What treatment options are available for a patient taking Vyvanse (lisdexamfetamine) and Adderall (amphetamine and dextroamphetamine) and Mirtazapine (mirtazapine) who is experiencing skin picking behavior?

Treatment of Skin Picking in a Patient on Vyvanse, Adderall, and Mirtazapine

Start with cognitive-behavioral therapy incorporating habit reversal training as first-line treatment, and if CBT is unavailable or insufficient, add N-acetylcysteine 1200-2400 mg/day in divided doses as the preferred pharmacological intervention. 1

Immediate Assessment

First, determine whether the skin picking represents excoriation (skin-picking) disorder versus a symptom of another condition:

• Excoriation disorder is characterized by recurrent picking leading to skin lesions with unsuccessful attempts to stop, causing significant distress or functional impairment 2
• Distinguish from body dysmorphic disorder, where picking is driven by attempts to improve perceived appearance defects rather than the picking behavior itself 1
• Consider stimulant contribution: While not commonly reported as a primary side effect, stimulants can cause compulsive behaviors including skin picking in some patients 2

First-Line Treatment: Behavioral Intervention

Cognitive-behavioral therapy with habit reversal training is the only treatment with demonstrated superiority over placebo in randomized controlled trials 3:

• Core components include awareness training (identifying triggers and patterns), development of competing responses (alternative behaviors when urge arises), and self-monitoring tools 1
• Exposure with response prevention techniques should be incorporated, where patients resist the urge to pick while experiencing the discomfort 1
• Meta-analysis shows behavioral treatments are the only interventions demonstrating significant benefits compared to inactive control conditions, unlike pharmacological agents 3

Second-Line Treatment: Pharmacological Options

If CBT is unavailable, inadequate, or the patient has moderate-to-severe functional impairment:

Preferred Pharmacological Agent: N-Acetylcysteine

N-acetylcysteine (NAC) is the best-established pharmacological option with minimal side effects 1:

• Dose: 1200-2400 mg/day in divided doses 1
• Mechanism: Glutamatergic modulation that reduces compulsive behaviors 4
• Well-tolerated with favorable side effect profile compared to other options 5

Alternative: SSRIs (Already Partially Addressed)

• Mirtazapine, which the patient is already taking, has limited evidence for skin picking disorder 5
• Consider optimizing or switching to a traditional SSRI (fluoxetine, sertraline, escitalopram) if not already at therapeutic doses for skin picking 1, 5
• SSRIs show the most promising results among antidepressants for reducing severity and frequency of skin-picking symptoms 5
• However, randomized controlled trials have not demonstrated SSRI superiority over placebo specifically for skin picking disorder 3

Other Options with Limited Evidence

• Naltrexone (opioid antagonist): Some case reports suggest benefit, but limited controlled data 5
• Topiramate: Mentioned in case reports but insufficient evidence; note it was used only in severe cases in other contexts 2
• Antipsychotics (olanzapine, aripiprazole): Often combined with antidepressants but lack robust evidence as monotherapy 5

Critical Consideration: Stimulant Contribution

Evaluate whether the stimulants (Vyvanse and Adderall) are contributing to or exacerbating the skin picking 2:

• Compulsive behaviors including skin picking can rarely occur with stimulant use 2
• Consider whether picking behavior correlates temporally with stimulant dosing
• If stimulants are contributory, dose reduction or medication holiday may be warranted, though this must be balanced against ADHD symptom control 2
• Question: Why is the patient on both Vyvanse AND Adderall? This dual stimulant regimen is unusual and may represent excessive stimulation

Adjunctive Strategies

• Online self-help programs based on CBT principles show moderate effect sizes and improve accessibility 1
• Stress management and relaxation training can reduce picking triggers 1
• Regular monitoring for complications: infection, scarring, tissue damage 1

Important Caveats

All interventions, including placebo, show significant improvement in short-term trials for skin picking disorder 3. This means:

• Uncontrolled trials are of limited utility for assessing true efficacy 3
• Natural fluctuation in symptoms is common
• Placebo response is substantial in this condition 3

Approximately half of patients with body-focused repetitive behaviors report self-harm, which may be related to appearance concerns and requires separate risk assessment 1.