What are the treatment options for an adult patient with skin picking disorder, also known as dermatillomania, with potential co-occurring anxiety and depression?

Treatment for Skin Picking Disorder (Dermatillomania)

Cognitive-behavioral therapy (CBT) with habit reversal training is the first-line treatment for skin picking disorder in adults, incorporating awareness training, competing response development, and self-monitoring tools. 1

First-Line Treatment: Behavioral Interventions

CBT with habit reversal training should be offered as initial treatment for all patients with skin picking disorder. 1 This approach has demonstrated large effect sizes (Cohen's d = 0.88-1.15) and achieves remission rates of 52-63% regardless of whether delivered individually or in group format. 2

Core Components of CBT Include:

• Awareness training to identify triggers, urges, and picking behaviors 1
• Development of competing responses - physical actions incompatible with picking (e.g., clenching fists, sitting on hands) 1
• Self-monitoring tools including picking logs and trigger identification 1
• Exposure with response prevention (ERP) techniques to reduce avoidance behaviors 3

Alternative Behavioral Approaches:

• Acceptance and commitment therapy (ACT)-enhanced group behavioral therapy shows comparable efficacy to traditional CBT 4
• Online self-help programs with CBT-based exercises demonstrate moderate effect sizes and improve accessibility 1, 4
• Expressive writing interventions may provide benefit as adjunctive treatment 4

Second-Line Treatment: Pharmacological Interventions

When CBT is insufficient, unavailable, or not tolerated, selective serotonin reuptake inhibitors (SSRIs) should be initiated, particularly in patients aged 12-18 years with moderate to severe functional impairment. 3, 1 This recommendation extends to adults with co-occurring anxiety or depression. 1

Pharmacological Options:

• SSRIs are the most established pharmacological treatment for the psychiatric component of dermatillomania 5, 6
• N-acetylcysteine (NAC) at 1200-2400 mg/day in divided doses is a well-established glutamatergic agent with minimal side effects 1, 6
• Naltrexone may be considered as an alternative agent 6
• Memantine can be used as second-line pharmacological treatment when CBT is insufficient, starting at 5 mg daily and titrating to 10-20 mg/day over 2-4 weeks 7

Monitoring Requirements:

• Assess treatment response at 4 weeks and 8 weeks using standardized measures 3
• If symptoms are stable or worsening after 8 weeks despite good adherence, adjust the regimen by adding psychological intervention to pharmacotherapy, changing medication, or switching from group to individual therapy 3
• Monitor for medication side effects, adverse events, and patient satisfaction at each follow-up 3

Critical Assessment and Risk Management

Thorough risk assessment is essential, as approximately half of patients with body-focused repetitive behaviors report self-harm. 3, 7 Skin picking can lead to significant tissue damage, infection, scarring, and may be associated with suicidal ideation. 3

Key Assessment Areas:

• Screen for self-harm and suicidal ideation at every visit, as skin picking disorder carries elevated psychiatric risk 3
• Evaluate for co-occurring conditions including anxiety (present in your patient), depression (present in your patient), OCD, body dysmorphic disorder, and autism spectrum disorders 5, 6
• Assess functional impairment in self-care, usual activities, and social functioning to guide treatment intensity 3
• Examine actual skin lesions to document severity and monitor for infection 2

Important Distinction:

Differentiate skin picking disorder from skin picking in body dysmorphic disorder (BDD) - in BDD, picking is driven by attempts to improve appearance of perceived defects, whereas in excoriation disorder, picking is not primarily motivated by appearance concerns. 1, 7

Treatment Algorithm for Your Patient

Given your patient has co-occurring anxiety and depression:

1. Initiate CBT with habit reversal training immediately - this addresses both the skin picking and can improve anxiety/depression symptoms 1, 2

2. Consider concurrent SSRI therapy given moderate-to-severe presentation with psychiatric comorbidities, rather than waiting for CBT failure 1, 5

3. If inadequate response after 8 weeks of combined treatment, add N-acetylcysteine (1200-2400 mg/day) to the SSRI 1, 6

4. Prioritize treatment of depressive symptoms when both depression and anxiety are present, as depression treatment often improves anxiety 3

5. Incorporate stress management and relaxation training to reduce picking triggers 1

Common Pitfalls to Avoid

• Do not delay treatment waiting for "stabilization" - begin trauma-focused or behavioral interventions immediately 8
• Do not use sedating antihistamines long-term as they may predispose to dementia 3
• Monitor for stimulant medications (if prescribed for comorbid ADHD) as these can cause or exacerbate compulsive skin picking 1
• Avoid requiring abstinence from picking before starting therapy - this is counterproductive 8
• Do not underestimate the importance of family involvement, particularly in providing support and reinforcing behavioral strategies 3, 1, 7

Treatment Delivery Considerations

Both individual and group CBT formats are equally effective (no significant difference, p=0.4), allowing flexibility based on patient preference and resource availability. 2 Group therapy may offer additional benefits through peer support while being more cost-effective. 2, 4

Online self-help programs represent a viable alternative when in-person therapy is unavailable, showing promising results with moderate effect sizes. 1, 4