Can naltrexone be used to treat skin-picking (excoriation) obsessive‑compulsive disorder?

Naltrexone for Skin-Picking Disorder

Naltrexone can be considered as a treatment option for skin-picking disorder (excoriation disorder), though it is not first-line therapy and evidence supporting its use is limited compared to SSRIs and N-acetylcysteine.

Treatment Hierarchy for Skin-Picking Disorder

The evidence-based approach prioritizes:

First-Line Treatments

• SSRIs show the most promising results for reducing severity and frequency of skin-picking symptoms 1
• N-acetylcysteine is well-established in treatment of skin-picking disorder 1
• Cognitive-behavioral therapy (specifically habit reversal or acceptance-enhanced behavior therapy) 2

Second-Line/Adjunctive Options

• Naltrexone can be used when first-line treatments fail or as an adjunct 1, 2

Evidence for Naltrexone

The support for naltrexone in skin-picking disorder is modest but present:

• A 2016 systematic review found insufficient evidence to support naltrexone use specifically for excoriation (skin-picking) disorder, though it showed benefit in related conditions like gambling disorder and kleptomania 3

• However, more recent evidence is emerging: A 2024 case report demonstrated improvement with low-dose naltrexone (4.5 mg daily) in a patient with excoriation disorder, with symptom worsening when temporarily discontinued and improvement upon resumption 4

• A 2025 review identified naltrexone among medications evaluated for skin-picking disorder, though noting that additional studies are needed to definitively establish its role 1

Practical Considerations

Dosing approaches:

• Traditional dose: 50 mg daily 2
• Low-dose option: 4.5 mg daily has shown benefit in at least one case 4
• The FDA-approved dose for other conditions is 50 mg daily 5

When to consider naltrexone:

• After inadequate response to SSRIs
• When N-acetylcysteine has failed or is not tolerated
• In patients with comorbid substance use issues (where naltrexone has established efficacy)
• When there appears to be a strong reward/gratification component to the picking behavior

Important caveats:

• Naltrexone is FDA-approved only for alcoholism and opioid dependence, not for skin-picking disorder 5
• Must ensure patient is opioid-free before initiating (naloxone challenge test may be needed) 5
• Monitor for hepatotoxicity, especially with doses above 50 mg 5
• The mechanism in skin-picking likely involves modulation of the opioid reward system

Clinical Algorithm

1. Start with SSRI (at higher doses than used for depression) combined with habit-reversal therapy
2. Add or switch to N-acetylcysteine if inadequate response after 8-12 weeks
3. Consider naltrexone (50 mg daily or trial of 4.5 mg daily) if:
   • Partial response to above treatments
   • Strong compulsive/reward-seeking component to behavior
   • Patient can comply with opioid-free requirement
4. Consider antipsychotic augmentation (olanzapine, aripiprazole) as alternative to naltrexone 1

The evidence for naltrexone remains weaker than for SSRIs and N-acetylcysteine, but it represents a reasonable option in treatment-resistant cases or when integrated into a comprehensive treatment plan.