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

Treatment for Dermatillomania (Skin Picking Disorder)

Cognitive-behavioral therapy with habit reversal training is the first-line treatment for skin picking disorder, followed by pharmacological interventions such as N-acetylcysteine when behavioral approaches are insufficient. 1

First-Line Treatment: Behavioral Interventions

• Cognitive-behavioral therapy (CBT) with habit reversal training is the recommended initial treatment for skin picking disorder, including components such as awareness training, development of competing responses, and self-monitoring tools 1
• Brief cognitive-behavioral therapy (even just four sessions) has shown significant effectiveness with large effect sizes (0.90 to 1.89) in reducing skin picking severity, psychological impact, and skin injury 2
• CBT should incorporate exposure with response prevention (ERP) techniques, which may be adapted to the individual's developmental level 3
• Family involvement in therapy is recommended, particularly for younger patients, to provide support and reinforce behavioral strategies 3

Second-Line Treatment: Pharmacological Interventions

• N-Acetylcysteine (NAC) is the most well-established pharmacological treatment for skin picking disorder, typically dosed at 1200-2400 mg/day in divided doses 1
• Selective serotonin reuptake inhibitors (SSRIs) should be considered when there is inadequate response to CBT, particularly when there is moderate to severe functional impairment 3, 4
• For patients aged 12-18 years with moderate to severe functional impairment who haven't responded to CBT, SSRIs are recommended as second-line treatment 3

Treatment Algorithm Based on Severity and Comorbidities

• For mild to moderate skin picking:

  • Begin with CBT with habit reversal training 1
  • Add online self-help programs with educational materials and self-monitoring tools as adjunctive therapy 1
  • Implement regular stress management techniques to reduce picking triggers 1

• For severe skin picking or cases with inadequate response to behavioral interventions:

  • Continue CBT while adding N-acetylcysteine (1200-2400 mg/day) 1
  • Consider SSRIs, particularly when comorbid anxiety or depression is present 3, 4
  • Monitor for higher severity associated with increased impulsivity and anxiety, which may require more intensive treatment 5

Special Considerations

• Risk assessment is crucial, as skin picking can lead to significant self-harm, including infection, scarring, and tissue damage 3, 4
• Approximately half of young people with body-focused repetitive behaviors report self-harm, which may be related to appearance concerns 3
• Skin picking may be a symptom of body dysmorphic disorder when it's primarily motivated by appearance concerns, requiring a different treatment approach 1
• For patients with intellectual disabilities, ensure regular skin care and hygiene to minimize irritation that might trigger picking, and consider a stepped approach to medication when non-pharmacological interventions have failed 6

Monitoring and Follow-Up

• Regularly assess skin condition and document frequency and severity of picking behaviors 6
• Evaluate for medication side effects if pharmacological interventions are used 6
• Assess impact on quality of life and overall functioning to determine treatment effectiveness 6
• Treatment effects from CBT can be maintained at follow-up, suggesting long-term benefits 2

Treatment Pitfalls to Avoid

• Don't focus solely on skin treatment without addressing the underlying psychological factors 4
• Avoid assuming that skin picking is simply a bad habit; it's a recognized disorder requiring specific evidence-based interventions 3
• Don't overlook comorbid conditions such as anxiety disorders, OCD, or depression that may exacerbate skin picking behaviors 5
• Be aware that skin picking severity is strongly associated with impulsivity and anxiety, which should be targeted in treatment 5