scarring? Is your hair thinning rapidly? Are others noticing a high rate of frequency? When you try to stop, is the urge overpowering? If it's making regular functioning difficult, that's when it can be safely labeled 'serious.'”
What Are The Dangers Of BFRBs?
In addition to the psychological toll that body-focused repetitive behaviors have, they also extract a physical one. As esthetician Renée Rouleau, a former skin picker herself, describes it, “For me, [skin picking] was simply my need to feel like I was taking control of my skin by making a blemish go away faster by picking at it and squeezing it—only to eventually realize that I was only making it worse with more bleeding, scabbing and scarring.” If you are a chronic skin picker, she explains, you are most likely going to be dealing with varying degrees of scarring and hyperpigmentation as your picking continues. Dr. Onyeka Obioha, an L.A.-based dermatologist and member of Byrdie’s Beauty & Wellness Board, echoes those concerns, noting that while there are many professional treatments available, the more severe cases of dermatillomania can lead to irreversible scarring of the skin.
But skin picking isn’t the only BFRB that can cause long-lasting damage. Cuticle biting and nail chewing can lead to a scarring and deformity of the nails, called habit tic deformity, says Dr. Day. And trichotillomania (aka hair pulling) can eventually lead to the scarring of the hair follicle, after which, says Dr. Day, hair cannot regrow in that area.
While there are many professional treatments and solutions aimed at reversing the damage done by BFRBs—microneedling, radiofrequency, PRP, lasers, fillers—at a certain point, the damage may become too great for even a dermatologist or doctor to correct.
Why Can’t People Just Stop Doing BFRB?
This is perhaps one of the most frustrating parts of BFRBs and something that only drives people dealing with them into a deeper shame spiral. The most important thing anyone needs to know about this condition is that it’s not something that people suffering from it are making an active choice to do. “Skin picking, for me, isn’t a bad habit—it’s a compulsion I feel I have no control over,” explains Alix. “I get upset when I confide in people about it and they tell me to ‘just stop,’ as if I haven’t thought of that already. Dermatillomania is a mental disorder and I wish there was more awareness of how hard it is to overcome.”
Joanna Saporito, a 39 year-old teacher’s assistant in Brooklyn, agrees. “Dermatillomania wasn’t even entered into the DSM [Diagnostic and Statistical Manual of Mental Disorders] until 2013, so most of my therapists never knew what to do with me.” After Googling “non-stop skin picking,” she stumbled upon a description of dermatillomania. “I told my cousin, 'this is a thing—there’s an actual name for this.' Then I kept trying to find my own answers.”
As one Byrdie Collective member puts it, “I know better, so why can’t I stop? Being in lockdown and always on Zoom, it seems as though I care about my face looking its best. And if that’s the case, then why would I pick the imperfections so that they stand out even more? But, I can’t stop. It’s boredom, it’s frustration, it’s a blurred vision of perfection."
And the pandemic has only exacerbated the addiction for many BFRB sufferers. “It’s all the time alone in my apartment plus the lack of plans that makes it harder for me to come up with reasons not to,” admits Alix. “In normal times, I’m more motivated to look good and I can usually get myself to stop and let my skin heal ahead of a vacation or event. Right now I’m like, well, I’ll just work harder on stopping when the world opens up again.”
Rouleau has seen the same attitude from many of her clients and followers. “In a time when we don’t feel like we have control,” she says, “people are doing what they feel like they can do to have some control—and this could be picking at their skin.” Koury agrees, noting, “The pandemic has brought up loneliness, feelings of claustrophobia, anxiety, and depression for many. Everyone's different coping go-tos have magnified big-time—people are seeking ways to cope, or find release.”
What Can Be Done To Manage BFRB?
Just like with any other impulse control disorder, finding ways to manage BFRB is not a one-size-fits-all solution. Depending on the severity of your behavior and how it manifests, you may find that different approaches may have varying levels of effectiveness. For some mild pickers, like Rouleau, it was a multi-tiered approach of distraction and accountability. “I kept my hands busy with the No Picking! Twisty Toy—a fun twisty, twirly gadget that helped to keep my hands busy and off of my face,” she says. “I also created a No Picking Contract to help hold me accountable. There was something about signing something that kept me motivated. I taped it on the mirror in my bathroom as a daily reminder.” She also set an alarm on her phone—the “Don’t Do It” alarm—and set it for the nighttime when she was most likely to pick. And, most importantly, she got her loved ones involved. “I leaned on my husband for support. He knew all too well of my skin picking, so I informed him of trying to break it and asked him to help keep me strong to push through moments of weakness.”
Covering up the areas you are prone to picking can also be a helpful distraction for mild to moderate pickers, notes Dr. Day. If you are a blemish or blackhead popper, pimple stickers or hydrocolloid bandages are excellent barriers that will help keep your hands from being able to dig into your skin. (Another option Joanna swears by: finger sleeves for long drives, her “prime picking time.”) For nail fixators, Dr. Day recommends applying nail ointments that can be rubbed into the cuticles, rather than repetitively pressing or pulling on the area and for the hair she suggests gently massaging in a hair conditioner. You can also try covering up your nails with bandages or putting on a hat or cap to physically block your hands from pulling or tugging on those areas.
For those with more severe BFRB, removing the temptation might not be enough to curb the behavior. Alix, for instance, says she has thrown away more pairs of tweezers than she can count over the years in an effort to remove her main tool of enablement, only to cave and buy another pair a few days later. “If a genie could only grant me two wishes, I’d ask for Elon Musk’s money and to never pick again,” she says. “But it’s like any other addiction—it can feel like such a comforting release and put me into this Zen state for a period. I think in order for me to be able to stop, I’d need to find another coping mechanism that matches the sensation and I’m not sure what that is. I’ve tried talk therapy, tracking when and why I pick in an app, snapping rubber bands on my wrist every time I think about doing it, hanging up photos of my skin at its worst on my mirror, and hypnotherapy.” She notes that she actually did see some success with hypnotherapy (“I stopped picking for months after just one session”), but the treatment was expensive and not covered by insurance, so she wasn’t able to continue.
Seeking out professional help is a necessity for those with severe cases of BFRB, and not just from your derm. Says Dr. Obioha, “These conditions are best managed by a dermatologist alongside a therapist. Cognitive behavioral therapy directed by a therapist is really important.” Also known as CBT, cognitive behavioral therapy is a form of psychotherapy that is used on a variety of disorders, from PTSD to OCD, to help develop coping strategies and change harmful behaviors. A psychiatrist may also recommend medication to help control your compulsive disorder.
Developing a mindfulness practice can also be useful for all levels of BFRB, says Koury. “Mindfulness empowers you to notice how often you're doing it, when, and what the preceding trigger may have been. Self-awareness is always the first step to active change.” This can include things like holding a stone or some kind of grounding object, meditation, breath work, but most of all paying attention to your thoughts with practiced awareness. But, she stresses, these are only half measures. “Short-term solutions without deeper exploration of the behavior or developing a practice of awareness about the behavior might prove to be frustrating and discouraging,” she says. “If it was so easy to stop, we just would. A distressing and compulsive behavior needs to be understood and addressed holistically, so while short-term distractors may help, it’s necessary to develop a deeper awareness about what’s going on.”
What Should You Do If You Think You Might Be Suffering From BFRB?
First of all, don’t be ashamed—attempting to hide the behavior is only going to make you feel worse. “As cliché as it is, it helps to remember you’re not alone in this,” says Alix. “I’ve written a lot of stories about my skin picking and my DMs always get flooded after with women saying how much they relate and sharing their experiences. I try to just go easy on myself and not punish myself in other ways for picking. It also helps me to talk about this—it’s my biggest insecurity, but opening up about it takes away some of the shame.”
If you have the ability, seek out professional help from a dermatologist or therapist to talk about your BFRB and help find an appropriate treatment course. Remember that BFRBs aren’t just a “bad habit” that you’re just too weak-willed to break—they are a mental disorder that may require the intervention of a trained medical professional to help manage.
And, most importantly, cut yourself some slack. It’s so easy to berate yourself for doing something you know is wrong, even when it is out of your control. But that thinking will only lead to more shame and can even trigger the behavior by adding on to your stress and anxiety. As Rouleau so beautifully puts it, “Just like anything in life that we consider a struggle, it’s important to give yourself some grace from perfection. We all have our challenges, no one escapes this world without one.”
Consult a healthcare professional if you feel you are suffering from symptoms of BFRB.