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Russell’s Sign: What It Is, What It Means, and What Comes Next

Russels sign is another name for a mark that appears on some people’s knuckles due to self-induced vomiting. If you notice it, you’re likely worried about what it means for yourself or someone else. Those who see it on another person might fear for their well-being or wonder if it is what they think it is. Alternatively, people who notice it on themselves might fear getting caught or want to know whether it’ll go away during eating disorder recovery.

It can be frightening or disorienting, but view this as a step in the right direction. Detection is what makes recovery possible. It puts a name to what the person is going through and opens the door to treatment.

What is Russell’s Sign?

Russell’s sign refers to calluses, scars, or abrasions on the knuckles from repeated contact with upper teeth during self-induced vomiting. It’s named after psychiatrist Gerald Russell, who described it in 1979 in his foundational paper on bulimia nervosa. Russell’s sign is considered a physical diagnostic marker in eating disorder clinical assessment. In other words, this mark on the knuckles is a possible indicator of an eating disorder that can help guide diagnosis. It ranges from mild redness to scarring and open cuts on the knuckles. The severity depends largely on the frequency and duration of purging behaviors, or how much teeth come into contact with the skin when a person vomits.

What Does Russell’s Sign Look Like?

Here are a couple of ways to detect possible knuckle scars from an eating disorder: 

  • Location. Typically, Russell’s sign is on the knuckles of the index and middle fingers of the person’s dominant hand (the hand they write with). 
  • Appearance. You might see redness, thickening, abrasions, scarring, discoloration, small, open wounds (cuts), or cracked skin, depending on severity. When Russell’s signs first develop, it’s less noticeable than it is if it becomes chronic. The more a person purges, the more likely permanent scarring becomes: it continues to worsen the more the teeth hit the knuckles.

What sets it apart from ordinary calluses? Generally, the location, pattern, and specific skin changes you’ll see with Russell’s sign distinguish it from marks on the knuckles attributed to other causes. It’s usually clear that it most likely comes from the person’s teeth.

What Causes Russell’s Sign?

The primary cause of Russell’s sign is repeated friction of the knuckles against the upper front teeth during self-induced vomiting. The dominant hand is most commonly affected because that is the hand people usually use to induce vomiting when they’re purging that way. The placement is because a lot of people use their fingers, which is where you’ll see the mark, to make contact with the gag reflex. 

Some people who purge don’t develop visible Russel’s sign. This is important to talk about because not having Russell sign does not mean that a person does not purge or have a serious eating disorder. 

First, people purge in different ways. It’s not always vomiting. It can also be excessive exercise or laxative abuse, as a couple of examples. These could occur alone or alongside vomiting. Second, people might use items other than their hands to induce vomiting, like toothbrushes. Some vomit without using any tools at all. If you’re concerned about someone else, possible signs of these purging methods may be worth looking out for.

Individual skin differences are another factor that can play a role. Some people’s skin is more prone to scarring than others. If that’s true, the person is more prone to developing Russell’s sign or more pronounced knuckle scars from bulimia or related conditions. Other people will have more resilient skin, which means that they might not scar as easily, even if they purge via self-induced vomiting.

Is Russell’s Sign Always Caused by Bulimia?

A lot of people want to know what Russell’s sign means. Is it always caused by bulimia? Actually, Russell’s sign, or similar marks, can have a number of different causes:

  • Bulimia nervosa (binge-purge subtype). This is the most common cause of Russell’s sign. 
  • Anorexia nervosa binge-purge subtype (anorexia paired with bingeing and purging episodes – this includes atypical anorexia). 
  • Other specified feeding or eating disorder (OSFED). Though not always, some people with OSFED vomit and may have Russell’s sign as a result. Specifically, people with purging disorder.
  • Other causes. Rarely, similar scarring, cuts, or calluses can occur in a similar location due to a person’s work (e.g., manual labor) or certain dermatological conditions. 

In short, Russell’s sign is almost always associated with purging behaviors. The sign alone isn’t a diagnosis. However, its presence in the context of other eating disorder signs raises clinical concern.

Other Physical Signs That Often Appear Alongside Russell’s Sign

Purging takes a toll on the body. Russell’s sign rarely appears alone. Other potential physical signs of self-induced vomiting include: 

  • Dental erosion and enamel loss from stomach acid.
  • Parotid gland swelling, causing facial puffiness (“bulimia face.”)
  • Dehydration and its physical signs (such as dry mouth, chapped lips, and/or dark urine).
  • Acid reflux and throat irritation (can come with vocal hoarseness).
  • Broken blood capillaries under the eyes (very small red or purple-ish marks).
  • Electrolyte imbalances (low potassium, sodium). 
  • Changes in heart rate or blood pressure. 
  • Callused or irritated throat tissue.
  • Dizziness or fainting. 
  • Watery, red eyes.
  • Mouth sores. 

While many potential physical signs of bulimia and related disorders, like acid reflux, have other possible causes, they’re common in people who purge. If Russell’s sign appears alongside other potential signs and symptoms of conditions that may lead a person to purge, whether mental, physical, or behavioral, it can strengthen your hunch that this is what’s going on.

Infographic showing the physical and long-term effects of purging, including dental damage, facial swelling, dehydration, digestive issues, heart complications, electrolyte imbalances, weakened immunity, and other health risks associated with eating disorders and bulimia.

What are the Effects of Purging? Health Risks Associated with the Behaviors that Cause Russell’s Sign

It’s important to take purging seriously. Regardless of a person’s age, size, or background, the behaviors that cause Russell’s sign can lead to severe complications. Health risks associated with purging include: 

  • Cardiovascular problems (e.g., heart attack, heart failure, palpitations), which generally stem from low potassium/electrolyte imbalance
  • Digestive problems (e.g., ulcers, gastritis, stomach rupture, chronic acid reflux, disrupted gastric or esophageal motility).
  • Dental destruction, which can include irreversible enamel erosion from stomach acid exposure.
  • Kidney problems, including acute renal injury and kidney disease requiring dialysis.
  • Esophageal damage, including tears, inflammation, and, in severe cases, rupture. 
  • Dehydration.

Many of these (e.g., stomach rupture) can occur whether a person’s been struggling with purging short or long-term. However, risk severity increases in those who purge frequently or for a longer period of time. Early support can make a huge difference in preventing the worsening of eating disorders and their effects, including the physical health risks of purging. When possible, it is not something to take a watch and wait approach with.

Can Russell’s Sign Heal?

Does Russell’s sign go away? Healing bulimia knuckles is possible. It’s a gradual process, but for most people, it does happen. The skin often recovers significantly, or fully, when purging stops. If you’re in recovery or are considering it, this is a great reason to seek support if you haven’t already. The timeline and expectations can differ depending on severity:

  • Early-stage or mild redness and abrasions typically resolve within weeks to months of stopping purging. 
  • Long-standing scars may persist but often improve. The degree of permanence varies by individual. 
  • Calluses on the knuckles tend to soften and fade significantly over time.

Medical and dermatological support can assist with skin recovery alongside eating disorder treatment. This is most common for those with severe scarring. Usually, people see a dermatologist after they have been in recovery for a while. That way, scars have a chance to improve on their own first.

What to do if You or Someone You Love Has Russell’s Sign

Do not get mad at your loved one if you suspect they are purging. Prior to treatment, it very much feels like the eating disorder is in control of the person going through it. This is something much deeper than the media portrays. And, it is blame-free. Eating disorders are treatable, even if they can’t always be prevented. 

Medical evaluation is critical for people who have been purging. It’s part of the standard intake process for an eating disorder treatment program. This should involve tests such as lab work to assess electrolyte levels and an EKG to evaluate cardiovascular health. 

It can be difficult to seek help for an eating disorder. If you’re seeking treatment for yourself, remember that a professional’s role is not to get mad at you for struggling. A good treatment provider is someone who understands the complexity of eating disorders.

Often, Russell’s sign is the first thing that prompts someone to seek professional help. Fear is common. Taking the leap does not require an overnight transformation. Being open and honest, and finding a safe space to do it, is what matters.

Learn more about what eating disorder treatment looks like at Sanford.

FAQs

Is Russell’s sign permanent?

Russell’s sign usually goes away or fades. For people who have been in recovery for a long time and have not experienced fading to the extent they desire, dermatologists can suggest or provide treatments. These range from topical creams to other interventions such as laser therapy.

No. Many people with bulimia do not have Russell’s sign.

Usually, Russell’s sign is attributed to bulimia or other conditions that can cause purging, like purging disorder. But there are other situations where it might not be attributed to an eating disorder at all. For example, similar markings can be attributed to martial arts or labor work.

How long Russell’s sign takes to heal varies from person to person. The more severe the scarring is, the longer it usually takes to fade. If it does not go away entirely, it improves over time. Making sure that a person has adequate nutritional rehabilitation can support the healing process.

“Bulimia knuckles” are caused by repeated contact with the teeth.

Russell’s sign itself (as in, the physical scarring) is not usually dangerous, save for cases where cuts or wounds associated with Russell’s sign or bulimia become infected. However, the self-inducted vomiting that causes Russell’s sign is dangerous.

Physical signs of purging can vary. People who purge via self-induced vomiting usually notice a combination of: 

  • Watery, red eyes (especially directly after purging).
  • Broken blood capillaries under the eyes.
  • Sore throat or voice hoarseness. 
  • Puffy, swollen lymph nodes or face.
  • Upset stomach.

Many people experience weight fluctuations, though this is not always true.

If you are purging, you should seek medical attention. A professional’s role isn’t to shame you. There are harm reduction measures that treatment professionals might be able to help with as you work toward full recovery. If a person in your care, such as a child, shows Russell’s sign alongside other signs of self-induced vomiting, it is important to see a doctor.

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