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 and other stimulants have to play.
Skin picking due to excessive crack cocaine use (or amphetamines) has become more common as more people use crack and meth problematically and we are now seeing a variety of health issues arise because of it. However, skin picking through stimulant overuse is really quite complex. Medically, skin picking in this context is known 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.
“...Skin picking in this context is known 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 (Ritalin), phenelzine, amphetamine and anticholinergic drugs often produce increased nerve activity – actual tactile sensations like burning, tingling and crawling (that feel like worms just 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 – which manifested as 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 but it is understandable that you feel like there is something there, as nerve endings over react) 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?
(updated Dec 2015)
Habit Reversal Training (HRT) encourages one to seek either alternate hand activities or ones that prevents you from using your fingers to pick. Keeping your hands busy or distracted from the act of pulling or picking, for example, by using a handled mirror when applying make-up because then both hands are occupied and cannot pick while holding the mirror. Other distractions and activities to keep your hands busy such as craft activities and, interestingly, pickers talk about using bubble wrap, keeping a small square in your purse or desk, wherever your picking environments tend to be so that you may pop the bubble wrap instead of picking your skin! Sounds like it could actually work!
But for many people, skin picking is closely linked to the anxiety that grows after the drugs have gone, especially in relation to crack or coke. Relaxation will be essential here, and you CAN help yourself chill after coke use -meaning, you can certainly make any ‘leftover’ wiredness and anxiousness, get a lot worse if you let it build up. Easier said than done, we know. It is important to remove yourself from any situations that make you anxious -people, places, things. Music helps to calm and relax people, and can takes away the urge to start picking when confronted with a situation that causes anxiety. Regular sufferers of Trichotillomania should not use only one technique in order to reduce picking, but should employ the different tools in conjunction with one another.
Another effective method of CBT is the use of stimulus control. One of the most important things you can do if you suffer from Trichotillomania is to reduce your exposure to stimuli in your environment that triggers picking. Dana mentions in the video that,
…mirrors and good lighting are the enemies of skin picking
Many skin pickers describe mirrors as huge triggers for engaging in skin picking. It is no surprise then that many skin pickers pick in the bathroom. Not only is there a mirror you can lean in very close, but the lighting in bathrooms also tend to be conducive to close inspection of one’s own skin. Covering all the mirrors in the house and leaving only a small square open right at the top so that you have to stand on your tiptoes to see yourself in the mirror, can actually help. It’s difficult to balance and pick at the same time so this reduces the behaviour. It’s also a good idea to dim the lighting in your bathroom, making it harder to see the skin.
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).
In addition to this article BP has added this interesting information about the opiate induced itch. It may be worth looking into opiates if a skin picking person is also on a methadone ‘script, for example. An interesting, though slightly different angle to skin picking. Follow this link for additional detailed information on skin ‘itching’ which covers treatment options, tests, research etc
When injected intradermally, some opioid agonists cause local itching and a typical histamine weal and flare response, e.g. morphine and methadone. In contrast, intradermal fentanyl and oxymorphone do not. Further, although H1‐antihistamines relieve the local itch of intradermal morphine injection, naloxone does not when morphine 5 μg or more is administered. Nor does naloxone prevent the release of histamine from mast cells incubated for 45 min in solutions containing various concentrations of morphine sulphate. This indicates that histamine release by intradermally injected opioids is not opioid receptor‐mediated.
Generalized itch occurs in about 1% of those who receive an opioid agonist by mouth or by subcutaneous or intravenous injection, and in 10–90% of patients who receive spinal opioids for labour pain or peri‐operatively. The incidence depends on which opioid is used and whether the patient is opioid‐naïve. After spinal injection, itch spreads rostrally through the thorax from the level of the injection, and is characteristically maximal in the face. In some patients it is limited just to the nose. (This may explain why patients given opioid premedication before endoscopy are often observed scratching their nose.)
In contrast to itch induced by opioids injected intradermally, histamine release from dermal mast cells isnot responsible for itch induced by clinical doses of opioids administered spinally or systematically. In these circumstances, the itch is relieved by naloxone but not by H1‐antihistamines. Indeed, the dose of morphine or methadone needed to release histamine from rat peritoneal mast cells is some 10 000 times greater than the dose needed to inhibit evoked contractions of the guinea pig ileum (a model for mu‐opioid receptor activation). It is therefore necessary to postulate a central opioid receptor‐mediated mechanism for generalized itch associated with spinal or systemic opioids. Interestingly, plasma concentrations of histamine increase after intravenous morphine but not after spinal morphine.
Other neurotransmitter systems interact with the opioid system in relation to the mediation of itch, notably the serotonin system. For example, ondansetron, a specific 5HT3‐receptor antagonist, relieves itch caused by spinal morphine and prevents recurrence of itch for 24 hr. Ondansetron is also effective prophylactically.
In animals, intracisternal administration of small amounts of morphine causes intense scratching activity. Facial scratching is triggered by injecting morphine into certain areas of the medullary dorsal horn, but subsequent intramuscular morphine reduces the facial scratching. The effect of morphine, therefore, seems to depend both on the site of action of morphine in the CNS and on relative changes in opioidergic tone. In other words, the dose‐response curve for opioid‐induced itch appears to be bell‐shaped. This would be analogous to the emetic effect of morphine. Small doses generally do not cause nausea and vomiting; middle of the range doses commonly do; large doses may not.
On the other hand, it has recently been suggested that the mu‐opioid receptors mediate itch, whereas the kappa‐opioid receptors may suppress itch.96 In keeping with this hypothesis is the observation that a kappa‐opioid receptor agonist, TRK‐820, reduces scratching in a mouse model.132 Further, in haemodialysis patients with itch, the expression of all opioid receptors on lymphocytes is lower than that in healthy volunteers, with mu‐opioid receptors being less affected than kappa‐opioid receptors. This imbalance in the expression of mu‐ and kappa‐opioid receptors could contribute to the pathogenesis of uraemic itch.When itch is induced by a systemic opioid, switching to an alternative may help, e.g. from morphine to hydromorphone.121
Black Poppy Issue 12.