What is the recommended approach for evaluating and managing persistent skin picking in the elderly?

Evaluation and Management of Persistent Skin Picking in the Elderly

The recommended approach for evaluating and managing persistent skin picking in the elderly is to first rule out underlying dermatological conditions with a thorough assessment, then implement a combination of habit reversal therapy and selective serotonin reuptake inhibitors (SSRIs) as first-line treatment. 1, 2

Diagnostic Evaluation

Initial Assessment

• Conduct a complete dermatological examination to distinguish between:
  • Excoriation (skin-picking) disorder: repetitive skin picking not driven by appearance improvement 3
  • Pruritus-related picking: common in elderly (Willan's itch) often associated with xerosis 3
  • Potential underlying conditions: bullous pemphigoid, which can rarely present as pruritus in the elderly 3

Key Differential Diagnoses

• Excoriation disorder: repetitive skin picking causing tissue damage and significant distress 1
• Pruritus in elderly skin: often related to dry skin but may have other causes 3
• Body dysmorphic disorder: skin picking driven by attempt to improve appearance of perceived defects 3

Diagnostic Workup

• Skin biopsy and indirect immunofluorescence if bullous pemphigoid is suspected 3
• Assess for psychiatric comorbidities (depression, anxiety disorders) which are common 3
• Evaluate for suicidality, which is prevalent in patients with skin picking disorders 3

Management Approach

First-Line Treatment

1. Dermatological Management

   • Emollients with high lipid content applied immediately after bathing 3, 4
   • Avoid soap products and use dispersible cream as soap substitute 4
   • Short-term low-potency topical corticosteroids (limit to 2 weeks) for inflammation and itching 4

2. Behavioral Interventions

   • Habit reversal therapy (HRT): the most evidence-based behavioral treatment 2, 5
     • Awareness training: identifying triggers and early warning signs
     • Competing response training: substituting picking with incompatible behaviors
     • Social support and reinforcement

3. Pharmacological Treatment

   • Non-sedating antihistamines for pruritus (avoid sedating antihistamines in elderly) 3, 4
   • SSRIs have shown the most effectiveness for skin picking disorder 1
   • N-acetylcysteine has demonstrated efficacy in controlled trials 1
   • Gabapentin may benefit elderly patients with pruritus 3

Environmental and Self-Care Recommendations

• Maintain adequate humidity in the home environment 4
• Wear cotton clothing rather than wool or synthetic fabrics 4
• Keep fingernails short to minimize damage from picking 4
• Apply cool compresses for immediate relief of itching 4

Referral Considerations

• Refer to secondary care if there is diagnostic doubt or if primary care management fails to relieve symptoms 3
• Consider multidisciplinary approach involving both dermatology and psychiatry 6
• Regular follow-up is essential to identify underlying causes and monitor treatment response 3, 4

Treatment Efficacy

• Cognitive-behavioral therapy, even in brief form (4 sessions), has shown large effect sizes (0.90-1.89) with maintained results at follow-up 5
• Combined approaches (behavioral and pharmacological) often yield better outcomes than either approach alone 6

Common Pitfalls and Caveats

• Failing to distinguish between primary skin picking disorder and picking secondary to pruritus
• Not addressing underlying psychiatric comorbidities
• Using sedating antihistamines in the elderly, which should be avoided 3
• Discontinuing emollients after symptom resolution (should be continued for prevention) 4
• Patients may decline referral to mental health professionals; dermatologists should be prepared to implement basic HRT techniques 2