Is clonidine beneficial for dermatillomania (skin picking)?

Clonidine for Skin Picking Disorder (Dermatillomania)

Clonidine is not recommended as a first-line treatment for skin picking disorder (dermatillomania) as there is insufficient evidence supporting its efficacy for this condition.

Understanding Skin Picking Disorder

Skin picking disorder (dermatillomania or excoriation disorder) is classified under the obsessive-compulsive and related disorders in the DSM-5. It is characterized by:

• Repetitive picking of one's skin
• Resulting in skin lesions
• Significant distress or functional impairment
• Not attributable to another medical condition or substance

According to the DSM-5 classification, skin picking disorder is distinct from but related to other body-focused repetitive behavior disorders 1.

Evidence-Based Treatment Recommendations

First-Line Treatments

1. Behavioral Therapies:

   • Habit Reversal Training (HRT) and stimulus control are first-line behavioral treatments for all severity levels 2
   • Particularly effective when picking is done with lowered awareness
   • Acceptance and Commitment Therapy (ACT) and Dialectical Behavior Therapy (DBT) can augment HRT, especially when negative emotions trigger picking 2

2. Pharmacological Options:

   • N-acetylcysteine (NAC) should be considered for all severity levels due to its moderate efficacy and low side effect profile 2, 3
   • Selective Serotonin Reuptake Inhibitors (SSRIs) have shown the most effectiveness among pharmacological interventions 3, 4

Second-Line and Alternative Treatments

• Olanzapine may play a role in treatment 5
• Serotonin-norepinephrine reuptake inhibitors have been described in case reports and trials 3
• Glutaminergic-modulating agents have shown some efficacy 3

Clonidine's Role in Skin Picking

Clonidine, an alpha-2 adrenergic receptor agonist, is not specifically mentioned in any of the guidelines or research evidence as a treatment for skin picking disorder. While clonidine has established roles in:

• Hypertension management 6
• ADHD treatment 1, 6
• Management of menopausal hot flashes 1
• Treatment of nightmares in PTSD 1
• Management of acute agitation in children 1

There is no evidence in the provided literature supporting its use for dermatillomania.

Important Clinical Considerations

1. Differential Diagnosis:

   • Rule out other conditions where skin picking may be a symptom, such as body dysmorphic disorder 1
   • Consider comorbid conditions like OCD, anxiety disorders, or depression 4

2. Treatment Approach:

   • A multidisciplinary approach involving dermatology and psychiatry is recommended 3
   • Treatment should address both the behavioral component and any underlying psychiatric conditions 4

3. Monitoring and Follow-up:

   • Regular assessment of skin damage and healing
   • Evaluation of treatment response and side effects
   • Adjustment of treatment plan as needed

Conclusion

For patients with skin picking disorder, evidence supports cognitive-behavioral therapy (particularly HRT) and pharmacological treatments like NAC and SSRIs. Clonidine is not supported by current evidence for the treatment of dermatillomania and should not be considered unless other evidence-based treatments have failed and there are specific reasons to believe it might help an individual patient (such as comorbid conditions for which clonidine is indicated).