From the Guidelines
Treating excoriation disorder in patients with intellectual disability requires a comprehensive approach that prioritizes behavioral interventions, environmental modifications, and selective use of medication, with a focus on minimizing side effects and maximizing quality of life. When developing a treatment plan, it's essential to consider the individual's strengths and weaknesses, as noted in the practice parameter for assessing and treating psychiatric disorders in children and adolescents with intellectual disability 1. This approach should begin with a functional behavioral assessment to identify triggers for skin picking, such as anxiety, boredom, or sensory seeking. Implementing habit reversal training adapted to the patient's cognitive level can help them recognize urges and substitute alternative behaviors like squeezing a stress ball or using fidget toys.
Environmental modifications are also crucial, including keeping nails trimmed short, using protective clothing or gloves when necessary, and ensuring proper skin care to prevent infection of picked areas. For medication options, consider N-acetylcysteine (NAC) at 1200-2400 mg daily divided into two doses, which has shown efficacy for compulsive behaviors with minimal side effects. In cases with significant anxiety, SSRIs like fluoxetine (10-20 mg daily) or sertraline (25-50 mg daily) may help, starting at lower doses and titrating slowly due to potential sensitivity in this population, as suggested by the updated clinical practice recommendations for managing adults with 22q11.2 deletion syndrome 1. Topical treatments with lidocaine or antibacterial ointments can reduce discomfort that triggers picking. Caregiver training is essential, teaching them to redirect behavior gently and reinforce positive alternatives. Regular monitoring for side effects and treatment response is necessary, with adjustments made based on the individual's specific needs and cognitive abilities.
Key considerations in managing excoriation disorder in intellectually disabled patients include:
- Early detection and prompt institution of treatment
- Awareness of the patient’s long-term baseline state and monitoring for changes in emotions, thinking, sleep, fatigue, and other physical states
- Attention to other associated conditions and caution about endless searches for physical causes of treatable psychiatric illness
- A "start low, go slow" approach to medication dosing to minimize side effects
- Adaptation of standard non-pharmacologic treatments to the specific needs of the affected individuals, as these may need to be tailored to address the unique challenges and strengths of each patient 1.
From the Research
Treatment Options for Excoriation Disorder in Patients with Intellectual Disability
There is limited research specifically focusing on the treatment of excoriation disorder in patients with intellectual disability. However, the following treatment options have been identified for excoriation disorder in general:
- Cognitive-behavioral therapy, particularly habit-reversal therapy and acceptance and commitment therapy, have shown promise in treating excoriation disorder 2, 3
- Pharmacological interventions, such as selective serotonin reuptake inhibitors (SSRIs), serotonin-norepinephrine reuptake inhibitors, antipsychotics, and glutaminergic-modulating agents, have been used to treat excoriation disorder 2, 3, 4
- N-acetylcysteine (NAC) has been shown to be effective in treating excoriation disorder, with a moderate gain and low side effect profile 3, 4
Considerations for Treatment
When treating excoriation disorder, it is essential to consider the following:
- A full clinical and dermatologic examination and multidisciplinary approach is crucial in diagnosing and treating excoriation disorder 2
- The treatment approach should be individualized, taking into account the severity of the disorder, comorbidities, and behavioral style 3
- A combination of behavioral therapies, such as habit reversal training and stimulus control, and pharmacological interventions may be effective in treating excoriation disorder 3, 4
Interdisciplinary Approach
An interdisciplinary team approach, consisting of a liaison with psychiatry, is recommended in the management of excoriation disorder 5. The specific roles of dermatologists and psychiatrists should be discussed in detail to ensure a comprehensive treatment plan.
Limitations of Current Research
While there is some evidence to support the effectiveness of various treatments for excoriation disorder, there is a lack of studies specifically focusing on patients with intellectual disability 4, 6. Further research is necessary to enhance our understanding of the clinical manifestations, epidemiology, and comorbidities of excoriation disorder in this population.