Ask Dr. Roach: Skin-picking treatments vary from SSRI drugs to therapy

DEAR DR. ROACH >> I have had an unsightly rash on my legs for many years. I finally went to the dermatologist today, and he said I have skin-picking syndrome and that all of the findings on my leg are due to my picking at the skin. He suggested I talk to my doctor about starting an SSRI drug, but my regular doctor didn’t agree. What do you think?

— R.C.

Dear R.C. >> Skin-picking disorder is more common than you might think (accounting for2% of visits to dermatologists), but some studies have shown that 2% to 5% of adults skin-pick to the point of noticeable skin damage. Part of the diagnosis is that the behavior (which includes many types of self-injurious behavior, from nail-biting to hair-pulling) leads to visual tissue damage and impairment in social functioning.

Skin-picking disorder isn’t picking at something once or twice; it’s an obsessive disorder that leads to self-harm. People with skin-picking disorder are more likely to have psychological issues, including major depression, bipolar disorder, obsessive-compulsive disorder and anxiety disorders, but none are essential for a diagnosis.

In addition to proper skin care, which may include topical steroids, psychological treatment is effective at stopping the behavior. Cognitive-behavioral therapy, habit reversal therapy and other behavioral programs have been proven effective.

If treatment without medication is unhelpful, or specific behavioral programs are not available, or the person prefers medication, then SSRI medicines, such as fluoxetine or citalopram, are often used. There are specialists with expertise in both skin disease and psychological issues who are the ideal consultants, if needed.

DEAR DR. ROACH >> I am a 75-year-old woman with a mild bunion. I remain fairly active with walking, biking and yoga. My regular doctor has suggested some shoes, which I purchased, and also orthotics, which I didn’t purchase. These are only stopgap measures. Meanwhile, there are times when my foot aches and I have sharp pains. The foot specialist who my doctor sent me to doesn’t seem to be a fan of surgery, citing negative outcomes, reactions to anesthesia, etc. How successful is this type of surgery?

— E.V.

Dear E.V. >> A bunion, also known as a hallux valgus deformity, is a common issue. It’s thought that poorly designed footwear exacerbates the underlying anatomical issues that predispose people to the development of a bunion. The conservative measures of well-

designed footwear (adequate room for the toes with low heels) and orthotics do help a bit with slowing progression and relieving symptoms.

The decision to consider therapy is based on symptoms. Since you are having pain, it was worth getting a surgical opinion, but it really sounds like your foot specialist is telling you that your symptoms are not at the point where they can recommend surgery.

When I first started practicing over 30 years ago, nearly every patient I saw who underwent bunion surgery regretted the surgery. However, surgical procedures to treat bunions have improved. With more judicious referrals to surgery, far more patients are satisfied with the outcome. Depending on the study and specific procedure, about 75% to 90% of people are fully satisfied with the results when they are appropriately referred.

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