What are the recommended medications for treating skin picking disorder in a patient with a history of anxiety, depression, and skin conditions such as eczema or psoriasis?

Medication Treatment for Skin Picking Disorder

Selective serotonin reuptake inhibitors (SSRIs), particularly fluoxetine, are the first-line pharmacologic treatment for skin picking disorder, with demonstrated efficacy in reducing picking frequency and severity in controlled trials. 1, 2, 3

Primary Pharmacologic Approach

First-Line: SSRIs

• Initiate fluoxetine at 20 mg daily, titrating up to 60-80 mg/day over 4-6 weeks based on response, as this dosing range showed significant superiority over placebo in reducing skin-picking symptoms 2, 3
• SSRIs demonstrate efficacy independent of baseline depression or anxiety levels, suggesting a direct effect on the compulsive picking behavior rather than merely treating comorbid mood disorders 3
• Response typically occurs within 6-10 weeks of treatment, with responders maintaining improvement as long as medication is continued 2, 3
• Other SSRIs beyond fluoxetine can be considered, though fluoxetine has the strongest evidence base for this specific indication 1, 4

Second-Line: Glutamatergic Agents

• N-acetylcysteine (NAC) 1200-2400 mg daily is well-established as an alternative or adjunctive treatment when SSRIs are insufficient or not tolerated 1, 4
• Memantine represents another glutamatergic option with emerging evidence, though data are more limited than for NAC 1

Augmentation Strategies for Partial Response

Antipsychotic Augmentation

• Add low-dose aripiprazole (5-15 mg daily) or olanzapine (2.5-10 mg daily) to ongoing SSRI therapy when SSRIs alone provide inadequate response 1
• Antipsychotics are typically used in combination with antidepressants rather than as monotherapy 1

Opioid Antagonist Option

• Naltrexone 50-100 mg daily can be considered for patients with prominent urge-driven picking behavior, particularly when other treatments have failed 1

Other Augmentation Options

• Lamotrigine and topiramate (antiepileptics) have limited evidence but may be considered in refractory cases, though their role remains less definitively established 1
• Mirtazapine has been studied but evidence is insufficient to make strong recommendations 1
• Lithium has been evaluated but lacks robust supporting data 1

Critical Considerations for Comorbid Skin Conditions

Managing Concurrent Eczema or Psoriasis

When skin picking disorder coexists with inflammatory dermatoses like eczema or psoriasis, aggressive topical management of the underlying skin condition is essential to reduce picking triggers. 5, 6

• Apply high-potency topical corticosteroids (clobetasol propionate 0.05% or betamethasone dipropionate 0.05%) twice daily for 2-4 weeks maximum to active inflammatory lesions that may trigger picking behavior 5, 6
• Use low-potency corticosteroids or topical calcineurin inhibitors (tacrolimus 0.1%) on face, genitals, and intertriginous areas where picking commonly occurs 5
• Transition to maintenance therapy with vitamin D analogs (calcipotriol) or weekend-only corticosteroid application after initial control 5
• Avoid systemic corticosteroids entirely in psoriasis patients, as withdrawal can precipitate severe flares that worsen picking behavior 7, 6, 8

Medications That Worsen Both Conditions

Avoid lithium, chloroquine, mepacrine, beta-blockers, and NSAIDs in patients with both skin picking disorder and psoriasis, as these agents can severely exacerbate the underlying dermatosis and potentially trigger more picking 7, 6, 8

Treatment Algorithm

1. Start fluoxetine 20 mg daily, increase to 60-80 mg/day over 4-6 weeks 2, 3
2. Simultaneously treat any underlying inflammatory skin conditions aggressively with appropriate topical therapy to eliminate itch and inflammation as picking triggers 5, 4
3. Assess response at 6-10 weeks: if inadequate improvement, add NAC 1200-2400 mg daily 1, 4
4. If still insufficient at 12-16 weeks, augment with low-dose aripiprazole 5-15 mg daily 1
5. Consider naltrexone 50-100 mg daily for refractory cases with prominent urge-driven behavior 1

Common Pitfalls to Avoid

• Do not discontinue SSRIs prematurely: response requires 6-10 weeks at therapeutic doses, and early discontinuation leads to symptom return 2
• Do not neglect the dermatologic component: untreated pruritus from eczema or active psoriatic plaques perpetuates the picking cycle regardless of psychiatric medication 4
• Do not use systemic corticosteroids in psoriasis patients, as rebound flares upon discontinuation dramatically worsen both the skin condition and picking behavior 7, 6
• Do not assume picking will resolve by treating comorbid depression/anxiety alone: skin picking disorder responds to SSRIs independent of mood symptom improvement 3

Interdisciplinary Approach

Pharmacologic treatment must be combined with habit-reversal therapy or cognitive behavioral therapy for optimal outcomes, as medication alone addresses only part of the disorder 9, 4

• Dermatologists should manage wound care, topical treatments for underlying skin conditions, and screen for infection in picked lesions 4
• Psychiatrists should prescribe and monitor psychotropic medications while coordinating behavioral therapy 4
• Both specialties should communicate regularly about treatment response and adjust the plan collaboratively 4