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

Treatment for Skin Picking Disorder (Dermatillomania)

Cognitive-behavioral therapy with habit reversal training is the first-line treatment for skin picking disorder, followed by N-acetylcysteine (1200-2400 mg/day) as the most effective pharmacological option. 1

First-Line Treatment: Behavioral Interventions

• Cognitive-behavioral therapy (CBT) with habit reversal training is the recommended first-line treatment, including awareness training, competing response development, and self-monitoring tools 1
• Online self-help programs based on CBT principles have shown promising results with moderate effect sizes for patients who cannot access in-person therapy 1
• Acceptance and commitment therapy (ACT), particularly ACT-enhanced group behavioral therapy, has demonstrated significant effectiveness in reducing skin picking behaviors 2
• Expressive writing has also shown positive outcomes in managing skin picking symptoms 2

Second-Line Treatment: Pharmacological Interventions

• N-acetylcysteine (NAC), a glutamatergic agent, is the best-established pharmacological treatment, typically dosed at 1200-2400 mg/day in divided doses 1, 3
• Selective serotonin reuptake inhibitors (SSRIs) have shown promising results in reducing the severity and frequency of skin picking symptoms and are increasingly used in combination with psychotherapy 3
• For patients with severe symptoms or inadequate response to first-line treatments, combination therapy with both behavioral and pharmacological approaches may be most effective 3

Special Considerations

• Skin picking disorder must be differentiated from skin picking in body dysmorphic disorder, where picking is driven by attempts to improve appearance of perceived defects 4, 1
• Psychiatric comorbidities are common in patients with skin picking disorder, particularly personality disorders (19.2%) and substance-related disorders (16.8%), which may require additional targeted treatment 5
• Higher symptom severity is associated with greater impulsivity (both attentional and motor) and higher anxiety/depression, suggesting these may be important treatment targets 6

Treatment Algorithm

1. Begin with CBT with habit reversal training as first-line treatment 1, 2
2. For patients with limited access to in-person therapy, consider online self-help CBT modules 1, 2
3. If response is inadequate after 8-12 weeks of behavioral therapy:
   • Add N-acetylcysteine 1200-2400 mg/day 1, 3
   • Consider an SSRI if anxiety or depression symptoms are prominent 3
4. For severe or treatment-resistant cases:
   • Consider combination therapy with both behavioral and pharmacological approaches 3
   • Evaluate for psychiatric comorbidities that may require specific treatment 5

Monitoring and Follow-Up

• Regular assessment of skin picking frequency and severity is essential, as inadequate follow-up is common (only 41% of patients in one study had medical follow-ups) 5
• Monitor for development or worsening of skin infections or tissue damage that may require dermatological intervention 7
• Assess impact on quality of life and overall functioning throughout treatment 8

Important Caveats

• Skin picking disorder is often underreported and undertreated despite significant impact on quality of life 7
• A collaborative approach between mental health providers and dermatologists is ideal for comprehensive care 5
• Treatment adherence may be challenging, particularly for behavioral interventions that require consistent practice 2