What medications are used to treat skin picking disorder?

Medication Treatment for Skin Picking Disorder

Selective serotonin reuptake inhibitors (SSRIs) are the first-line pharmacological treatment for skin picking disorder, particularly when cognitive-behavioral therapy is insufficient or when moderate to severe functional impairment exists. 1

First-Line Pharmacological Approach

SSRIs should be considered as second-line treatment (after CBT) for patients aged 12-18 years with moderate to severe functional impairment who haven't responded to behavioral interventions. 1 The evidence base is strongest for fluoxetine, which demonstrated significant superiority over placebo in reducing skin-picking symptoms in controlled trials. 2 In open-label studies followed by double-blind continuation, fluoxetine responders maintained clinically significant improvement when continued on active medication, while those switched to placebo returned to baseline symptom levels. 3

Practical SSRI Implementation:

• Start with fluoxetine at standard dosing, titrating up to 55-80 mg/day as tolerated 2
• SSRIs are particularly indicated when comorbid anxiety or depression is present 1
• The therapeutic effect on skin picking appears independent of changes in depression, anxiety, or obsessive-compulsive symptoms 2

Second-Line Glutamatergic Agents

N-acetylcysteine (NAC) is a well-established alternative with minimal side effects, typically dosed at 1200-2400 mg/day in divided doses. 1 This glutamatergic agent represents an important option when SSRIs are not tolerated or insufficient. 4

Memantine should be considered as second-line pharmacological treatment when CBT is insufficient, unavailable, or not tolerated. 5 Start memantine at 5 mg daily and titrate to 10-20 mg/day over 2-4 weeks to minimize side effects. 5 Memantine can be used as monotherapy or combined with CBT for enhanced outcomes. 5

Third-Line Options for Refractory Cases

Antiepileptic Agents:

Lamotrigine showed promising results in open-label trials, with 66.7% of subjects rated as "much improved" or "very much improved." 6 Mean time to response was 8 weeks at a dose of 200 mg/day, with dosing ranging from 25 mg every other day to 300 mg/day. 6 However, lamotrigine lacks robust controlled evidence and should be reserved for severe, treatment-resistant cases. 1

Topiramate has been mentioned in case reports for severe cases but lacks robust evidence. 1

Other Agents:

• Antipsychotics (olanzapine, aripiprazole) are often combined with antidepressants in treatment-resistant cases 4
• Naltrexone (opioid antagonist) has been studied but requires additional research to establish definitive efficacy 4
• Mirtazapine has limited evidence but may be considered in specific cases 4

Critical Clinical Considerations

Differential Diagnosis:

It is essential to differentiate skin picking disorder from skin picking in body dysmorphic disorder (BDD), as the underlying motivations differ fundamentally. 5 In BDD, picking is driven by attempts to improve appearance of perceived defects, whereas in excoriation disorder, picking is not primarily motivated by appearance concerns. 1

Medication-Induced Picking:

Consider whether stimulants are contributing to or exacerbating skin picking, and if so, dose reduction or medication holiday may be warranted. 1 Stimulants can cause compulsive behaviors, including skin picking, in some patients. 1

Risk Assessment:

Regular monitoring should assess risk of self-harm, infection, scarring, and tissue damage, as approximately half of young people with body-focused repetitive behaviors report self-harm. 5 Skin picking can lead to significant complications including infection, scarring, and tissue damage. 1

Combination Therapy Strategy

Although habit-reversal psychotherapy has traditionally been first-line treatment, SSRIs are now increasingly being used in combination with psychotherapy when a patient presents with skin picking disorder. 4 Family involvement is recommended, particularly for younger patients, to provide support and reinforce behavioral strategies. 1, 5

Treatment Algorithm Summary:

1. Start with CBT with habit reversal training 1
2. Add SSRI (fluoxetine preferred) if inadequate response or moderate-severe impairment 1, 2
3. Consider N-acetylcysteine (1200-2400 mg/day) or memantine (10-20 mg/day) as alternatives or augmentation 1, 5
4. Reserve lamotrigine, antipsychotics, or naltrexone for treatment-resistant cases 4, 6