What is the best treatment for dermatillomania (skin picking)?

Best Treatment for Skin Picking (Dermatillomania)

The most effective treatment for dermatillomania (skin picking disorder) is cognitive-behavioral therapy, particularly habit reversal therapy, combined with selective serotonin reuptake inhibitors (SSRIs) for moderate to severe cases. 1, 2

Understanding Dermatillomania

Dermatillomania, also known as excoriation disorder, is classified under obsessive-compulsive and related disorders in the DSM-5. It involves repetitive picking of skin leading to tissue damage, significant distress, and functional impairment. It's important to differentiate it from other conditions:

• Unlike skin picking in Body Dysmorphic Disorder (BDD), dermatillomania is not primarily driven by appearance concerns 1
• Often comorbid with other psychiatric conditions including OCD, anxiety disorders, and depression 3, 2

Treatment Algorithm

First-line Treatment: Behavioral Interventions

1. Habit Reversal Therapy (HRT) - Most strongly supported behavioral intervention 4

   • Awareness training: Helping patients recognize triggers and early warning signs
   • Competing response training: Teaching patients alternative behaviors to perform when urges arise
   • Social support: Involving family/friends in treatment

2. Acceptance and Commitment Therapy (ACT)

   • Focuses on accepting urges without acting on them
   • Particularly helpful when emotional triggers are prominent 2

Pharmacological Treatment

For moderate to severe cases or when behavioral therapy alone is insufficient:

1. First-line medication: SSRIs

   • Most effective pharmacological intervention 2
   • Dosing should be similar to that used for OCD (often higher than for depression)
   • May take 8-12 weeks for full effect

2. Second-line medication: N-acetylcysteine (NAC)

   • Glutamatergic agent showing efficacy in controlled trials 2, 5
   • Typical dosing: 1200-2400 mg/day
   • Generally well-tolerated with minimal side effects

3. Third-line options:

   • Olanzapine (antipsychotic) for treatment-resistant cases 5
   • Serotonin-norepinephrine reuptake inhibitors (SNRIs) 2

Addressing Skin Damage

• Topical wound care for existing lesions
• Antibiotics if secondary infection present 3
• Moisturizers to reduce irritation and promote healing

Special Considerations

• Comorbid conditions should be addressed concurrently, especially OCD, anxiety, and depression

• Trigger identification is crucial - common triggers include:

  • Anxiety/stress
  • Boredom
  • Tactile sensations (rough spots on skin)
  • Visual cues (seeing imperfections)

• Treatment resistance may require combination therapy (both medication and behavioral approaches)

Common Pitfalls to Avoid

1. Focusing only on skin damage without addressing the underlying psychological components
2. Dismissing the condition as merely a "bad habit" rather than a recognized psychiatric disorder
3. Inadequate treatment duration - both behavioral and pharmacological treatments require sufficient time
4. Overlooking comorbidities that may perpetuate skin picking behavior
5. Failing to involve the patient in developing specific strategies for their unique triggers

Dermatillomania is a chronic condition that often requires ongoing management. Regular follow-up and adjustment of treatment strategies are essential for long-term success in reducing skin picking behaviors and improving quality of life.