Cross-sectional Survey Examining Skin Picking and Hair Pulling Disorders During The COVID-19 Pandemic.

To the Editor: Body-focused repetitive behaviors (BFRBs) include repetitive hair pulling (trichotillomania), nail biting, and skin picking (excoriation disorder). The ritualized behaviors are distinct and classified among obsessive-compulsive and related disorders in the Diagnostic and Statistical Manual of Mental Disorders. BFRBs can cause distress, visible damage, and lead to social impairment.

Societal changes from the COVID-19 pandemic present a unique challenge to those with BFRBs. Individuals with BFRBs have high baseline levels of anxiety and report a correlation between anxiety and symptom severity. Rapid implementation of changes to daily life, including COVID-19 social distancing directives, have the potential to compound the increased social isolation already experienced by those with BFRBS.

We created a survey to examine how changes during the COVID-19 pandemic have affected those with BFRBs, including symptom severity and access to treatment.

This study was exempted by the University of Minnesota Institutional Review Board. An online survey link was shared among BFRB Facebook groups and in a newsletter sent to consumers of a BFRB awareness device (HabitAware, Minneapolis, MN). Responses were collected between July 1 and July 31, 2020. Participants who indicated hair-focused BFRBs completed a modified Massachusetts General Hospital Hairpulling Scale and those with skin-focused BFRBs completed a modified Skin Picking Scale-Revised comparing symptoms before and during the pandemic. , Paired-samples t tests were used to compare means.

A total of 460 individuals with a self-reported BFRB diagnosis completed the survey (Table I ). Skin picking was reported by 133 (28.9%) participants, hair pulling was reported by 181 (39.3%) participants, and 141 (30.7%) participants reported both. A majority (67.2%) reported increased BFRB symptoms during COVID-19. Of the 145 (31.5%) participants receiving active treatment for BFRBs, 55 (37.9%) experienced an interruption in therapy because of COVID-19. Those with skin picking disorders reported a significant (2.2) increase on the modified Skin Picking Scale-Revised (P = .00). Participants with hair pulling disorders reported a 1.6 point increase on the Massachusetts General Hospital Hairpulling Scale (P = .01; Table II ).

Table I

Demographics, therapy, and dermatologic care

Category
Age, y, mean (SD)	32.5 ± 12.4
Diagnosis, n
Formal BFRB diagnosis	460
No formal BFRB diagnosis, excluded	25
Location, n (%)
United States	342 (74.3)
Outside of the United States	118 (25.7)
Race, ethnicity, or origin, n (%)
Asian or Pacific Islander	15 (3.3)
Black or African American	7 (1.5)
Hispanic or Latino	15 (3.3)
Middle Eastern or North African	4 (0.9)
White	411 (89.3)
Other race, ethnicity, or origin	8 (1.7)
Gender/gender identity, n (%)
Transgender	11 (2.4)
Nonbinary	9 (2.0)
Genderqueer∗	5 (1.1)
Female	457 (99.3)
Male	13 (2.8)
Chose not to disclose	1 (0.2)
BFRB classification, n (%)
Repetitive skin picking	133 (28.9)
Repetitive hair pulling	181 (39.3)
Both	141 (30.7)
Other BFRB	5 (1.1)
Self-rated impact of COVID on BFRB, n (%)
Improved	60 (13.0)
No change	81 (17.6)
Worsened	309 (67.2)
No answer	10 (2.2)
BFRB therapy, n (%)
Active treatment for BFRB before COVID	145 (31.5)
Interruption to active treatment because of COVID	55 (37.9)
No active treatment for BFRB before COVID	315 (68.5)
Desire to start therapy since COVID	127 (40.3)
Dermatologic care, n (%)
History of dermatologic care	249 (54.1)
History of dermatologic care for BFRB	55 (12.0)

Genderqueer is as a term for self-identification and includes those who have a gender identity that does not align with sex assigned at birth. For more information, see the American Academy of Dermatology Lesbian, Gay, Bisexual, Transgender, and Queer Sexual and Gender Minority Expert Resource Group position statement on Sexual and Gender Minority Health in Dermatology, available at https://server.aad.org/Forms/Policies/Uploads/PS/PS-Sexual%20and%20Gender%20Minority%20Health%20in%20Dermatology.pdf?.

Table II

Modified Skin Picking Scale-Revised and modified Massachusetts General Hospital Hairpulling Scale scores before and after COVID

Scale and score	Pre-COVID mean	COVID mean	Mean difference	P value
SPS-R (modified) scale item (0-4)
Overall urge	1.8	2.2	0.4	.00
Intensity of urges	1.8	2.3	0.4	.00
Time spent picking skin	1.6	1.9	0.3	.00
Control over skin picking behavior	2.1	2.5	0.3	.00
Emotional distress from skin picking	1.7	1.9	0.2	.02
Social impairment caused by skin picking	1.1	1.2	0.2	.05
Social avoidance behavior	0.8	1.0	0.2	.00
Physical damage to skin from skin picking	1.6	1.7	0.2	.00
Total modified SPS-R (max 32)	12.5	14.7	2.2	.00
MGH-HPS (modified) scale item (0-4)
Frequency of urges	2.2	2.6	0.4	.00
Intensity of urges	2.3	2.6	0.4	.00
Ability to control the urges	2.0	2.3	0.2	.02
Frequency of hairpulling	1.8	2.0	0.3	.01
Control over hairpulling	2.9	3.0	0.1	1.03
Associated distress	2.3	2.5	0.2	.02
Total modified MGH-HPS (max 24)	13.5	15.1	1.6	.01

MGH-HPS, Massachusetts General Hospital Hair Pulling Scale; SPS-R, Skin Picking Scale-Revised.

For those with BFRBs, the COVID-19 pandemic has led to increased symptoms. Although this study was limited by modification of standardized scales and its self-reported survey design, it suggests that anticipated psychologic effects of the pandemic are, in fact, materializing. Respondents with both skin and hair BFRBs reported increased distress and functional impairment.

BFRBs are psychiatric disorders with dermatologic manifestations. While only 12.0% of those surveyed in our study reported seeing a dermatologist for their BFRB before COVID-19, the rapid spread of telemedicine may change that. Dermatologists should be aware that those with BFRBs may be experiencing increased skin picking and hairpulling during COVID-19. Proactive outreach to existing patients with BFRBs may be helpful.

Although there are no treatments for BFRBs approved by the US Food and Drug Administration, treatment options include serotonin reuptake inhibitors, N-acetylcysteine, behavioral therapies, and wearable devices. , In addition, many health systems have expanded telemedicine capabilities. In the context of lessened geographic and social barriers (eg, appearance stigma), patients with BFRBs may have greater access to treatment. Thus, it is more important than ever for dermatologists to consider BFRBs in their differential diagnosis and management.

Conflicts of interest

Ms Idnani is the cofounder and president of HabitAware. HabitAware did not provide any funding for this study. The remaining authors have no disclosures.