What medications are used to treat skin picking disorder?

Medications for Skin Picking Disorder

Selective serotonin reuptake inhibitors (SSRIs) are the first-line pharmacological treatment for skin picking disorder, with N-acetylcysteine (NAC) as an effective alternative or adjunctive option. 1

First-Line Treatments

SSRIs

SSRIs show the most promising results for reducing the severity and frequency of skin picking behaviors:

• Fluoxetine: Demonstrated efficacy in a double-blind, placebo-controlled trial at doses up to 80 mg/day (mean effective dose: 55 mg/day) 2
• Paroxetine: Shown to be effective in case reports, particularly when skin picking is comorbid with OCD features 3
• Sertraline: May be considered as a third-line treatment for pruritus in hepatic disease 4, which suggests potential benefit in pruritus-related picking

Glutamatergic Agents

• N-acetylcysteine (NAC): Well-established as an effective treatment for skin picking disorder 1

Second-Line Treatments

Anticonvulsants

• Lamotrigine: In an open-label study, 66.7% of subjects showed significant improvement at doses up to 300 mg/day (mean effective dose: 200 mg/day) 5
• Topiramate: May be used in severe cases of skin picking 4

Other Options

• Antipsychotics: Olanzapine has shown benefit, particularly when combined with antidepressants 6
• Opioid antagonists: Naltrexone has been studied for skin picking 1

Treatment Algorithm

1. Start with an SSRI:

   • Begin with fluoxetine 20 mg daily, titrating up to 80 mg daily as needed
   • If ineffective after 8-12 weeks at maximum tolerated dose, switch to another SSRI or add a second agent

2. Consider adding N-acetylcysteine:

   • Can be used as monotherapy or in combination with an SSRI

3. For treatment-resistant cases:

   • Consider lamotrigine (starting at 25 mg and titrating slowly to 200-300 mg/day)
   • Consider olanzapine at low doses (2.5-5 mg)
   • Consider naltrexone as an alternative approach

Behavioral Therapy Integration

Habit reversal therapy should be used alongside medication for optimal results:

• Awareness training
• Use of competing responses (e.g., making a fist instead of picking) 4

Special Considerations

• Comorbidities: When skin picking co-occurs with OCD features, SSRIs may be particularly effective 3
• Monitoring: Regular assessment of treatment response is essential
• Caution: Long-term use of topical antibiotics is not recommended due to risk of resistance and sensitization 4
• Common pitfall: Focusing only on the skin picking without addressing underlying anxiety, depression, or OCD symptoms that may be driving the behavior

Practical Tips

• Skin picking disorder may be part of the obsessive-compulsive spectrum, explaining the efficacy of SSRIs
• Treatment response may take 8 weeks or longer to achieve maximum benefit
• Consider the potential for skin picking as a manifestation of body dysmorphic disorder, which may require more intensive treatment 4
• Avoid sedating antihistamines as primary treatment, as histamine is not the major contributor to picking behaviors

Remember that skin picking disorder often requires a combination of pharmacological intervention and behavioral therapy for optimal outcomes.