🖐️ Understanding Dermatillomania: Prevention, Response, and Visual Cues in Occupational Therapy

What is Dermatillomania?

Dermatillomania, also known as excoriation disorder or skin-picking disorder, is a body-focused repetitive behavior (BFRB) characterized by compulsive skin picking that leads to tissue damage (American Psychiatric Association, 2013). It is often associated with anxiety, obsessive-compulsive tendencies, and sensory processing difficulties (Snorrason et al., 2012).

For individuals with memory deficits or dementia, skin picking may not be driven by anxiety alone but can also result from cognitive decline, sensory dysregulation, or a lack of environmental stimulation. These individuals may forget that they have already picked at an area, leading to repeated damage. Additionally, neuropathy or altered sensation may cause them to focus excessively on certain areas of the skin (Singh et al., 2016).

How to Prevent Dermatillomania 🛑

1. Identifying Triggers

A key step in prevention is recognizing what leads to picking episodes. Common triggers include:

• Stress or anxiety (Grant et al., 2012)

• Boredom or lack of engagement

• Sensory discomfort, such as dry or irritated skin

• Cognitive impairment leading to repetitive behaviors

For individuals with dementia, occupational therapy strategies focus on modifying the environment and daily routine to reduce triggers.

2. Sensory Substitutions and Environmental Modifications

Providing alternative sensory input can help redirect picking behaviors:

• Fidget tools: Textured fabrics, stress balls, or worry stones (Stein et al., 2018)

• Lotion application: Encouraging use of soothing, unscented lotion as a tactile alternative

• Gloves or finger coverings: Wearing soft gloves during high-risk times (e.g., while watching TV)

• Keeping skin covered: Long sleeves or bandages can reduce visual cues to pick

  
  

3. Routine and Engagement

For individuals with dementia, structured activities can reduce idle time, which often leads to picking:

• Guided hand exercises

• Engaging in arts and crafts

• Encouraging tasks that require both hands (e.g., folding laundry, sorting objects)

  
  

How to Respond to Dermatillomania ❤️

1. Compassionate Redirection

Rather than focusing on stopping the behavior outright, redirect attention to a competing activity. Occupational therapists often use task engagement to shift focus. For example:

• Hand massages with calming scents

• Using a warm compress on the affected area

• Distracting with a sensory-friendly activity

For dementia patients, redirection is particularly important. A caregiver might say, "Let’s put on some lotion together. It will make your hands feel so much better."

2. Addressing Underlying Needs

If skin picking is due to anxiety, mindfulness or deep pressure techniques may help (Teng et al., 2006). If caused by sensory discomfort, an occupational therapist may assess skin sensitivity and suggest appropriate modifications.

Using Visual Cues in Occupational Therapy 👀

Visual cues are a powerful tool for memory deficits and behavioral modification. Effective options include:

• Picture schedules: Step-by-step images for applying lotion or engaging in a replacement activity

• Sticky notes with reminders: “Apply lotion after washing hands”

• Color-coded gloves: A bright color can remind the individual to avoid picking

• Mirror placement: Reducing mirror access can decrease the visual reinforcement of imperfections

  
  

Strategies for Dermatillomania During Toileting or Routine Tasks 🚽

Daily tasks like toileting, dressing, or brushing teeth can be boring, leading to increased skin picking. Here are strategies to help:

1. Engaging Both Hands 👐

• Encourage holding a washcloth or soft towel during toileting. The texture can provide a substitute sensory input.

• Use a weighted lap pad or sensory item to hold while sitting.

• Provide a stress ball or fidget to squeeze while brushing teeth.

2. Shorten Task Duration ⏳

• Use a timed visual cue (like a sand timer) to limit time in the bathroom and prevent prolonged picking.

• Break tasks into smaller steps with gentle verbal reminders: “First, wipe. Now flush. Now wash hands.”

3. Play Audio or Music 🎵

• Play calming music or an audiobook to keep the mind occupied.

• For dementia clients, familiar tunes can provide comfort and reduce anxious behaviors.

4. Modify the Environment 🏡

• Use soft lighting to reduce visual focus on the skin.

• If mirrors trigger picking, cover them partially or use a smaller mirror.

5. Provide Positive Reinforcement 🌟

• Praise the individual for completing the task without picking: “You did a great job washing your hands. Let’s put on some lotion together.”

• Use a reward chart or token system for motivation.

  
  

Conclusion

Dermatillomania is a complex disorder influenced by multiple factors, including memory deficits and dementia. Occupational therapy plays a crucial role in prevention and intervention by using visual cues, sensory substitutions, and engagement strategies to manage symptoms. Addressing both the behavioral and cognitive components ensures a compassionate and effective approach for individuals struggling with skin picking.

References

• American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.).

• Grant, J. E., et al. (2012). "The association between excoriation disorder and anxiety disorders." Comprehensive Psychiatry, 53(7), 975-980.

• Singh, S., et al. (2016). "Skin picking in dementia: A clinical challenge." Journal of Geriatric Psychiatry and Neurology, 29(5), 281-285.

• Snorrason, I., et al. (2012). "Skin picking disorder." Psychiatric Annals, 42(6), 219-225.

• Stein, D. J., et al. (2018). "Body-focused repetitive behaviors: A review of assessment and treatment." Psychiatric Clinics of North America, 41(3), 393-407.

• Teng, E. J., et al. (2006). "Habit reversal training for pathological skin picking." Journal of Behavior Therapy and Experimental Psychiatry, 37(3), 263-270.