What is the treatment for dermatillomania (skin picking disorder) in a patient with a history of anxiety and depression?

Treatment for Dermatillomania (Skin Picking Disorder)

Cognitive-behavioral therapy with habit reversal training is the first-line treatment for dermatillomania, and SSRIs or N-acetylcysteine should be added when CBT alone is insufficient or when moderate-to-severe functional impairment exists, particularly in patients with comorbid anxiety and depression. 1, 2

Initial Treatment Approach: Behavioral Interventions

Start with CBT incorporating habit reversal training as your primary intervention. 1, 2 This approach includes:

• Awareness training to help patients identify specific triggers, emotional states, and situations that precipitate picking episodes 1, 2
• Development of competing responses where patients learn alternative behaviors to perform when the urge to pick arises (e.g., clenching fists, sitting on hands) 1, 2
• Self-monitoring tools such as daily logs to track picking episodes, duration, and associated emotions 1, 2
• Exposure with response prevention (ERP) techniques adapted to the patient's developmental level 1

Involve family members in therapy, especially for younger patients, to provide support and reinforce behavioral strategies. 1, 2 This family involvement is crucial for treatment adherence and long-term success.

When to Add Pharmacological Treatment

Add medication when CBT alone produces inadequate response after 8 weeks, particularly when moderate-to-severe functional impairment is present or when comorbid anxiety or depression exists. 1, 2

First-Line Pharmacological Options:

SSRIs are the recommended first pharmacological choice for patients aged 12-18 years and adults who haven't responded adequately to CBT. 1, 3, 4 SSRIs are particularly appropriate when:

• Comorbid anxiety or depression is present 1
• Moderate to severe functional impairment exists 1
• The patient has failed an adequate trial of CBT alone 1

N-acetylcysteine (NAC) is an equally valid first-line pharmacological option with minimal side effects. 1, 2, 5 Dosing:

• Start at 1200 mg/day in divided doses 1, 2
• Titrate to 2400 mg/day as needed 1, 2
• NAC works through glutamatergic modulation and has an excellent safety profile 1, 2

Second-Line Pharmacological Options:

Consider memantine as second-line treatment when first-line agents are insufficient, unavailable, or not tolerated. 6 Dosing protocol:

• Start at 5 mg daily 6
• Titrate to 10-20 mg/day over 2-4 weeks to minimize side effects 6
• Can be used as monotherapy or combined with CBT 6

Naltrexone may be considered in refractory cases. 5

Critical Diagnostic Distinction

Ensure you are treating dermatillomania and not skin picking secondary to body dysmorphic disorder (BDD). 1, 2, 6 The key difference:

• Dermatillomania: Picking is not primarily motivated by appearance concerns; it's driven by urges, tension relief, or habit 2
• BDD with skin picking: Picking is specifically driven by attempts to improve perceived appearance defects 1

This distinction is critical because treatment approaches differ fundamentally between these conditions.

Addressing Comorbid Conditions

Prioritize treatment of depressive symptoms when both depression and anxiety are present. 7 Given that approximately half of patients with body-focused repetitive behaviors report self-harm related to appearance concerns, comprehensive psychiatric assessment is essential. 2, 6

Screen for and address underlying psychiatric conditions including:

• Obsessive-compulsive disorder 3
• Anxiety disorders 3
• Depression 3
• Substance use disorders 3
• Autism spectrum disorders 3

Adjunctive Approaches

Incorporate stress management techniques and relaxation training to reduce picking triggers. 1, 2 These can include:

• Regular relaxation exercises 1
• Mindfulness practices 2
• Sleep hygiene optimization, as sleep disturbance can exacerbate picking behaviors 7

Consider online self-help programs with educational materials and CBT-based exercises, which show moderate effect sizes. 1, 2

Monitoring and Treatment Adjustment

Assess treatment response regularly at pretreatment, 4 weeks, 8 weeks, and end of treatment using standardized validated instruments. 7

If symptoms are stable or worsening after 8 weeks despite good adherence, adjust the regimen by:

• Adding a pharmacological intervention to CBT 7
• Changing the medication if already on pharmacotherapy 7
• Switching from group to individual therapy if applicable 7

Monitor for medical complications including:

• Risk of infection from open wounds 6, 3
• Scarring and tissue damage 6
• Significant self-harm requiring wound care 3

Practical Pitfalls to Avoid

Do not prescribe stimulants without careful consideration, as they can cause or exacerbate compulsive skin picking in some patients. 1 If the patient is already on stimulants, consider dose reduction or a medication holiday if picking worsens. 1

Do not delay wound care while addressing the psychiatric component. 3 The patient in the expanded question context may require:

• Topical wound care and antibiotics for any active lesions 3
• Treatment of pruritus if present 3
• Concurrent dermatological management while psychiatric treatment is initiated 8

Ensure an interdisciplinary approach with liaison between dermatology and psychiatry for optimal outcomes. 8