What is the recommended treatment approach for a patient with excoriation (skin picking) disorder?

Treatment of Excoriation (Skin Picking) Disorder

Cognitive-behavioral therapy with habit reversal training should be initiated as first-line treatment for all patients with excoriation disorder, incorporating awareness training, competing response development, and self-monitoring tools. 1, 2

Initial Treatment Approach: Behavioral Interventions

Start with CBT incorporating habit reversal training (HRT) as the primary intervention for all severity levels. 1, 2 This approach is effective regardless of whether picking occurs with high or low awareness. 3

Key components of HRT include:

• Awareness training to identify specific triggers (emotional states, environmental cues, physical sensations) 2
• Development of competing responses (alternative behaviors incompatible with picking, such as clenching fists or holding objects) 1, 2
• Self-monitoring tools (tracking frequency, duration, and contexts of picking episodes) 1, 2
• Exposure with response prevention techniques adapted to developmental level 1

Family involvement is crucial, particularly for younger patients, to provide support and reinforce behavioral strategies. 1, 2 This collaborative approach improves treatment adherence and outcomes. 2

For patients whose picking is triggered by negative emotions, augment HRT with acceptance and commitment therapy (ACT) or dialectical behavior therapy (DBT) techniques. 3 Regular stress management and relaxation training help reduce picking triggers. 1

Second-Line Treatment: Pharmacological Interventions

Add medication when CBT alone produces inadequate response, particularly with moderate-to-severe functional impairment or comorbid anxiety/depression. 1, 2

N-Acetylcysteine (NAC)

NAC should be considered for all severity levels given its moderate efficacy and minimal side effect profile. 3 The American College of Neuropsychopharmacology recommends dosing at 1200-2400 mg/day in divided doses. 1, 2 NAC is a well-established glutamatergic agent that can be used as monotherapy or combined with CBT. 1, 4

Selective Serotonin Reuptake Inhibitors (SSRIs)

SSRIs are recommended as second-line treatment for patients aged 12-18 years with moderate to severe functional impairment who haven't responded to CBT. 1 Recent evidence shows SSRIs demonstrate the most promising results in mitigating severity and frequency of skin-picking symptoms. 5 SSRIs are increasingly used in combination with psychotherapy and should be considered when comorbid anxiety or depression is present. 1, 5

Alternative Glutamatergic Agent

Memantine can be considered as second-line pharmacological treatment when CBT is insufficient, unavailable, or not tolerated. 4 Start at 5 mg daily and titrate to 10-20 mg/day over 2-4 weeks to minimize side effects. 4 Memantine can be used as monotherapy or combined with CBT for enhanced outcomes. 4

Critical Diagnostic Distinction

Differentiate excoriation disorder from skin picking in body dysmorphic disorder (BDD), as the underlying motivations differ fundamentally. 2, 4 In excoriation disorder, picking is not primarily motivated by appearance concerns, whereas in BDD, picking is driven by attempts to improve appearance of perceived defects. 1, 2

Risk Assessment and Monitoring

Regularly assess for significant self-harm risk, including infection, scarring, and tissue damage. 1, 4 Approximately half of patients with body-focused repetitive behaviors report self-harm related to appearance concerns. 2, 4 This substantial psychiatric burden requires ongoing monitoring throughout treatment. 2

Adjunctive Approaches

Online self-help programs with educational materials and CBT-based exercises show moderate effect sizes in reducing symptoms. 1, 2 These can supplement in-person therapy or serve as accessible alternatives when traditional therapy is unavailable. 2

Special Medication Considerations

Assess whether stimulant medications are contributing to or exacerbating skin picking. 1 If stimulants are implicated, dose reduction or medication holiday may be warranted. 1

Other pharmacologic interventions, including antipsychotics (olanzapine, aripiprazole), opioid antagonists (naltrexone), and antiepileptics (lamotrigine, topiramate), should be reserved for cases with significant comorbidities or previous behavioral/NAC/SSRI treatment failure. 3, 5 These agents have been studied in case reports and trials but lack the robust evidence base of SSRIs and NAC. 5