Treatment of Excessive Hand Washing in OCD
Cognitive-behavioral therapy (CBT) with exposure and response prevention (ERP) is the first-line treatment for excessive hand washing in OCD, with SSRIs recommended as first-line pharmacotherapy either alone or in combination with CBT for more severe cases. 1
Initial Treatment Approach
Begin with psychoeducation about OCD, establishing a therapeutic alliance with the patient and family members, and explaining that OCD is a treatable condition with evidence-based interventions that can significantly reduce symptoms and improve quality of life. 1 Address stigma and identify family accommodation behaviors (such as enabling excessive hand washing or providing reassurance) that may maintain the compulsive behavior. 1
Cognitive-Behavioral Therapy with ERP
ERP is the gold-standard psychological treatment for OCD, including contamination-based compulsions like excessive hand washing. 1, 2, 3
Core ERP Components:
Gradual exposure to contamination fears combined with instructions to abstain from hand washing compulsions. 4 This directly targets the threat learning that characterizes OCD through habituation (fear extinction) and inhibitory learning. 5
10-20 sessions are typically recommended, with patient adherence to between-session homework (ERP exercises in the home environment) being the strongest predictor of good short-term and long-term outcomes. 1, 6
CBT has larger effect sizes than pharmacotherapy alone, with a number needed to treat of 3 for CBT versus 5 for SSRIs. 1, 6
Treatment Delivery Options:
Individual or group CBT delivered in-person or via internet-based protocols are all effective for OCD treatment. 1
Computer-assisted self-help CBT interventions that include ERP components and last more than 4 weeks can be effective alternatives when in-person therapy is not available, though dropout rates are higher than with therapist-guided treatment. 1, 7
Pharmacotherapy for Hand Washing Compulsions
SSRIs are the first-line pharmacological treatment based on efficacy, tolerability, safety, and absence of abuse potential. 1, 8
SSRI Dosing Specifics:
Higher doses are typically required for OCD than for depression or other anxiety disorders. 1, 8
For fluoxetine: Start at 20 mg/day in adults, with a dose range of 20-60 mg/day recommended (maximum 80 mg/day). 9 The full therapeutic effect may be delayed until 5 weeks of treatment or longer. 9
For sertraline: Dosing follows similar principles with gradual titration to therapeutic doses. 10
Allow at least 8-12 weeks at the optimal dose to determine efficacy before considering the medication ineffective. 8, 6
Combined Treatment Strategy
For severe hand washing compulsions, combine CBT with SSRI treatment from the outset. 1, 8 Combined treatment is particularly beneficial for patients with severe symptoms, those with partial response to monotherapy, and cases with significant functional impairment. 1
Intensive Treatment for Severe or Treatment-Resistant Cases
High-intensity ERP protocols (multiple sessions over a few days, sometimes in inpatient settings) may be beneficial for treatment-resistant hand washing compulsions. 1, 5 This condensed format delivers more and/or longer sessions and has demonstrated efficacy for adults and youth with OCD who have not responded to standard weekly outpatient ERP. 5
Addressing Dermatological Complications
While treating the underlying OCD, address skin damage from excessive hand washing:
Use lukewarm or cool water (avoid hot water) and wash for the minimum necessary time. 7
Apply moisturizer immediately after any hand washing to prevent irritant contact dermatitis. 7
Look for soaps devoid of allergenic surfactants, preservatives, fragrances, or dyes, preferably synthetic detergents with added moisturizers. 7
At night, apply moisturizer followed by cotton gloves to create an occlusive barrier and promote healing. 7
Long-Term Management
Continue effective treatment for at least 12-24 months after achieving remission due to the high risk of relapse, as OCD is often a chronic condition. 1, 8, 6 Monthly booster CBT sessions for 3-6 months after initial treatment may help maintain gains. 1
Critical Pitfalls to Avoid
Do not rely on reassurance or accommodation of the hand washing behavior, as this maintains the OCD cycle. 1
Do not discontinue SSRIs prematurely—the full effect requires 8-12 weeks at therapeutic doses. 8, 6, 9
Do not use antibacterial soaps, as they are unnecessary for proper hand hygiene and may worsen skin damage. 7
Ensure family members understand their role in not enabling compulsions through accommodation behaviors. 1, 6