What are the treatment options for skin picking disorder?

Treatment for Skin Picking Disorder

Cognitive-behavioral therapy (CBT) with habit reversal training is the first-line treatment for skin picking disorder, and should be started immediately upon diagnosis. 1, 2

First-Line Treatment: Behavioral Interventions

CBT with habit reversal training should incorporate the following specific components:

• Awareness training to help patients identify triggers and recognize when picking behavior begins 1, 2
• Development of competing responses where patients learn alternative behaviors to replace picking (e.g., clenching fists, sitting on hands) 1, 2
• Self-monitoring tools including daily logs to track picking episodes, triggers, and duration 1, 2
• Exposure with response prevention (ERP) techniques adapted to the patient's developmental level 1

Family involvement is crucial, particularly for younger patients, to provide support and reinforce behavioral strategies at home 1, 2. Recent systematic reviews confirm that CBT demonstrates the best outcomes among nonpharmacological treatments, with large effect sizes ranging from 0.90 to 1.89 3, 4.

Online self-help programs based on CBT principles have shown moderate effect sizes and can be used when in-person therapy is unavailable 1, 2.

Second-Line Treatment: Pharmacological Interventions

Add medication when CBT alone is insufficient, particularly with moderate-to-severe functional impairment or when CBT is unavailable. 2

Medication Options (in order of preference):

1. N-Acetylcysteine (NAC) - Preferred pharmacological agent:

• Dose at 1200-2400 mg/day in divided doses 1, 2, 5
• Well-established glutamatergic agent with minimal side effects 1, 5
• Can be used as monotherapy or combined with CBT 5

2. Selective Serotonin Reuptake Inhibitors (SSRIs):

• Consider for patients aged 12-18 years with moderate to severe functional impairment who haven't responded to CBT 1
• Particularly effective when comorbid anxiety or depression is present 1
• Recent evidence shows SSRIs are the most promising pharmacological option in terms of mitigating severity and frequency of symptoms 6

3. Memantine - Alternative glutamatergic agent:

• Start at 5 mg daily and titrate to 10-20 mg/day over 2-4 weeks to minimize side effects 5
• Consider as second-line when CBT is insufficient, unavailable, or not tolerated 5
• Can be used as monotherapy or combined with CBT 5

4. Other agents with limited evidence:

• Olanzapine may play a role in treatment-resistant cases 7
• Naltrexone has been studied but requires more evidence 8, 6
• Topiramate mentioned in case reports for severe cases but lacks robust evidence 1

Critical Clinical Considerations

Risk assessment is mandatory as skin picking can lead to significant self-harm including infection, scarring, and tissue damage 1, 2. Approximately half of patients with body-focused repetitive behaviors report self-harm related to appearance concerns 2.

Distinguish skin picking disorder from body dysmorphic disorder (BDD): In skin picking disorder, picking is not primarily motivated by appearance concerns, whereas in BDD, picking is driven by attempts to improve perceived defects 1, 5. This distinction fundamentally changes treatment approach.

Assess for stimulant medications: Stimulants can cause or exacerbate compulsive behaviors including skin picking 1. If stimulants are contributing, dose reduction or medication holiday may be warranted 1.

Adjunctive Strategies

Stress management techniques including relaxation training should be incorporated to reduce picking triggers 1, 2.

Regular monitoring should assess:

• Frequency and duration of picking episodes
• Severity of skin lesions and tissue damage
• Risk of infection
• Functional impairment in social, occupational, or other areas
• Comorbid psychiatric conditions (depression, anxiety, OCD) 1, 2

Treatment Algorithm Summary

1. Start with CBT with habit reversal training (awareness training, competing responses, self-monitoring, ERP) 1, 2
2. Involve family members in treatment, especially for younger patients 1, 2
3. Add N-Acetylcysteine (1200-2400 mg/day) if CBT insufficient after adequate trial 1, 2, 5
4. Consider SSRIs if comorbid anxiety/depression or inadequate response to NAC 1, 6
5. Trial memantine (5-20 mg/day) as alternative glutamatergic agent if NAC not tolerated 5
6. Refer to dermatology for wound care and infection management as needed 1