What is the treatment for excoriation disorder?

Treatment of Excoriation Disorder

The first-line treatment for excoriation disorder is N-acetylcysteine (1200-3000 mg/day), which has demonstrated significant efficacy in reducing skin-picking symptoms in randomized controlled trials, with 47% of patients achieving much or very much improvement compared to 19% with placebo. 1

Pharmacological Treatment Approach

Primary Pharmacotherapy

• N-acetylcysteine should be initiated as first-line pharmacotherapy, starting at 1200 mg/day and titrating up to 3000 mg/day over 12 weeks, as this glutamate-modulating agent has the strongest randomized controlled trial evidence for excoriation disorder. 1

• This medication works by restoring extracellular glutamate concentration in the nucleus accumbens, targeting the neurobiological basis of compulsive picking behavior. 1

• N-acetylcysteine is well-tolerated with minimal side effects, making it an appropriate first choice for most patients. 1

Alternative Pharmacological Options

• Selective serotonin reuptake inhibitors (SSRIs) represent the second-line pharmacological approach when N-acetylcysteine is ineffective or not tolerated, though evidence is limited to case studies and small open trials rather than large randomized controlled trials. 2, 3

• SSRIs that have shown benefit in case reports include fluoxetine, sertraline, paroxetine, and citalopram, though optimal dosing has not been established through controlled trials. 3

• Other agents with case report evidence include clomipramine, naltrexone (including low-dose naltrexone at 4.5 mg daily), doxepin, pimozide, and olanzapine, though these should be reserved for refractory cases. 3, 4

Behavioral and Psychological Interventions

Habit Reversal Therapy

• Habit reversal therapy should be offered as a primary behavioral intervention, either alone or in combination with pharmacotherapy, as this technique has evidence-based success in treating excoriation disorder. 2, 3

• This approach involves self-monitoring of picking episodes, recording triggers and frequency, and implementing alternative competing responses when the urge to pick arises. 3

Multicomponent Behavioral Programs

• Comprehensive behavioral programs that combine self-monitoring, episode recording, and procedures producing alternative responses to scratching have demonstrated effectiveness in case reports. 3

• Eclectic psychotherapy programs incorporating both insight-oriented and behavioral components may benefit patients with significant psychological comorbidity. 3

Critical Diagnostic Differentiation

It is essential to distinguish excoriation disorder from skin picking in body dysmorphic disorder (BDD), as the treatment approaches differ significantly. 5

• In excoriation disorder, skin picking is not driven by an attempt to improve appearance but rather represents a compulsive behavior that may provide temporary relief or occur during states of boredom or anxiety. 5

• In BDD, skin picking is specifically intended to improve the appearance of perceived defects in the skin, and treatment must address the underlying appearance preoccupations with BDD-specific interventions. 5

Interdisciplinary Management Considerations

• An interdisciplinary team approach involving both dermatology and psychiatry is recommended for optimal management of excoriation disorder, as patients require both medical management of skin complications and psychiatric treatment of the underlying compulsive behavior. 2

• The dermatologist's role includes treating secondary infections, managing wound care, and monitoring for medical complications such as scarring or cellulitis. 2

• The psychiatrist's role focuses on pharmacological management, psychotherapy, and treatment of common psychiatric comorbidities including mood disorders, anxiety disorders, and other obsessive-compulsive spectrum conditions. 2, 3

Special Populations

Older Adults

• Older adults with excoriation disorder require heightened vigilance for complications including infection and hospitalization, as age-related skin changes increase vulnerability to poor outcomes. 6

• Risk factors contributing to disease burden in older adults include decreased skin integrity, delayed wound healing, and higher rates of medical and psychiatric comorbidities. 6

• Treatment plans must account for polypharmacy concerns and potential drug interactions when prescribing pharmacotherapy in geriatric populations. 6

Treatment Algorithm

1. Initiate N-acetylcysteine 1200 mg/day, titrating to 3000 mg/day as tolerated over 12 weeks. 1

2. Simultaneously refer for habit reversal therapy or other evidence-based behavioral interventions. 2, 3

3. If inadequate response after 12 weeks, consider switching to or adding an SSRI (fluoxetine, sertraline, or paroxetine). 2, 3

4. For refractory cases, consider alternative agents such as naltrexone, clomipramine, or atypical antipsychotics, though evidence is limited to case reports. 3, 4

5. Address psychiatric comorbidities including depression, anxiety disorders, and other obsessive-compulsive spectrum disorders, as these are common and may perpetuate skin-picking behavior. 3

Common Pitfalls to Avoid

• Do not assume all skin picking is excoriation disorder—carefully assess whether picking is driven by appearance concerns (suggesting BDD) or represents true compulsive behavior. 5

• Do not rely solely on pharmacotherapy—combination treatment with behavioral interventions produces superior outcomes compared to either modality alone. 2, 3

• Do not overlook medical complications—regularly assess for secondary infections, scarring, and tissue damage that may require dermatological intervention. 2, 6

• Do not neglect psychiatric comorbidity screening—mood disorders, anxiety disorders, and other impulse control disorders are highly prevalent and require concurrent treatment. 3