What is the recommended treatment for frequent skin picking behavior in patients with severe intellectual disability?

Treatment for Frequent Skin Picking in Patients with Severe Intellectual Disability

For patients with severe intellectual disability who engage in frequent skin picking, a combination of non-pharmacological interventions should be offered first-line, with medication reserved for cases with severe risk of harm or when non-pharmacological approaches have failed. 1

First-Line Approach: Non-Pharmacological Interventions

Behavioral Management Strategies

• Implement behavioral management techniques with a focus on habit reversal therapy, which has shown effectiveness for skin picking behaviors 2, 3
• Use differential reinforcement to reward periods without skin picking 4
• Provide preferred items and activities as alternative stimuli to reduce boredom or sensory-seeking behaviors that may trigger skin picking 4
• Consider response interruption and redirection techniques to break the cycle of picking behavior 4

Environmental Modifications

• Use protective clothing (e.g., gloves, long sleeves) when necessary to prevent access to commonly picked areas 4
• Ensure regular skin care and hygiene to minimize irritation that might trigger picking 1
• Modify the environment to reduce triggers that may precipitate skin picking behaviors 4

Functional Assessment

• Conduct a thorough functional assessment to identify triggers and maintaining factors for skin picking behavior 4
• Common functions include automatic reinforcement (sensory stimulation), attention-seeking, or escape from demands 4
• Tailor interventions based on the identified function of the behavior 4

Second-Line Approach: Pharmacological Interventions

When to Consider Medication

• Medication should be considered when non-pharmacological interventions have failed or when there is severe risk of harm from skin picking 1
• The UK National Institute for Health and Care Excellence (NICE) guidelines recommend this stepped approach 1

Medication Options

• Selective Serotonin Reuptake Inhibitors (SSRIs) show the most promising results for reducing severity and frequency of skin-picking symptoms 5
• N-acetyl cysteine (NAC) has been well-established as an effective treatment for skin picking disorder 5
• In severe cases, consider antipsychotics (often combined with antidepressants) or naltrexone 5
• Topiramate may be considered in cases that are resistant to other treatments 5

Monitoring and Follow-Up

Assessment of Treatment Effectiveness

• Regularly monitor skin condition and document frequency and severity of picking behaviors 1
• Evaluate for side effects of medications if pharmacological interventions are used 1
• Assess impact on quality of life and overall functioning 1

Risk Assessment

• Conduct ongoing risk assessment for infection, scarring, and other medical complications 1
• Monitor for self-harm behaviors that may be related to skin picking 1
• Assess for comorbid conditions that may exacerbate skin picking, such as anxiety or impulsivity 6

Important Considerations and Caveats

• Meta-analyses show small but significant intervention effects for self-injury behaviors (SMD –0.238) and overall challenging behaviors (SMD –0.422) in people with intellectual disabilities 1
• There are no significant differences in efficacy between non-pharmacological and pharmacological interventions, supporting the recommendation to try non-pharmacological approaches first 1
• Despite guidelines recommending non-pharmacological interventions first, medication prescription and polypharmacy remain common in this population 1
• Be aware that medication may be used inappropriately as the primary response to challenging behaviors, potentially leading to significant side effects and poorer long-term outcomes 1
• Higher levels of impulsivity and anxiety are strongly associated with worse skin picking severity, suggesting these may be important treatment targets 6