Cross-sectional survey examining skin picking and hair pulling disorders during the COVID-19 pandemic
Authors: James T. Pathoulas, Sonia J. Olson, Aneela Idnani, Ronda S. Farah, Maria K. Hordinsky, Alik S. Widge
Journal: Journal of the American Academy of Dermatology (2020)

To the Editor: Body-focused repetitive behaviors (BFRBs) include repetitive hair pulling (trichotillomania), nail biting, and skin picking (excoriation disorder). The ritualized behaviors are distinct and classified among obsessive-compulsive and related disorders in the Diagnostic and Statistical Manual of Mental Disorders. BFRBs can cause distress, visible damage, and lead to social impairment. Societal changes from the COVID-19 pandemic present a unique challenge to those with BFRBs. Individuals with BFRBs have high baseline levels of anxiety and report a correlation between anxiety and symptom severity.1Keuthen N.J. Deckersbach T. Wilhelm S. et al.Repetitive skin-picking in a student population and comparison with a sample of self-injurious skin-pickers.Psychosomatics. 2000; 41: 210-215Crossref PubMed Scopus (163) Google Scholar Rapid implementation of changes to daily life, including COVID-19 social distancing directives, have the potential to compound the increased social isolation already experienced by those with BFRBS.1Keuthen N.J. Deckersbach T. Wilhelm S. et al.Repetitive skin-picking in a student population and comparison with a sample of self-injurious skin-pickers.Psychosomatics. 2000; 41: 210-215Crossref PubMed Scopus (163) Google Scholar We created a survey to examine how changes during the COVID-19 pandemic have affected those with BFRBs, including symptom severity and access to treatment. This study was exempted by the University of Minnesota Institutional Review Board. An online survey link was shared among BFRB Facebook groups and in a newsletter sent to consumers of a BFRB awareness device (HabitAware, Minneapolis, MN). Responses were collected between July 1 and July 31, 2020. Participants who indicated hair-focused BFRBs completed a modified Massachusetts General Hospital Hairpulling Scale and those with skin-focused BFRBs completed a modified Skin Picking Scale-Revised comparing symptoms before and during the pandemic.2Keuthen N.J. O'Sullivan R.L. Ricciardi J.N. et al.The Massachusetts General Hospital (MGH) Hairpulling Scale: 1. Development and factor analyses.Psychother Psychosom. 1995; 64: 141-145Crossref PubMed Scopus (335) Google Scholar,3Snorrason I. Ólafsson R.P. Flessner C.A. Keuthen N.J. Franklin M.E. Woods D.W. The Skin Picking Scale-Revised: factor structure and psychometric properties.J Obsessive Compuls Relat Disord. 2012; 1: 133-137Crossref Scopus (85) Google Scholar Paired-samples t tests were used to compare means. A total of 460 individuals with a self-reported BFRB diagnosis completed the survey (Table I). Skin picking was reported by 133 (28.9%) participants, hair pulling was reported by 181 (39.3%) participants, and 141 (30.7%) participants reported both. A majority (67.2%) reported increased BFRB symptoms during COVID-19. Of the 145 (31.5%) participants receiving active treatment for BFRBs, 55 (37.9%) experienced an interruption in therapy because of COVID-19. Those with skin picking disorders reported a significant (2.2) increase on the modified Skin Picking Scale-Revised (P = .00). Participants with hair pulling disorders reported a 1.6 point increase on the Massachusetts General Hospital Hairpulling Scale (P = .01; Table II).Table IDemographics, therapy, and dermatologic careCategoryAge, y, mean (SD)32.5 ± 12.4Diagnosis, n Formal BFRB diagnosis460 No formal BFRB diagnosis, excluded25Location, n (%) United States342 (74.3) Outside of the United States118 (25.7)Race, ethnicity, or origin, n (%)Asian or Pacific Islander15 (3.3)Black or African American7 (1.5) Hispanic or Latino15 (3.3) Middle Eastern or North African4 (0.9) White411 (89.3) Other race, ethnicity, or origin8 (1.7)Gender/gender identity, n (%) Transgender11 (2.4) Nonbinary9 (2.0) Genderqueer∗Genderqueer is as a term for self-identification and includes those who have a gender identity that does not align with sex assigned at birth. For more information, see the American Academy of Dermatology Lesbian, Gay, Bisexual, Transgender, and Queer Sexual and Gender Minority Expert Resource Group position statement on Sexual and Gender Minority Health in Dermatology, available at https://server.aad.org/Forms/Policies/Uploads/PS/PS-Sexual%20and%20Gender%20Minority%20Health%20in%20Dermatology.pdf?.5 (1.1) Female457 (99.3) Male13 (2.8) Chose not to disclose1 (0.2)BFRB classification, n (%) Repetitive skin picking133 (28.9) Repetitive hair pulling181 (39.3) Both141 (30.7) Other BFRB5 (1.1)Self-rated impact of COVID on BFRB, n (%) Improved60 (13.0) No change81 (17.6) Worsened309 (67.2) No answer10 (2.2)BFRB therapy, n (%) Active treatment for BFRB before COVID145 (31.5)Interruption to active treatment because of COVID55 (37.9)No active treatment for BFRB before COVID315 (68.5) Desire to start therapy since COVID127 (40.3)Dermatologic care, n (%) History of dermatologic care249 (54.1) History of dermatologic care for BFRB55 (12.0)∗ Genderqueer is as a term for self-identification and includes those who have a gender identity that does not align with sex assigned at birth. For more information, see the American Academy of Dermatology Lesbian, Gay, Bisexual, Transgender, and Queer Sexual and Gender Minority Expert Resource Group position statement on Sexual and Gender Minority Health in Dermatology, available at https://server.aad.org/Forms/Policies/Uploads/PS/PS-Sexual%20and%20Gender%20Minority%20Health%20in%20Dermatology.pdf?. Open table in a new tab Table IIModified Skin Picking Scale-Revised and modified Massachusetts General Hospital Hairpulling Scale scores before and after COVIDScale and scorePre-COVID meanCOVID meanMean differenceP valueSPS-R (modified) scale item (0-4) Overall urge1.82.20.4.00 Intensity of urges1.82.30.4.00 Time spent picking skin1.61.90.3.00 Control over skin picking behavior2.12.50.3.00 Emotional distress from skin picking1.71.90.2.02 Social impairment caused by skin picking1.11.20.2.05 Social avoidance behavior0.81.00.2.00 Physical damage to skin from skin picking1.61.70.2.00Total modified SPS-R (max 32)12.514.72.2.00MGH-HPS (modified) scale item (0-4) Frequency of urges2.22.60.4.00 Intensity of urges2.32.60.4.00 Ability to control the urges2.02.30.2.02 Frequency of hairpulling1.82.00.3.01 Control over hairpulling2.93.00.11.03 Associated distress2.32.50.2.02Total modified MGH-HPS (max 24)13.515.11.6.01MGH-HPS, Massachusetts General Hospital Hair Pulling Scale; SPS-R, Skin Picking Scale-Revised. Open table in a new tab MGH-HPS, Massachusetts General Hospital Hair Pulling Scale; SPS-R, Skin Picking Scale-Revised. For those with BFRBs, the COVID-19 pandemic has led to increased symptoms. Although this study was limited by modification of standardized scales and its self-reported survey design, it suggests that anticipated psychologic effects of the pandemic are, in fact, materializing. Respondents with both skin and hair BFRBs reported increased distress and functional impairment. BFRBs are psychiatric disorders with dermatologic manifestations. While only 12.0% of those surveyed in our study reported seeing a dermatologist for their BFRB before COVID-19, the rapid spread of telemedicine may change that. Dermatologists should be aware that those with BFRBs may be experiencing increased skin picking and hairpulling during COVID-19. Proactive outreach to existing patients with BFRBs may be helpful. Although there are no treatments for BFRBs approved by the US Food and Drug Administration, treatment options include serotonin reuptake inhibitors, N-acetylcysteine, behavioral therapies, and wearable devices.4Sani G. Gualtieri I. Paolini M. et al.Drug treatment of trichotillomania (hair-pulling disorder), excoriation (skin-picking) disorder, and nail-biting (onychophagia).Curr Neuropharmacol. 2019; 17: 775-786Crossref PubMed Scopus (31) Google Scholar,5Himle J.A. Perlman D.M. Lokers L.M. Prototype awareness enhancing and monitoring device for trichotillomania.Behav Res Ther. 2008; 46: 1187-1191Crossref PubMed Scopus (15) Google Scholar In addition, many health systems have expanded telemedicine capabilities. In the context of lessened geographic and social barriers (eg, appearance stigma), patients with BFRBs may have greater access to treatment. Thus, it is more important than ever for dermatologists to consider BFRBs in their differential diagnosis and management. Ms Idnani is the cofounder and president of HabitAware. HabitAware did not provide any funding for this study. The remaining authors have no disclosures. We acknowledge the members of the body-focused repetitive behaviors social media community who helped disseminate the survey.