What is the treatment for excoriation disorder?

Treatment for Excoriation Disorder

First-Line Treatment: Habit Reversal Training

Habit reversal training should be initiated as the primary treatment modality for all patients with excoriation disorder, following the same evidence-based approach proven effective for trichotillomania and other body-focused repetitive behaviors. 1

Core Components of Habit Reversal Training

• Awareness training helps patients identify triggers, situations, and early warning signs that precede skin-picking episodes 1
• Competing response training involves practicing alternative behaviors when the urge to pick emerges, such as clenching fists, sitting on hands, or engaging in tactile substitutes 1
• Deliver 10-20 sessions of individual or group cognitive-behavioral therapy, either in-person or via internet-based protocols 1
• Patient adherence to between-session homework exercises is the most robust predictor of both short-term and long-term treatment success 1

The evidence for behavioral therapy in excoriation disorder parallels that of trichotillomania, as both are classified as body-focused repetitive behaviors within the obsessive-compulsive related disorder spectrum 2, 3. Group therapy formats have also demonstrated efficacy, with both psychodrama and support group approaches showing improvement in skin excoriation severity 4.

Pharmacotherapy: When Behavioral Therapy Is Insufficient

First-Line Medication: N-Acetylcysteine

• N-acetylcysteine is the preferred first-line pharmacological treatment due to significant benefits and low risk of side effects, with three out of five randomized controlled trials demonstrating superiority to placebo 1, 3
• Typical dosing ranges from 1200-2400 mg daily, though specific dosing protocols should follow the evidence from trichotillomania trials 1

Second-Line Medications: SSRIs

• SSRIs (fluoxetine, escitalopram) have demonstrated improvement in skin picking in case studies and open trials 5, 3, 6
• Higher doses are typically required for body-focused repetitive behaviors compared to depression treatment 7
• Allow at least 8-12 weeks at maximum tolerated dose before declaring treatment failure 8
• All SSRIs show similar efficacy; choose based on side effect profile and drug interactions 8

Alternative Pharmacological Options

When first-line treatments fail, consider:

• Clomipramine requires 8-12 weeks at maximum tolerated dose, with monitoring for seizures, cardiac arrhythmias, and serotonin syndrome 1, 6
• Low-dose naltrexone (4.5 mg daily) has shown efficacy in case reports, with improvement in compulsion to pick and healing of lesions 9
• Mirtazapine as augmentation therapy, particularly when antihistaminergic effects may relieve skin itching and pain 5
• Antipsychotic augmentation (olanzapine, aripiprazole) for treatment-resistant cases 5, 6

The evidence base for excoriation disorder pharmacotherapy is less robust than for OCD, relying primarily on case reports and small open trials rather than large randomized controlled trials 3, 6.

Treatment Algorithm

Step 1: Initial Assessment

• Confirm diagnosis using DSM-5 criteria: recurrent skin picking resulting in skin lesions, repeated attempts to decrease or stop, and clinically significant distress or impairment 2, 3
• Screen for psychiatric comorbidities (mood disorders, anxiety disorders, OCD, body dysmorphic disorder, substance use disorders) which are common and may require concurrent treatment 3, 6
• Assess for emotional dysregulation, as this correlates with excoriation severity and predicts treatment needs 4

Step 2: Choose Initial Treatment

• Start with habit reversal training (10-20 sessions) if patient is motivated for behavioral therapy and has no severe comorbidities requiring immediate medication 1
• Start with N-acetylcysteine plus habit reversal training if moderate-to-severe symptoms or if patient prefers combined approach 1, 3
• Start with SSRI plus habit reversal training if severe comorbid depression or anxiety requiring medication 7, 3

Step 3: Inadequate Response After 8-12 Weeks

• If on behavioral therapy alone: add N-acetylcysteine 1, 3
• If on N-acetylcysteine alone: add or intensify behavioral therapy 1
• If on SSRI: optimize dose, ensure adequate trial duration (8-12 weeks), then consider switching to different SSRI or adding N-acetylcysteine 8, 3

Step 4: Treatment-Resistant Cases

• Consider antipsychotic augmentation (aripiprazole, olanzapine) 5, 6
• Trial low-dose naltrexone (4.5 mg daily) 9
• Consider mirtazapine augmentation, particularly if pruritus is prominent 5
• Evaluate for intensive outpatient or group therapy programs 4

Treatment Duration and Maintenance

• Continue successful interventions for at least 12-24 months after achieving remission, given the chronic, fluctuating nature of excoriation disorder 1, 3
• Consider monthly booster CBT sessions for 3-6 months after acute response to prevent relapse 7
• Develop a relapse prevention plan identifying triggers, warning signs, and action steps 1

Critical Pitfalls to Avoid

• Do not prematurely discontinue medication trials before completing 8-12 weeks at maximum tolerated dose, as delayed response is common 1
• Do not neglect comorbid conditions, particularly mood and anxiety disorders, which are present in the majority of patients and may maintain skin-picking behavior 3, 6
• Do not overlook emotional dysregulation, which is associated with excoriation severity and may require specific therapeutic focus 4
• Do not ignore family accommodation of symptoms, as this can maintain the disorder; include family in treatment when possible 7
• Premature discontinuation of medication leads to high relapse rates 7

Monitoring Requirements

• Assess skin-picking frequency, duration, and severity at each visit using both self-report and clinician rating 4
• Monitor for medical complications including infection, scarring, and tissue damage 6
• Screen for emergence or worsening of depression, anxiety, and suicidal ideation 3
• If using antipsychotics, monitor metabolic parameters including weight, glucose, and lipids 8
• Assess for serotonin syndrome if combining serotonergic medications 8