What is the treatment plan for neurotic excoriations?

Treatment Plan for Neurotic Excoriations (Excoriation Disorder/Skin Picking Disorder)

Cognitive-behavioral therapy with habit reversal training is the first-line treatment for neurotic excoriations, with SSRIs or N-acetylcysteine reserved for patients who fail behavioral interventions or have moderate-to-severe functional impairment. 1, 2

First-Line Treatment: Behavioral Interventions

Start all patients with cognitive-behavioral therapy (CBT) incorporating habit reversal training as the primary intervention. 1, 2 This approach addresses the compulsive nature of skin picking without the risks associated with pharmacotherapy.

Core CBT Components

• Awareness training: Identify specific triggers (boredom, anxiety, stress) and situations that precipitate picking episodes 1, 2
• Competing response development: Create alternative behaviors incompatible with picking (e.g., clenching fists, sitting on hands) when urges arise 1, 2
• Self-monitoring tools: Daily tracking of picking episodes, duration, triggers, and emotional states 1, 3
• Exposure with response prevention (ERP): Gradual exposure to picking triggers while preventing the picking response 1

Family Involvement

• Engage family members in therapy, particularly for younger patients, to provide support and reinforce behavioral strategies 1, 2
• Family participation improves treatment adherence and outcomes 1

Second-Line Treatment: Pharmacological Interventions

Add medication only when CBT alone is insufficient or when moderate-to-severe functional impairment exists. 1, 2

Medication Options (in order of preference):

1. N-Acetylcysteine (NAC): 1200-2400 mg/day in divided doses 1, 2

   • Well-established glutamatergic agent with minimal side effects 1, 2
   • Preferred over SSRIs due to superior tolerability profile 1

2. Selective Serotonin Reuptake Inhibitors (SSRIs): Consider when NAC is ineffective or when comorbid anxiety/depression is present 1, 2, 3

   • Fluoxetine and escitalopram have demonstrated efficacy in case studies 3, 4
   • Dose and duration should be tailored to individual response 2

3. Alternative agents for refractory cases:

   • Doxepin, clomipramine, naltrexone, pimozide, or olanzapine 3
   • Mirtazapine for augmentation, particularly when pruritus is prominent 4
   • Lamotrigine or opioid antagonists in severe cases 4

Critical Diagnostic Considerations

Distinguish neurotic excoriations from body dysmorphic disorder (BDD) before initiating treatment, as the approaches differ significantly. 2, 5

• In excoriation disorder: Picking is compulsive, provides temporary relief, and occurs during boredom or anxiety—not primarily motivated by appearance concerns 2, 5
• In BDD: Picking is specifically intended to improve perceived defects in appearance 2, 5
• Misdiagnosis leads to inappropriate treatment selection 5

Assessment of Comorbidities and Risk Factors

Screen all patients for psychiatric comorbidities, as 78.9% have at least one Axis I disorder. 6

• Most common comorbidities: Major depressive disorder, anxiety disorders, obsessive-compulsive disorder, substance use disorders, eating disorders, trichotillomania 3, 6
• Childhood trauma assessment is essential: Emotional neglect, emotional abuse, and physical abuse are significantly elevated in patients with neurotic excoriations 6
• Risk assessment for self-harm: Approximately 50% report self-harm related to appearance concerns, with risks including infection, scarring, and tissue damage 1, 2

Adjunctive Approaches

• Online self-help programs with educational materials and CBT-based exercises show moderate effect sizes 1, 2
• Regular stress management techniques (relaxation training, mindfulness) help reduce picking triggers 1, 2
• Topical treatments for wound care and infection prevention as needed 7

Treatment Algorithm Summary

1. Initial assessment: Rule out BDD, assess for comorbidities, evaluate childhood trauma history 2, 5, 6
2. Start CBT with habit reversal training for all patients 1, 2
3. Add NAC (1200-2400 mg/day) if CBT insufficient after 8-12 weeks or if moderate-to-severe impairment 1, 2
4. Switch to or add SSRI if NAC fails or comorbid depression/anxiety present 1, 2
5. Consider augmentation strategies (mirtazapine, antipsychotics) for refractory cases 3, 4
6. Maintain long-term behavioral interventions even when medications are used 1, 2

Common Pitfalls to Avoid

• Do not start with medication alone: Behavioral interventions are first-line and should not be bypassed 1, 2
• Do not confuse with BDD: Treatment approaches differ fundamentally based on whether picking is appearance-driven or compulsive 2, 5
• Do not overlook childhood trauma: Early traumatic events are closely related to self-injurious behaviors and require psychotherapeutic intervention 6
• Do not ignore comorbidities: Untreated psychiatric conditions will undermine treatment success 3, 6