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Russell's sign: bulimia knuckles, hands and fingers

Bulimia symptoms are not always obvious—they include hiding food, avoiding confrontation about their eating habits, binging in private, and self-isolating. Most harmful effects to the body from these compensatory behaviors are happening internally, such as: (2)

  • Heart problems (e.g., heart failure or irregular heartbeat)
  • Dehydration
  • Irregular or absent menstrual cycles in females
  • Digestive problems
  • Mental health issues

Education about the outward signs of bulimia and purging are more noticeable and include signs like tooth decay and damage to the hands and knuckles from purging.

Within Health offers compassionate, highly-personalized eating disorder treatment programs.

What does that look like?

Last updated on 
March 8, 2023
April 5, 2023
Russell's sign
In this article

What is Russell's sign?

Russell's sign is a pattern of calluses on the knuckles or back of the hand due to frequent purging (via self-induced vomiting) over a long period of time. It is a key indicator of bulimia nervosa. "Bulimia knuckles" develop due to the repeated contact of the teeth on the back of the hand or knuckles when fingers are used to trigger a gag reflex. (3)

British psychiatrist Gerald Russell first recognized this sign as a common indicator among his eating disorder patients, hence the name. (1) Just as bulimia nervosa and other eating disorders can affect all genders and ethnicities, Russell's sign can also be present in any person. 

Although bulimia nervosa is usually associated with oral purging, purging does not always mean inducing vomiting. Purging can also take place in the form of diuretic or laxative abuse or a mixed presentation. Because of this, Russell's sign cannot be used as a sole method of diagnosing or confirming the presence of bulimia.

It should also be noted that only those who use their hand to induce a gag reflex to purge through vomiting develop this sign of "bulimia knuckles." Many who purge may use an object, such as a toothbrush handle or straw, to trigger the gag reflex. In addition, some bulimia patients are capable of "hands-free purging" over time, meaning that they can induce vomiting without external triggering of the gag reflex. (1) Thus, although Russell's is sometimes a reliable indicator of bulimia, its absence does not exclude the possibility that an individual is engaging in purging. 

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How serious is Russell’s sign?

Of the physical characteristics related to bulimia and purging, Russell’s sign is a fairly late one, indicating that someone is undergoing a more advanced stage of the disease as they are purging frequently enough to induce callouses on the back of the hand. Thus, it may be a sign in particularly advanced disease or in patients with very serious, persistent purging behaviors.

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How serious is Russell's sign?

Of the physical characteristics related to bulimia and purging, Russell's sign may indicate that someone is undergoing a more advanced stage of the disease as they purge frequently enough to induce callouses on the back of the hand. Thus, the condition generally arises later in patients with severe, persistent purging behaviors. 

Other Physical Signs of Purging 

One of the first signs of bulimia nervosa is usually a decline in oral health, such as cavities, enamel erosion, and teeth discoloration from purging. (4) Russell's sign is usually one of the later signs, indicating persistent, frequent vomiting, re-injuring the same area without a chance to heal between purges. 

Other physical signs of bulimia include: (4)

  • Obvious weight fluctuations
  • Gastrointestinal issues (e.g., acid reflux, constipation, stomach cramps)
  • Dry skin
  • Brittle and dry nails
  • Fine, fuzzy hair on the body (lanugo)
  • Yellow skin
  • Irregular menstrual cycles
  • Thinning of hair on the head
  • Dental issues (e.g., cavities, teeth discoloration, enamel erosion)
  • Dizziness and fainting
  • Swollen feet

The good news is that Russell's sign is just that—a sign. It does not cause permanent harm to the hands and knuckles. The internal metabolic effects of purging can cause more lasting damage.

woman sitting looking out at water

How to get rid of Russell's sign 

Recovery from bulimia nervosa is an emotional journey; above all, support is needed. It is essential to understand that the physical signs of bulimia are only the visible part of a mental health condition that affects every facet of a person's life. (1)

At Within Health, we offer virtual eating disorder treatment programs for patients with eating disorders like bulimia nervosa. Speak to our admissions team today to learn how to get started. 

Disclaimer about "overeating": Within Health hesitatingly uses the word "overeating" because it is the term currently associated with this condition in society, however, we believe it inherently overlooks the various psychological aspects of this condition which are often interconnected with internalized diet culture, and a restrictive mindset about food. For the remainder of this piece, we will therefore be putting "overeating" in quotations to recognize that the diagnosis itself pathologizes behavior that is potentially hardwired and adaptive to a restrictive mindset.

Disclaimer about weight loss drugs: Within does not endorse the use of any weight loss drug or behavior and seeks to provide education on the insidious nature of diet culture. We understand the complex nature of disordered eating and eating disorders and strongly encourage anyone engaging in these behaviors to reach out for help as soon as possible. No statement should be taken as healthcare advice. All healthcare decisions should be made with your individual healthcare provider.

Resources

  1. Barry, C. (2021). What is Russell's Sign l Understanding Russell's Sign. Retrieved January 31, 2022.
  2. Bulimia nervosa. (2018). Mayo Clinic. Retrieved March 8, 2023. 
  3. Daluiski, A., Rahbar, B., & Meals, R.A. (1997). Russell's sign. Subtle hand changes in patients with bulimia nervosa. Clinical Orthopaedics and Related Research, 343, 107-109.
  4. Bulimia Nervosa. (n.d.). National Eating Disorders Association. Retrieved March 8, 2023.

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