What is the best approach to treating dermatillomania (skin picking disorder)?

Treatment of Dermatillomania (Skin Picking Disorder)

Cognitive-behavioral therapy, specifically habit-reversal therapy, combined with selective serotonin reuptake inhibitors (SSRIs) represents the most effective evidence-based approach for treating dermatillomania, with N-acetylcysteine serving as a promising alternative pharmacologic option. 1, 2

Initial Assessment and Diagnosis

The diagnosis requires recognition of repetitive skin picking causing tissue damage, significant distress, and functional impairment 3, 4. Key features to identify include:

• Picking patterns: Typically affects hand-accessible areas, often starting around nail beds and progressing to other sites 3
• Triggers: Episodes worsen with anxiety, nervousness, or stress 3
• Psychiatric comorbidities: Screen for obsessive-compulsive disorder, body dysmorphic disorder, autism spectrum disorder, anxiety disorders, depression, borderline personality disorder, and substance use 3, 1
• Severity assessment: Document extent of tissue damage, frequency of picking episodes, and impact on quality of life 4

Treatment Algorithm

First-Line Treatment: Combined Approach

The optimal strategy combines psychological and pharmacological interventions rather than using either modality alone. 4, 1

Psychological Intervention (Primary)

• Habit-reversal therapy: This behavioral technique has the strongest evidence base among psychotherapies 1, 2
• Acceptance and commitment therapy: Shows promise as an alternative behavioral approach 1
• Cognitive-behavioral therapy: Effective for addressing underlying anxiety and compulsive behaviors 3

Pharmacological Intervention (Concurrent)

SSRIs represent the most effective pharmacologic class with the strongest evidence for reducing picking severity and frequency 1, 2. These should be initiated alongside behavioral therapy, not as monotherapy 2.

Second-Line Pharmacologic Options

When SSRIs prove insufficient or are not tolerated:

• N-acetylcysteine: Well-established glutamatergic agent with strong evidence for efficacy 1, 2
• Other glutamatergic agents: Memantine may be considered 2
• Combination therapy: Antipsychotics (olanzapine, aripiprazole) combined with antidepressants for refractory cases 2

Third-Line Options

For treatment-resistant cases:

• Opioid antagonists: Naltrexone has been studied with some success 2
• Antiepileptics: Lamotrigine and topiramate have limited evidence 2
• Mirtazapine: Alternative antidepressant option 2

Wound Management

Acute skin lesions require concurrent dermatologic treatment to prevent complications and support healing 3, 4:

• Topical wound care for active lesions 3
• Antibiotics (topical or oral) when infection is present or suspected 3
• Treatment of pruritus if contributing to picking behavior 3

Interdisciplinary Approach

Dermatillomania requires collaboration between dermatology and psychiatry for optimal outcomes 4:

• Dermatologist role: Wound assessment and management, infection treatment, documentation of physical findings 4
• Psychiatrist role: Psychiatric evaluation, comorbidity management, pharmacotherapy, coordination with behavioral therapists 4

Physical Barrier Strategies

Biomaterial-based physical barriers can serve as adjunctive treatment, particularly for patients with severe, localized picking 5:

• Protective coverings for high-risk areas
• Specialized clothing or bandaging systems
• These strategies remain underexplored but show synergistic potential with standard treatments 5

Critical Pitfalls to Avoid

• Do not delay psychiatric referral: This is a neuropsychiatric disorder requiring specialized mental health intervention, not purely a dermatologic condition 4, 1
• Do not use pharmacotherapy alone: Behavioral therapy should be the foundation, with medications as augmentation 1, 2
• Do not underestimate severity: The disorder significantly impacts quality of life and can cause serious tissue damage requiring emergency care 3, 5
• Do not miss comorbidities: Approximately 70% have additional psychiatric diagnoses that require concurrent treatment 6

Monitoring and Follow-up

Track the following parameters to assess treatment response 4, 1:

• Frequency and duration of picking episodes
• Extent of skin damage and healing progress
• Functional impairment and quality of life measures
• Adherence to behavioral therapy techniques
• Medication side effects and tolerability