Stimulant Induced Skin Picking

Skin Picking pattern and effect on the skin

Problematic Skin Picking

For the first time, BP looks  into an increasingly common and distressing manifestation of excessive cocaine / stimulant use: Skin picking. Hours spent in front of mirrors squeezing and tweezing as the smallest of spots becomes a painful wound. Hair pulled out, bugs under the skin, insects or mites in your clothes and house. BP helps shed some light on this extremely upsetting, hidden behaviour, examining the chemistry behind why it happens and the role cocaine /stimulants have to play.

Skin picking due to excessive crack cocaine use has become more common as more people use crack problematically and we are now seeing a variety of health issues arise because of it. However, skin picking through stimulant overuse is complex. Medically, skin picking in this context is seen as a compulsive foraging response (CICF – ‘cocaine induced compulsive foraging’) but the compulsion to skin pick has also been called psychogenic excoriation, delusional parasitosis, self-inflicted dermatoses, dermatillomania, formication, or hypoesthesia; which is quite surprising considering that there has been so little research on the subject.

It’s characteristics include excessive scratching, picking, gouging, lancing, digging and squeezing of normal or slightly marred skin. Most commonly picked are fingernails, face, lips, scalp, arms and legs. This is because drugs like cocaine, methylephenidate, phenelzine amphetamine and anticholinergic drugs often produce increased nerve activity – tactile sensations like burning, tingling and crawling (worms under the skin) that can lead to skin picking. It might help to know that in (involuntary) drug trials, excessive doses of amphetamines were administered to horses, rats and dogs, all which led to self-injurious behaviour – excessive grooming, licking, pawing etc. So while it is clearly a chemical reaction to the drugs you’re taking, (there is really nothing under your skin) it can however, be closely linked with psychological issues such as extreme anxiety or childhood trauma. So why do some people skin pick excessively, where others don’t? And why is it most common in Caucasian women?

Studies suggest that it’s a coping mechanism for dealing with emotional pain. Physical pain distracts the individual and can help to alleviate feelings of guilt through self punishment. Many S-P’s (skin pickers) report increased levels of tension prior to skin picking and a sense of relief or satisfaction following the picking. Some experience an altered state of consciousness whilst picking – resembling a dissocialised state. However, lack of pain during picking episodes may also be related to opioid dysregulation. We can see elevated levels of B-endorphin in S-Ps, because pain, in this case through self-injurious behaviour, leads to the release of B-endorphins, which in turn leads to the release of tension.

Victims of childhood abuse often have elevated levels of B-endorphins too, in their CSF (cerebrospinal fluid) in the brain, because of repeated exposure to pain, or from being prohibited to reacting to the infliction of pain. Women with a history of childhood abuse also exhibit increased pituitary adrenaline and automatic heart rate responses to stress. Those with a current major depression diagnosis exhibite a more than 6-fold greater ACTH (adrenocorticotropic) response than their age-matched controls.

So in many cases, skin picking is a chemical reaction that has been built up from past trauma, where a person’s elevated b-endorphins or ACTH response is reacting with the drug they’re taking: crack cocaine.

Cocaine increases the activity of dopamine, a neurotransmitter in the automatic nervous system associated with pleasure which is important for reinforcement of behaviour.However, for reasons we don’t have the space to go into, too much use of cocaine can lead to a lack of dopamine in your system, which in turn leads to mood and anxiety disorders.

S-Ps often suffer from one or more of the following conditions: major depression, bipolar disorder (manic depression), dysthymia (depression tendencies), panic attacks, agoraphobia, post traumatic stress, obsessive compulsive disorder, eating disorders, trichotillomania (hair /eyelash/bodyhair pulling), kleptomania (compulsive stealing of objects), and body dysmorphic disorder (hated self image). In a 2002 study, more than half of the individuals with serious skin picking conditions also reported a history of body rocking, thumb sucking, knuckle cracking, cheek chewing and head banging.

Skin picking causes a lot of distress. Embarrassment and shame can lead to impaired social functioning and in some cases people withdraw altogether from social activities and confine themselves to their home. Some people also experience medical complications as a result of skin picking, like ulcers, infections, permanent discolouration and scarring. Too much scratching leads to open wounds and sores and when this is combined with injecting, infection can travel from the skin to the blood, causing serious illnesses such as septicemia or endocarditis.

Cocaine Induced Psychosis & ‘Foraging’

Chronic cocaine or crack use can result in cocaine induced paranoia (CIP) and coke-induced compulsive foraging (CICF) type behaviours. ‘Compulsive foraging’ covers a cluster of cocaine induced behaviours of which skin picking is just one. Another ‘foraging disorder’ is when coke users hunt for hours for specs of cocaine around a place where it was once used (also called ‘surfing’). Food deprivation or hunger increases the probability of foraging responses and because it’s an appetite suppressant, coke can make users vulnerable to malnutrition thus continuing foraging behaviour. Skin picking is a foraging response.

Case studies of stimulant psychosis reveal a progression of behavioural attitudes from heightened curiosity, repetitious examining, searching, sorting, to suspiciousness and the search for underlying/hidden meanings, to a more severe stage of hallucination, persecutory delusions and fearful, agitated hyper-reactivity!

Parasites & Skin Picking

Most bodily sensations of an ‘infestation’ are caused by metabolic disorders (including cocaine/stimulant use) or other medical problems. Certainly stopping drug use will greatly reduce, if not stop, symptoms of drug-induced feelings of parasitosis but until then, it is extremely hard if not impossible for the sufferer, even with adequate medical advice to believe it is not real.

Delusional Parasitosis’ is defined as a medical disorder in which the person has a mistaken belief of being infested by parasites such as mites, lice, fleas, spiders, worms, bacteria, or other organisms. The bases of this belief are sensations in the skin that are very real to the person. These sensations of irritation, itching or of crawling organisms are so real that you can rightfully believe that something is there. Usually, the sufferer scratches the itches, but they don’t go away. More scratching leads to rashes, open wounds and sores, then infections. Failure to obtain relief from over-the-counter or prescribed medications often drives the sufferer to apply unconventional and sometimes highly toxic compounds to his or her body in a desperate attempt to alleviate symptoms. Skin conditions become worse or much more complicated. When combined with intravenous injecting, infection again travels from the skin to the blood causing serious illness. Sometimes parasites are thought to be in the house, bed, walls etc.

Delusional parasitosis can become overwhelming, because it tends to heighten stress levels and, in turn, is also increased by stress. Reducing stress and cocaine use will help end or rapidly reduce delusional parasitosis but when delusional parasitosis occurs and is persistent, there are drug treatments available that can alleviate symptoms, at least temporarily. Don’t suffer in silence.

Social advise and support isn’t always enough and although stopping drug use would in turn quite probably stop the picking, things aren’t always that easy to do and other ‘self harm’ or anxiety related behaviours could develop. Behavioural psychotherapy can however, be very helpful. CBT –Cognitive Behavioural Therapy and a practice called ‘Habit-Reversal’ have both proved effective. As part of the treatment, the SP learns to recognise situations or stressors associated with the behaviour and records the episodes of scratching. Exercises that are incompatible with scratching are also developed, such as clenching fists when any urge to scratch occurs. Dermatologists and therapists/psychiatrists can work together to develop treatment protocols that minimise risk and maximize therapy for the patient.

Treating Skin Picking

In terms of medication, ‘SSRI’s – ‘selective serotonin reuptake inhibitors’ (antidepressants) are particularly effective. This is because people who suffer with depression and anxiety disorders tend to be lacking in serotonin, a neurotransmitter in the brain that helps interconnect brain cells that in turn send messages from one nerve to the next. Drugs like SSRI’s work by allowing the body to make the best use of the reduced amounts of serotonin that it has in it’s system at the time. In due course, the levels of natural serotonin rise again and the SSRI’s can be reduced and withdrawn. Antipsychotics are also used with effect.

Soothing creams that contain CORTISONE can bring immediate relief and help avoid the urge to scratch. NB. Don’t administer CORTISONE on your face without consulting your doctor first. If possible, have a chat with your local pharmacist.

Food: Because cocaine is an appetite suppressant, it can make users vulnerable to malnutrition, and food deprivation increases the probability of skin picking. Therefore it is even more important to eat something at least an hour before you intend to have a crack session, particularly foods high in vitamin B such as bananas, beans, avocados, brazil nuts, oats and fish.

If none of the above work: try and seek help. There are things that can be done to help you through it – including various support groups via the net or in person. If your sores become inflammed, red, are warm or hot to the touch, are weeping or generally look infected, seek medical advice urgently. Or stop in at your local needle exchange or drop in centre to get it looked at (some will also dress wounds with the appropriate bandaging.This can prevent septicemia (blood poisoning) occurring).

Like all stimulants, overuse or long term use can lead to heart problems with many added problems occurring relative to the way one ingests their coke (injecting, smoking, snorting etc). Remember, the use of stimulants can chemically induce and encourage skin picking behaviours. If you are ‘seeing and/or hearing’ parasites or organisms under your skin; spend hours picking your skin in front of mirrors; are using tools or special equipment to pick or gouge the skin; aren’t going outside because of embarrassment over sores; have infections from picking; or are unable to stop picking, please consider getting medical help or at least following some of the advice given above.

There are things that can be done to help.

See how to care for yourself if you do skin pick

Are You Skin Picking?

Points to Remember:

+Always eat something before a cocaine session like bananas, avocados, brazil nuts, fish, and take B vitamins (B complex is best). It terms of healing wounds, protein and vitamins—obtained by eating a good, well-balanced diet—are essential. Of particular importance is the mineral zinc. Good sources of zinc include roasted pumpkin and sunflower seeds, Brazil nuts, Swiss and cheddar cheeses, peanuts, dark meat turkey, and lean beef.

+Try and resist urge to scratch by doing something else (clenching of fists, eating or chewing gum, working on your hobby, washing up, jigsaws, – get involved in doing something else until the urge passes.)

+Put on cortisone cream on to prevent the urge (if you have a good pharmacist or GP –Ill check with mr stern for names of creams and prices). Perhaps your partner could rub creams into the areas you cant reach.

+Sometimes, reducing other anxieties in your life can help you reduce your picking as it can increase in severity as other life pressures increase.

+If you skin pick and are using needles to inject, it is crucial you wash your hands and injecting site before and after having a hit – bacteria is very easy to transmit and using syringes can mean germs get a free ride into your bloodstream – this can even be fatal.

+Don’t use anything rusty, extremely sharp, or dirty to itch or pick with, particularly on those areas you can’t see such as your back, back of the head etc. Keep things such as tweezers, scapels, blades etc out of easy reach and view.

+Always try and be as sterile as possible to avoid infections occurring, alcohol swabs to clean the area or the tool you use to pick with can be helpful. Try and get rid of your magnifying mirrors, specialist torches, scalpels etc.

+Keep your skin moisturised so it doesn’t get ‘dry or scaly’ and thus easier to pick.

+ Are you isolating yourself? It can be particularly difficult for women who have picked their faces and arms to go out on the street etc .Thus it can be a self perpetuating condition – rising anxiety from the wounds caused from picking, hiding indoors hoping they’ll heal, scoring to relieve the isolation and boredom of staying indoors, leading to more anxiety and picking…

+ It can be important to distinguish what is causing the skin picking – while drug toxicity can bring on skin disorders, so can drug reactions, infections, infestation (eg, scabies), and xerosis.

+ A wound that heals quickly and neatly is less likely to develop a scar than a wound that festers. Make sure all your cuts and scrapes are properly cleaned (hydrogen peroxide is a good cleanser), and try to keep the wound slightly moist with an antibiotic ointment while it is healing. Using vitamin E oil on skin reduces scarring. (all references avail from Black Poppy).

Black Poppy Issue 12.

Leave a comment

15 Comments

  1. Luke Skywalker

     /  June 14, 2014

    The use of some stimulants – even the legal ones – like Methylphenidate in certain doses causes my skin to break out and become very oily and clogs my pores. I’ve always been able to squeeze out the whiteheads and blackheads with no problem…. until about a year ago. Then, all hell broke loose and that started my “picking” demise!
    It’s a combo of old habits dying hard and then actually not being able to control it once I start. I’ve done this over and over again- and now have so many ugly scars on what was once a beautiful face. I also have Fibromyalgia and suffered constant trauma in my youth. It seems that there’s no easy way – either I get great energy from the Concerta/ Ritalin and have ugly skin that requires several layers of the most expensive make up – or I’m exhausted at home alone – unable to enjoy much of anything.
    I am glad to see this article- because until today- I didn’t know anyone else suffered this way. I DO get into this “zone” and don’t mean to go overboard but I always start with just an innocent peek in the mirror to make sure I’m looking OK- then one little squeeze leads to 30 separate scars, scabs, gouges, and blemishes that aren’t even my doing.
    I had nice skin all my life- and now that I’m in my 50’s…… I have the worst complexion ever. Maybe I’ll be able to control it – but the only way is to NOT even start! I guess I’m lucky I don’t feel bugs or any of that stuff- but I have to face that I’m not well and this is just another symptom inn a long list of ailments us humans suffer this side of Heaven.
    At least I’m not vain anymore- and I have so much compassion for those who suffer much worse conditions. I hope this helps others who might feel ashamed for only being human and trying to get by as best as they can.

    Reply
    • Hi Luke. I had a serious amphetamine habit in my youth, and I sympathise with you. The skin-picking habit you describe is called ‘knick-knacking’, and is often found among regular/heavy stimulant users. In its worst form, it’s combined with the tactile hallucination of itchy/tickling sensations on the skin (formication), or even the delusion that insects or bugs or crawling around on or inside the skin (parasitosis). When stimulant use is stopped, this habit and any accompanying hallucinations/delusions usually go away. But stimulant use – along with poor sleep, eating and hygiene habits – can also lead directly to spots and zits breaking out on your skin. Whether or not you are picking at ‘real’ spots/zits, or imaginary ones, being on stimulants tends to make you overdo it, and – as you say – you end up covered in more and bigger spots, along with scabs and scars.
      Apart from stopping using or reducing your use of stimulants, there’s only so much you can do. The best advice I can give you is: (1) try to avoid looking in mirrors except when you really have to; (2) try to learn to limit your skin-picking, and when you do it, make sure that your hands and nails have been washed clean, along with the area of skin you are focusing on; (3) use antiseptic/anti-bacterial ointments on the spots/zits; (4) when feasible, put plasters or bandages over areas of skin badly affected, so that you can’t pick at them any more; (5) put little signs up on or by your mirrors, saying stuff like ‘STOP PICKING!’.
      Answered by Dr Nuke.
      Additional answer by Erin:
      6) actually getting rid of mirrors, especially hand held ones helps somewhat, and remove everything that could possibly be used to pick with OFF the coffee table, out of easy access, throwing real common culprits you use, away. Up your B12 and B complex vitamins and foods. Keep your nails very short and clean. And when it starts, if you have partner with an agreed with you ‘enough’ word that they use when its getting excessive, do it. And try the great distraction technique s. Find something else to obsess about! May the Force be with you.

      Reply
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    Reply
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  4. Sean

     /  October 10, 2013

    Excellent article. I am very glad that my cocaine use has been minimal over the years, as I think my dermatillomania would be far worse than it already is, and it is very, very bad! Despite being able to relate to being the subject and victim of emotional pain during my earlier years, I am sceptical about its supposed relation to dermatillomania.

    I don’t pick my skin in response to stress, on the contrary most of my skin picking is done during moments in which I am relaxing. I can temporarily solve my dermatillomania by wearing an item of clothing which covers the area of skin that I would otherwise pick. However the moment the item of clothing is taken off (when changing into your pajamas for instance) then bam! I’ll be in a dream like state of repeated picking that can go on for up to an hour or more!

    It is an impulse control disorder rather than a compulsive disorder IMO, and very similar to a substance misuse disorder. My gratification through dermatillomania is derived from two sources; there is visual gratification based upon the manner and the amount of sebum that is expelled from the skin through picking and squeezing certain areas of my skin, and there is physical gratification through the pain which can sometimes be felt when expelling sebum from the skin. The gratification is definitely felt in the brain, and the buzz in your brain sometimes feels very similar to the effects of cocaine after a prolonged picking session.

    Reply
    • Hi, thanks so much for writing in, and I’m so glad u liked the article and u raised some interesting points for sure. As I understand it, you are indeed feeling a relaxing surge of, well, calm and wellbeing, from squeezing, picking etc, the actual action of doing it is a form of release, as you so eloquently explain and at the exact moment you are picking or creating pain, b-endorphins flood into the brain causing you to feel better. A compulsion pushes one forward to re seek that calming effect and the more one sees ‘progress’ such as by drawing blood, removing a scab etc, the bigger the flood of endorphine chemicals, essentially reinforcing ones behaviour. It can be hard then of course to see where the stress comes in once it has become a common occurance but the stress is in fact there. It emerges when you see, the next day, the damage you have inflicted on your skin, and its looking back at you in the cold hard lite of day and it hurts! Often one has no real idea that it went that far, you never meant to really hurt yourself….they seem to be saying, for those with childhood trauma, who have developed elevated levels of b-endorphins in order to cope with deep past pain, also carry an increaed adrenaline response to stress, almost I guess like being hyper vigilant and using a dramatic response in order to sooth oneself, so it really is, like u say, a comforting thing to engage in. however, I’m sure u have experienced the very upsetting side effects of this behaviour, but its hardto stop because like drug use, it constantly reinforces itself because you physically and emotionally get a positive initial response from it. But it is a painful and highly stigmatizing condition that, becoz of peoples reactions, one withdraws further, avoids intimacy, or sharing ones struggle.I hope u got some ideas as to hpw u might take things forward when and if u ever wish too. For sure tho, ditching the coke for a while should help considerably but counselling, particular antidepressants have really come to be helpful if u can get someone experienced in dermotillomania or psychogenic excoriation. In the meanti, perhaps embraace the tips on superfoods, cotisone creams, and removing ‘instruments for picking’ from reach near sofa and bed etc. Thanks so much for ur fascinating insights. Respect, bp xx

      Reply
  5. Beth

     /  April 20, 2013

    Are these skin sores contagious??? If someone touches these sores can they get an infection and start to have skin problems???

    Reply
    • No they are not contagious however if they are infected and green, red, or with pus and angry looking, they can be infectious when the germs from them get deposited by touch into another lesion -either on the person themselves therby spreading the infection, or onto someone else so long as they have an open sore for the infection to get into and take a hold. Hope that helps, otherwise dont touch other peoples sores, squeeze them and then end up squeezing your own sores – bad idea! Normal hand to hand touching should be fine but always best to wash hands after seeing someone with lots of open sores etc.

      Reply
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  7. I’ve been absent for a while, but now I remember why I used to love this website. Thanks , I will try and check back more often. How frequently you update your website?

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  8. Excellent blog you have here but I was curious if you knew of any forums that cover the same topics discussed in this article? I’d really like to be a part of online community where I can get feedback from other knowledgeable individuals that share the same interest. If you have any suggestions, please let me know. Thanks!

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  9. Susan

     /  March 7, 2013

    Thank you, thank you, thank you. I am so relieved to have read this article. I have “foraged” for info on this topic and have never found anything that addressed the issue so clearly, accurately and without judgement. I appreciate it :)

    Reply
  10. Nilsa Glunz

     /  February 6, 2013

    Scabies is a skin condition caused by infection with scabies mites (Sarcoptes scabiei). Scabies mites are microscopic parasite organisms that burrow deep inside the skin, causing inflammation, itching and rash. Later symptoms of scabies are: crusty aspect of the skin, pustules, blisters and nodules. Most of the symptoms generated by scabies are actually allergic reactions to the mites’ eggs and feces which are toxic to the human body. Skin rash is the first symptom to occur when suffering from scabies, emerging after only a few days from contamination with the parasite mites. Scabies rash is very persistent and it can last for up to several weeks or months after the mite infestation has been eradicated…

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    Reply
    • Tee

       /  April 18, 2014

      There’s also demodex and Norwegian Mites. Not in the drug users mind at all. Everyone has them but lowered immune system makes them get out of control.

      Reply
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