body focused repetitive behavior and your dermatologist

Body focused repetitive behavior is a self-grooming disorder that involved picking and pulling at skin, hair, and nails to the point of damage.  It falls under the category of obessive-compulsive disorder.  Names of conditions include trichotilomania (hair pulling), skin picking or neurotic excoriations, lip biting and nail biting. Dermatologists sometimes address problems that go beyond what is found on a patient’s skin, hair or nails. When the condition is primarily psychological in origin, it falls under the specialty of psychodermatology. Our board certified dermatologist Dr. Dina Strachan is an expert in helping patients with BFRB.  Watch her interview with Habitaware on body focused repetitive behavior and/or read the transcript below.  



Ellen:  0:00     All right. Hi welcome, everybody. I’m so excited to have you all join us for Coffee & Conversation with Dr. Dina, the dermatologist. I’m Ellen with Habitaware. And we’re thrilled to have you here to talk today. And Dr. Dina, why don’t you tell us a little about yourself. I want you introduce yourself for us?

Dina:   0:21     Well, thank you for having me, Ellen. I am Dr. Dina Strachan. I’m an internationally recognized, Harvard and Yale educated, board certified dermatologist, best-selling author, consultant and speaker. And one of my specialties is hair loss. And that’s how you and I met at a hair loss conference.

Ellen:  0:39     That’s right. That was back in September of last year. That was so great to meet you there. And one of the things that I so enjoyed about meeting you and getting to know you, is you’re one of those dermatologists that understands what body focused repetitive behaviors are. There’s been so many dermatologists I’ve talked to, and other people I’ve talked to, where the dermatologist says, “You know, just stop picking or just stop pulling.” And what I love about you is you understand both the medical as well as the mental part, because it goes together. And why don’t we talk about that for just a second. Could you explain the psycho dermatology part of Dermatology?

Dina:   1:22     Absolutely. So, dermatology is a specialty in medicine. And then there are sub-specialties, where it gets even more specialized. And psycho dermatology is a sub-specialty of the specialty of Dermatology that deals with conditions that involve a psychological aspect that affects the skin, hair, and nails. So not everyone who isn’t even trained as a board certified dermatologist necessarily gets extensive training in that. I mean, we are all introduced to certain conditions, but these are much more complicated things to deal with. So that’s why sometimes when people go to the dermatologist, they might find it a little frustrating because… Psycho dermatology is dealing with conditions that have an impact on the skin that are psychological behavioral in origin. But when someone walks in, unless they’re telling me that they have that, I can’t assume that it’s just in their head, because that’s considered insulting, and that’s considered bad medicine. You know, somebody has pig marks on their body, maybe they have scabies, maybe there’s something going on, maybe they have renal disease, and they’re itchy. I have to figure all of that out. And then the patient may not be aware that they’re doing that, or even if they are aware, feel comfortable. You know what I mean, acknowledging that that is what is going on, and then might even just feel judged, even if I’m not judging that it’s something that they’re doing, rather than something that’s happening to them in terms of what’s going on their skin. So one of the things that’s really important is, it’s the awareness of the patient, the awareness of the doctor, and that’s how you make a successful diagnosis and come up with an effective treating plan. Because the Derm part is what the consequences are, but it’s not the main disease. The main condition, the main problem is the behavior. It’s the skin and the hair problem would go away, if the behavior would go away. It’s just that the behavior is chronic. So then we have to… It’s that dance, we have to manage them both. …in life. And it’s hard to limit yourself based on how everyone else is going to react. And we all do it just as human beings in this particular case, in terms of dealing with this problem, and in other things. I think it’s important to deal with the judgment yourself. I think a lot of times that’s what’s really heavy for people. We people often have a judgment because they don’t understand they don’t know, they don’t believe their past experiences. And physicians are people too. And sometimes when people disagree with you, they think you’re judging. So I have patients who, I think, have body focused repetitive behaviors, and they think they have something else or they’re insisting it’s something else, because they’re judging that, and they don’t want to address that. They think it’s an infection. They think it’s a vitamin deficiency. And I don’t. “Am I right? Are they right?” I don’t know. But that’s the best of my discernment. I’m using information someone’s giving me and they may not receive it because they judge. So that’s something I think is just something we all have to kind of work on our own judgment.

Ellen:  5:32     Yeah. That’s so important, because we do we do judge ourselves. We judge ourselves all the time. And those of us who have BFRBs, we just want it to go away. And like I said, at the top, the question isn’t, “Why can’t I stop? Why is there no magic pill? Why do I have this? How do I manage it?”

Dina:   5:52     Exactly.

Ellen:  5:53     Yeah.

Dina:   5:54     Exactly.

Ellen:  5:54     And we have to normalize it. So I think it’s just… And I’ve said this before, and I’ll say it again, it’s also like diabetes. My mother has type one diabetes. She’ll always have it, but she can manage it [through] diet, insulin and exercise. And she will never have a diabetic free day. So she will always have it, but she can manage it. And I think sometimes we might have felt judged, or we judge ourselves that that it is important to also be open too. Well, maybe I do have a vitamin deficiency. Maybe I do. But maybe I also pull my pick my skin and pull my hair and I have to address both. Maybe I have allergies, and I have to address both.

Dina:   6:35     Exactly.

Ellen:  6:36     And it’s ways of managing it. But I’m glad you brought that up in Isla.

Isla:     6:39     Yeah. Yeah. There’s that acronym that fear… I forget. Its false expectations is real. Without [Inaudible 06:47] the way you are yourself fear. Yeah, your self-judgment.

Ellen:  6:52     Yeah.

Isla:     6:52     That’s really helpful. So there are two questions in the Q&A. And then there was a chat question. I guess, just as we go through the questions that everyone can see, will you please highlight which one we’re on. So folks can follow along. And then one person in the Q&A asks, “Is it worth going to a dermatologist if you haven’t gotten your skin picking under control yet?”

Woman scratching her shoulder with pimples on white background

Dina:   7:18     I would say yes. I mean, anything that’s chronic, goes through periods of control and not control. So, of course, it’s important to try to get help with the behavior. But there are actually things that dermatologists can offer you that even when it’s not under control, it can be helpful. So one thing I tend to do with people… You know, a lot of the patients who have this aren’t necessarily going to follow my advice. Like, “Let’s get you a therapist. Let’s do that immediately.” People take some time to accept things and process things. So I give them a substitute that’s less damaging to their skin, particularly the people who pick the skin and they can get the scars, which are permanent. So I say, “Well, how about this? Why don’t we give you this barrier Repair Cream that helps your skin heal? And when you feel that urge to pick, why don’t you do this instead, why don’t you take this cream and rub it instead of picking.” So at least you’re doing something, which is what you feel compelled to do, but at least it’s not something damaging. And sometimes that helps.

Ellen:  8:33     Yeah. Yeah, that’s really good advice. Well, why don’t we go through some of the questions and these are questions that you guys had asked us when you’re registered. And then [inaudible 08:45] as well, as things pop up. But why don’t we start just at the top with a lot of people ask, “How can I encourage hair growth?” And what do you think, Dr. Dana, what’s the best way for those of us who pull our scalp hair or even our eyelashes and eyebrows?

Dina:   9:03     Okay, so number one, how this affects hair growth, there’s the obvious one where you immediately pulled out the hair. And then the issue of if you’re causing any inflammation or scarring at the hair follicle level that would prevent the hair from growing back. And that would be permanent or long term. So depending on what part of the body you’re dealing with, you do want to get the behavior under control, especially if you’re pulling aggressively where it’s coming out by the route, you’re causing inflammation and scarring. We do have to get that under control. But sometimes topical steroids particularly in the scalp are helpful because they’re anti-inflammatory and that just shuts down the inflammatory response that causes a scar. And then we use a variety of things usually, Minoxidil, which people know is Rogaine over the counter to stimulate hair regrowth. But as long as you didn’t damage the hair follicle, the hair can grow back on, on its own, it’s just that did you pull it out again before it had a chance to grow back or did you cause some scarring? And then on the eyelashes, there is a medication called Lutece, which is FDA approved, people use it more cosmetically to just have longer, thicker, darker lashes. But you can use it in this case as well, to make your lashes longer, thicker, darker, it’s just that, you know, are you ever gonna get ahead of it? You know, if you don’t address the behavior as well.

Ellen:  10:30   Right? And that’s really important. I get a lot of people who ask, “How do I grow my hair back?” What’s the best cover ups? What’s the best makeup? And it’s like putting out you’ve got a fire burning and you’re just trying to get out all the embers, but you still have that fire burning, while the hair is growing, and while the skin is healing, you have to take care of the behavior. And that’s done in several different ways. And just as a real quick for those of you who have a keen bracelet or who don’t, just one thing to be aware of is this bracelet helps you be aware of where your hands are. So a lot of us who are hair polish and skin pickers, some of us are doing so automatically I know that’s mostly mine is automatic, where I’ll come up here and I’m just scanning as I’m concentrating or as I’m bored or as I’m nervous. And then I will pull. So having this tool that gives me that gentle vibration just to make me aware it goes from the lizard brain to the prefrontal cortex to go, “Oh, Ellen, guess what your hands are not where you want them to be.” So that I can then put them down and let my hair grow back and grab the cream that you prescribed for me to put that on my hands instead of picking. So we really do want to work on getting the behavior under control as well. And it’s just managing it, just managing it.

Dina:   11:51   Yeah, because I mean, you could grow your hair out long like it is now. But that’ll take months. And then you know, one good episode, one good poll and bang, it’s gone. So you do have to get the behavior under control.

Ellen:  12:04   Yeah. And sometimes people will put on fake nails because they bite their nails all the time, but they didn’t learn. And then once the nails come off, they start biting again, because you have to learn how to stop doing or reduce the unwanted behavior and start creating healthy behaviors. The two first bullets here, how to encourage hair growth, what’s the likelihood of hair regrowth? And I think you answered that it’s really going to depend.

Dina:   12:37   Yeah, whether or not there’s scarring.

Ellen:  12:38   Yeah. And the best way to do that is probably to see someone like you.

Dina:   12:43   Exactly.

Isla:     12:44   One new question around hair regrowth, Dr. Dina, in your experience, does hair regrowth differ with race and hair type?

Dina:   12:55   That’s a good question. I mean, every individual has a different rate of hair growth and a different duration of an individual hair growth. So hair grows over years, like an unbothered hair will grow over years. But how long your hair gets depends on how long the cycle is for you. So people with a curly or kinky hair tend to have shorter hair because one, it’s more delicate so it tends to break more easily. It tends to have a shorter growth cycle. And then it just looks shorter. I mean, my hair is short like this, but I can pull it back into a ponytail. It’s just you have the shrinkage. So my hair has grown quite a lot. When I first cut it short like this, it was the same length that is now except it’s much longer in reality, because it’s twisting on itself so you can’t see that so yes. And then curly, kinky, or hair is naturally drier, which is one of the reasons why it’s more likely to break. And one of the differences it’s easier to come wet where a straight hair is easy to comb dry.

Ellen:  14:07   Right and eyelashes and eyebrows have a very different cycle. I know hair be anywhere from three to maybe six years depending on the hair, where eyelashes and eyebrows six weeks, I’m trying to remember.

Dina:   14:21   Yes, those are like weeks to months. I mean, they’re much shorter hairs.

Ellen:  14:25   Yeah. Great. The fourth question, what are best creams to prevent infection or reduce scarring? I get that question a lot for skin pickers.

Dina:   14:39   So that’s a good question. So, the two things or maybe three things that people are really concerned about with the skin picking is one, your skin is a barrier and it’s designed to be intact to protect you from one thing, infections. So, obviously when you scratch it, you’ve compromised the barrier and then you have a risk of infection and Then, when you scratch or pick the skin, if you get deep enough into the dermis, anything that gets into the dermis can cause scarring, which is a change in the texture of your skin, you could get a raised scar, or depressed scar. And then you can also get discoloration. People with darker skin, I’m more likely to get what we call Post Inflammatory Hyperpigmentation, where you get a dark stain on the skin, which is different than the scar, even though people refer to that as a scar. And then people with lighter skin often get persistent redness, persistent [inaudible 15:34] instead of a brown spot, they get a red spot. And that just like the brown spot can take weeks to several months to sometimes years to go away. And so a lot of that’s caused by inflammation. And some of it’s caused by how far you anatomically get into the skin. So there are a lot of over the counter antibiotic ointments and creams. And you want to just be a little careful with those, those can be helpful if you use that as your substitute, except people develop allergic reactions to [inaudible 16:08] and Neosporin sometimes life threatening allergic reactions. So, I don’t generally want people just, you know, running out to get those. Most people, I’m assuming that it’s like clean picking it’s very different than if you like skinned your knee in the [inaudible 16:26] versus you’re relatively clean and you’re just picking out an area, you can probably get away with just cleaning it with soap and water and using Vaseline and a bandaid. But if you do develop an infection, there are things that we can give you that you could use topically or if it’s an extensive infection, which might spread more in someone whose skin picks, if they pick a lot, it might start in one place. But because there are all these areas where the skin barrier is compromised, it can spread throughout their skin more easily, they may need an [inaudible 17:00].

Ellen:  17:01   Yeah, people don’t remember it, our skin is our largest organ. And then I still remember the board book, when I would read it to my little kids and the skin keeps everything in.

Dina:   17:13   Yeah, exactly.

Ellen:  17:14   It protects our organs, it protects everything inside. And if you have a wound, be it skinning it by riding your bike or that you’re picking it, then dirt and grime can get in there. But we don’t want to over treat ourselves, like you said, homegrown CVS antibiotics, whatever it might be with, because that might not be the right thing and it might not be necessary.

Dina:   17:39   Yeah. And you know, there’s antibiotic resistance as well, I didn’t mention.

Ellen:  17:44   And for those so with infections, I hear what you’re saying to it’s important to try not to break the dermis, but if you do to clean it, put some Vaseline on it and cover it up so that it can heal then you’re less likely also to continue to pick at it.

Dina:   18:01   Yeah. What… Just, you mentioning, covering it up, a lot of people, grew up hearing that you should let the air get to your wound?

Ellen:  18:12   Oh, right. Tell us what should we do?

Dina:   18:14   But you should actually cover them because it’s scientifically proven that wounds heal better and faster when they’re covered. And you could do something as simple as a little glob of Vaseline, or [inaudible 18:29] and a bandaid and just change it every day or twice a day. Or you can get one of those hydrocolloid band aids, those waterproof band aids that you can cut out and you can wear that for several days at a time.

Ellen:  18:40   I love those band aids, those are great.

Dina:   18:43   Yeah, those are my faves.

Isla:     18:46   I have a follow up from some of this discussion on preventing infection and reducing scarring. So someone writes in I have a lot of Post Inflammatory Hyperpigmentation. I am also currently treating the behavior, can a dermatologist get rid of the discoloration through lasers or something else? And if so, what would the rough cost be?

Dina:   19:05   Okay, well, generally with Post Inflammatory Hyperpigmentation, I don’t recommend doing something like laser as your first choice, especially for something that’s probably chronic and ongoing. You might want to get a bleaching cream and there is one that is a combination cream that you can get as the brand or you can get it usually less expensively if it’s compounded meaning the pharmacy mixes up their own generic and it’s called [inaudible 19:33] which has hydroquinone, a topical retinoid and hydroquinone, the bleaching cream a topical retinoid and a steroid in it and you only have to put it on once a day. But, to decide how I’m going to treat hyperpigmentation based on how big it is? How dark it is? What part of the body it’s on? You know, sometimes you can use chemical peels to help but then I would get worried if somebody’s skin picking doing some of those treatments because it makes your skin more fragile. So if you’re picking and your skin is more fragile, you can do more damage. So I like the bleaching creams better for hyperpigmentation and say something like laser and laser, again, can be helpful depending on what it looks like. It’s just that, it’s usually more than one treatment. And I think in this particular case, because this is like an ongoing thing, that having a bleaching cream available is a better idea.

Ellen:  20:31   So those would be prescription.

Dina:   20:33   Those are prescriptions per strip, you want at least 4% hydrocodone, which is prescription, there are lower strength bleaching creams over the counter, like ambi, which is 2%. But I just don’t think that that’s likely to be terribly effective. I like to go for the strong stuff before going to bother, it always take some time, even with the stronger medicine. So I don’t really see the point using the 2%. So, you know, sometimes it fades when you do nothing. So I’m not sure that that does anything significantly more.

Ellen:  21:05   Yeah, and it’s a good point of where it is, because there’s a difference between if it’s right here in the middle of your face versus maybe it’s covered up here on your shoulder or on your thigh. Because it really depends on how visual it is and how important it is to you, if it’s something you want to treat?

Dina:   21:23   And in a scar because it’s harder to get things to penetrate into scar, you can have scar and hyperpigmentation together. And so, you know, it’s sort of whatever you do, it’s harder to penetrate that than it is to say penetrate your normal skin, which has a stain on it.

Ellen:  21:40   Got it. Okay. That is really good information. I’m so glad you told me about wounds heal better when they’re covered because, I [inaudible 21:49] “Oh, it needs air, let the air get at it at night.” And now I’m not going to do that. I’m going to cover it up.  So I learned something, too. So let’s go on to the question, “Why do I get excessive pimples and blemishes on my scalp?” That was something someone asked upon registering.

Dina:   22:08   Okay, so again, when you pull your hair out, you’re causing trauma, okay, which causes inflammation. So you can get pimples, you have little pus bumps or little red bumps that don’t seem to have pus in them just from inflammation that’s like sterile inflammation, meaning you have the inflammatory reaction, but you don’t have an infection or maybe you’re getting an infection. That would be the cause from the hair pulling. So how we would treat that, some of the, we might use similar things. For example, we might use a steroid, which is anti-inflammatory. Normally, we don’t want to treat an infection with steroids. But the steroids may calm down the inflammation enough so that it helps your barrier repair so that you don’t get an infection. Though, sometimes it’s hard to use them in here, you do something like benzoyl peroxide, which actually is anti-inflammatory and kills bacteria. And then, you know, sodium sulfacetamide sulfur, which is like, a lot of the Acme medicines, the things we use for acne, and even the topical antibiotic solutions. They can help with both inflammation and they kill bacteria.

Ellen:  23:29   Okay, that’s very helpful. That’s really good. And it still reminds me that I want to repeat because I think it’s so important that we have to take care of the body and the skin. So the hair and the skin, but we have to take care of the behavior. Because you have to do both in concert and it really is important to have a really good dermatologist and maybe a therapist that’s going to help you with the behavior and having strategies, so help to be able to do both. There’s one I want to address which says here, would you recommend two keen bracelets if you pick a pole with both hands? And the way I like to answer that one is I would start with one bracelet. And if you find that you need a second bracelet, you can always email me and I’m going to throw up my email at the end. Because we always offer a discount when people buy two bracelets at the same time. But if you don’t need two, why buy two. If you need to you email me and I’ll send you a code for a discount off your second bracelet. And the reason why is I started out with two. I had two bracelets because I pulled with both hands. But it’s a journey, right? These behaviors we learn a lot about ourselves. And what I learned about myself is I start left and if I’m successful, I move right. I also move all over. But if I’m not successful, and cane catches me with my hug, and I put my hands down, I take a deep breath and I play with something else. Then I don’t move right so I learned I really don’t need two bracelets, where some people will learn, “I only use my left hand and then their left hand is awesome.” But then they’ve moved right. So some people will need two bracelets. The other tip on the bracelet side is, and I’m one of these people. So I got mine, I was so excited. I think I told you guys, I trained four areas, four areas, I was kind of mad, I couldn’t train five areas. And I didn’t train them properly. And it was an epic fail, because I have vibrations going all the time at the wrong time. And the best thing to do is to train one bracelet and one area to start. And then add on in about three or four days after you get to know yourself and you get to know keen. And especially with skin pickers, I think I’ve trained hundreds and hundreds of people, what might happen is somebody has something going on here. So they’re picking here and then they train this area and this area heals, awesome. And they’re not touching it anymore. But now they’re going up here. So it’s good to know how to train the bracelet. So that you can delete one area or turn it off when you don’t need it and then add another area when you do need it. So I wanted to answer questions on that as well. And one, I also have because I pull my hair is and one of the second to last questions on here is, “Are my hair follicles damaged forever?” No, I pulled for 40 years, and I pulled behind my ears and then I pulled everywhere. And a lot of my hair has grown back. And I’m lucky that I have curly hair which like you when it’s wet as much longer and it bounces up and it gets fluffy. But I wonder if I have permanent damage back here? How would I know if my hair follicles are permanently damaged, I need to have somebody take a look at them?

Dina:   26:54   Well, I would think of it like grass. So one, if your hair has not grown back that it’s possible that you have some permanent damage. If your hair is back and thick, there could be a hair follicle here and there, like a blade of grass that’s gone. I think it’s more of a concern, if you don’t have hair. But that doesn’t mean that all of your hair follicles, even in the area that looks bald are permanently damaged. And one of the ways that we determine that is that, on physical exam, sometimes a trained person, board certified dermatologist who’s experienced with hair loss is able to see that sometimes you use a dramatic scope. Sometimes we do a biopsy. But even with a biopsy, I often treat people anyway, even if I see permanent damage with the biopsy because where I sampled is not the whole area. So it’s possible that even though I found permanent damage in a lot of the hair follicles on the biopsy, the area next to it may still grow back. So I think it’s always worth giving it a good six months of treating to see if people can get their hair to grow back, even when it looks, likely won’t.

Ellen:  28:09   That’s a good point because I know there’s different cycles with the hair growth. So it could be that it’s just an, I don’t know the technical term, but the dormant phase, maybe it’s just.

Dina:   28:20   The dormant phase would look different than scarring like absence. So, you’d see the hair follicle, and you may be able to determine what phase it is in but it would be there. Whereas usually with scarring, you see scar and you see abnormal anatomically abnormal hair follicles with scar or no hair follicle. But I don’t know that right next to it. There wasn’t a hair fall, because it’s just a sample.

Ellen:  28:50   Yeah. And what about on the last one here? Why does my hair pulling manifest as an itch in a particular part of my scalp? And why does it bring pleasure to pull or trim that area?

Dina:   29:06   Okay, so with this question, there are a couple things, so, when wounded skin heals, it itches. You know when your skin is healing, these cells called macrophages, which kind of clean up debris. And they also release histamine. That’s something you might be familiar with like with allergies, anti-histamine. Macrophages are one of the cells that release some histamine, they come to a healing area. And they, part of what they do is they release histamine. So histamine can make you itch. That’s what gets released when you get like a mosquito bite. It causes the release of a lot of histamine that’s why they itch so wounded skin itches. So if you’re picking in the same area a lot and you’re getting a wound, this is what the doctors sometimes are trying to figure out because someone’s picking their skin, they’re itchy, was the itch the primary problem? And am I treating eczema or bug bite something else? Or when someone already has all these wounds from skin picking even if they weren’t itchy initially, they may be itchy now, but that’s not really the problem.

Ellen:  30:24   Oh, good point, right?

Dina:   30:26   They’re still itchy. You know, so you’re probably itching, if you’re dealing with a long standing pulling disorder because you always have a little bit of a wound. Or you could have something else. But I would think, you know, in this particular context, it’s probably that.

Ellen:  30:48   Yeah, and then on the last part of it, why does it bring me pleasure, so for me, and I’d like to get your feeling on this too. So for me if I pull and I used to pull anywhere from 10 minutes to three hours every day and I’m not 100% pull free. And that’s okay with me, I actually think it’s better to aim to be pick or pull less versus pick or pull free. It’s like my mom’s never gonna have a diabetic free day, I’m always gonna have to wear my glasses. So if I am pulling or when I used to pull a lot, it did bring me pleasure, it felt good. And sometimes, even in an area where I would be pulling a lot and it was kind of getting sore, it still brought me pleasure to pull in that area. And I wonder if part of it is just part of our disorder or our behavior where that once you start, you want to continue doing it because it has some sort of relief, even if it hurts is why I’m thinking and it could also be that maybe it’s irritated and so wants me to continue to pull at it. Just like if I had a mosquito bite and it feel so good itch that mosquito bite. Is there a medical reason why it brings us pleasure, we want to continue to do it?

Dina:   32:11   There probably many answers to that. One, itch is a type of pain. And even the scratching, I mean scratching, it’s kind of an assault. But it feels good. Yeah, it’s just changing the sensation from one that is undesirable to one that’s a less undesirable. And that’s interpreted as pleasure. I mean, sometimes when we itch, we pat, we smack it. And that might not feel good. That might not be something, we interpret is good. But it feels better than the itch.

Ellen:  32:50   When I have a headache, and I do this, it still hurts but it hurts less or maybe more and then when I release it hurts less. So I guess it would be very similar.

Dina:   33:00   Exactly. If it’s an emotional thing, it’s just like you’re just distracting yourself. This is something that’s very common with people who have periodic disorders, itchy disorders, like eczema even, they complain that they itch more at night. And that’s because at night, you just generally are wearing fewer clothes, your clothes are actually touching your body. And you’re just, after a while your awareness of it, you get it, you accommodate. And you don’t think about it, you don’t notice your clothes but it’s distracting you from your itch when you take them off. They’re not there. So all you can notice is that you’re itching.

Ellen:  33:46   Yeah. Now I want to injure myself, now that you just even said the word.

Dina:   33:50   Yeah. So I think a lot of it is just our neural pathways are pain pathways. And some of it may be psychological. But it’s also like, a lot of the ways we treat pain are not a good necessarily getting rid of the pain, but distracting ourselves from the awareness.

Ellen:  34:10   Yeah, that’s very good. And the awareness is so important in so many ways. You know, being aware of where our hands are. And a lot of times what I say to people, is when we’re starting to feel the urge or we’re catching ourselves picking or pulling to just notice, feel your feet, feel your feet on the ground, feel your bum in the chair, because like right now everybody out there, do you feel your elbows, and I’m sure nobody’s feeling their elbows, right, because they’re not focused on their elbows. But if you’re feeling a sensation that you really want to scratch a pull or pick at some area to try to focus your attention somewhere else, it can be very, very helpful. And then, it’s just not just one thing. It’s a variety of things. It’s a toolbox. So your tools could be a cream, that you’re putting this cream on to help as well as a fidget toy that you’re going to play with, as well as an awareness bracelet, as well as feeling your feet on the ground, you have to have a collection of different go to things you’re going to do when you’re starting to feel that you have the urge, or you’re catching yourself picking or pulling, so important.

Dina:   35:21   I think that’s why Yoga is so popular now. Because it’s all about awareness and putting yourself in uncomfortable positions. And feeling your way through it or not focusing on it, focusing on something else while you stay in the uncomfortable position.

Ellen:  35:37   Yeah, and sometimes it’s okay to be uncomfortable. We say, you know, “I don’t want to be uncomfortable.” But you know, sometimes it’s okay to be in the uncomfortable situation and know that you can be and know that it’s not permanent, and know that you can come out of it. That’s also… So we’re getting close to the end of our time. Neil, are there any other questions that we should that have popped up through our chat?

Isla:     36:03   I think I have two questions. One is, we’ll taking an anti-histamine during the episode to help relieve the itch. So I’m assuming maybe it’s a skin picking episode or hair pulling episode. So right in the moment we’ll taking that anti-histamine help.

Dina:   36:21   It may, it may not, it just depends once the histamine is already released. You know, even for people who have insect bite reaction. Let’s say somebody had a lot of mosquito bites or they’re dealing with bedbugs or something like that. And while we clean the environment, they have all these really itchy bites and they may start to get others. The anti-histamine is really to prevent a new one from forming. It may help a little bit. But once it’s released, it’s released. What I use is I give people topical steroids to put in the area. Because that is going to immediately locally shut down the immune response in that area whereas the anti-histamine only helps in reducing the release of histamine. But once it’s released, it’s already out.

Ellen:  37:07   Oh, that’s very good to know. I did not know that. I learn so many good things today. This is fantastic. Yeah, and I do know and correct me if I’m wrong with steroids, it can also thin the skin. So you want to…

Dina:   37:20   Yes, so you want to manage your steroids. So steroids, they’re great drugs, but you want to manage their different strengths. So, the one over the counter is pretty low risk usually 1% hydrocortisone is the strongest. But if you got something from a doctor, you just want to make sure you know what part of the body you’re allowed to use that on? For how long? I mean, and even honestly, a lot of non-dermatology doctors are not aware of how strong some steroids are. And so you know, they think, “Oh, it’s just cream, its dermatology, how dangerous could it be? But if you’re using a very strong steroid cream in the wrong part of the body, I mean, I’ve had patients come in who are using a strong, we call them class one, that’s the strongest class, a steroid that they got from a physician who wasn’t a dermatologist and they’re using it in their armpit or in their groin. And they’re using it for months and weeks. And they’re literally getting stretch marks which are permanent.

Dina:   37:20   Yeah, you got…

Dina:   37:52   So you have to treat it with respect. It’s a drug. But using it for you know, under two weeks on most parts of the body that are not your eyelid or not your armpit or not you’re groin, should be safe to use twice a day for two weeks. Yeah, but you probably won’t even need to use it that long to get rid of the itch from that.

Ellen:  38:47   And the other thing, too, I think is important is nothing’s 100%, there are some drugs that are more benign than others but nothing is 100%, or we say walking across the street is not 100%.

Dina:   39:00   Exactly. That’s not… Yeah, there’s a risk to everything.

Ellen:  39:03   Yeah. So you always want to ask the doctor, what are the side effects? How benign or severe is this drug, so you know what you’re working with?

Dina:   39:17   And how to use it correctly. So, I mean, if you’re using things correctly, you should have pretty low risk for some things. If you’re using it incorrectly, well, you’re not good. Yeah. Yeah. What can I mention one thing that I also advise people with skin picking about a lot that just didn’t come up that I noticed but I think it’s very important. If you’re a skin picker, you need to cut your nails. I know it’s very popular for people to have really long nails now and really long artificial nails and I know that’s the style. But if you have this challenge, you can just do a lot more damage with super long pointy nails than you can with short nails. I’ve seen people with short nails get something else to dig, especially when you’re not aware of something having super long, sharp nails, when you can’t help, picking, it’s like kind of like… It’s not safe.

Ellen:  40:17   Yeah, that’s a very good point. I mean, I like having short nails. And the other thing too, is you get a lot of dirt underneath your nails. So if they are long, you’re gonna have more of it and bacteria. And it can cause infections and with COVID and everything that’s going on now, we don’t want to touch her faces, which is impossible. But it’s doable with awareness. So that’s the other thing too. I’m really glad you brought up about the nails. That’s so important. And we’re just about… Any last questions before we call it an hour, this was so much fun. I’m so glad we got an opportunity to talk.

Isla:     40:56   I have two more questions. So hopefully they’re quick. There’s one question about, “I’m in my mid-30s. And I have acne on my back. Why do I get acne on my back? And then also, is that an over the counter way to treat acne on the back?” So that’s the first question. And then the other question is, “how would a person know if they have an infection from picking?” And there might be one or two more, but maybe just start with those, and I’ll see if I can find if there’s any more.

Dina:   41:25   Okay, so I’ll answer the question about acne first, acne is probably the most common human medical condition. We generally think of it as affecting the face, but it can affect the neck, chest, back and arms and the back is very common. And we would treat it you know, there are many ways to treat it there over the counter solutions, which are generally medications that have just been shown to be safe without a doctor’s monitoring. So there are many benzoyl peroxide, washes that are available, different which is topical retinoid with Vitamin A type cream is also available over the counter. There are some products with glycolic and salicylic acid in them that work for acne over the counter. But sometimes it can be harder to treat body acne because the skin on the back is thicker. And acne can be caused by hormonal issues, some things in our diet, particularly dairy seems to be associated or make the acne worse, I don’t know that you necessarily can clear acne, if you have it just from not taking dairy. But I have patients who are vegan, who still get acne. So you know, that’s one thing. And in terms of knowing when your skin is infected, I mean, whenever you cut your skin or compromise the barrier, there’s going to be some redness and inflammation. And sometimes that can look like an infection. But it’s usually when something’s not getting better or it’s getting very, very red or you get pus and it seems to have a ring of redness spreading or you’re getting a fever. But if you’re concerned that you have an infection and you don’t feel that you can tell, then you should see a doctor to help you determine that. But sometimes just a wound can look like an infected because a wound can be red and painful.

Ellen:  43:30   And I’ve got a slide up here now so that you know how to reach us. So here’s Dr. Dina’s information with her website, her email, and you can schedule a visit to see her by video. And if you have any questions for me or need some help with your cane bracelet, you can reach me at Ellen at and you can also visit our website and Aniela. Thank you for helping triage the questions, Aniela is the co-founder and head trickster behind habit aware and one of my dearest friends. So I’m glad you were able to be our behind the scenes post today.

Isla:     44:09   Me too. Thanks for having me. And thanks to my husband for taking the kids out.

Ellen:  44:16   And those are my chief barking officers telling everybody goodbye. I’m sure some of you have those at home too. So thank you everybody. And thank you Dr. Dina. This has been just so great. And I hope you stay safe and well when you head back to work.


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