What is the next step in managing a patient with obsessive-compulsive disorder (OCD) and hidradenitis suppurativa (HS) who has shown minimal response to fluvoxamine (Luvox) at 100 mg, is tolerating it well, and is undergoing habit reversal therapy for severe skin picking symptoms?

Management Plan for OCD with Minimal Response to Fluvoxamine 100mg

Increase fluvoxamine to 150mg immediately, then titrate by 50mg increments every 4-7 days toward a target of 200-300mg daily while continuing habit reversal therapy, and simultaneously address the hidradenitis suppurativa with dermatology referral for combined medical management. 1

Immediate Medication Adjustment

Your patient is significantly underdosed. The current 100mg dose is at the lower end of the therapeutic range for OCD, and the FDA label explicitly states that controlled trials establishing effectiveness used doses of 100-300mg/day. 1

Titration Protocol

• Increase to 150mg now (add 50mg to current dose) 1
• Continue increasing by 50mg every 4-7 days as tolerated until reaching 200-250mg daily 1
• Divide doses above 100mg into twice-daily dosing, with the larger dose at bedtime 1
• Maximum dose is 300mg/day if needed and tolerated 1

The FDA label is clear: doses should be increased in 50mg increments every 4-7 days until maximum therapeutic benefit is achieved. 1 Since your patient is tolerating well with minimal response, this indicates room for dose escalation rather than treatment failure.

Timeline Expectations

Allow 8-12 weeks at the maximum tolerated dose before declaring treatment failure. 2 However, early response by weeks 2-4 on a stable target dose predicts ultimate treatment success. 2

• Full therapeutic effect may not appear until 5 weeks or longer, with maximal improvement by week 12 2
• Each dose change requires another 5-7 days for pharmacological stabilization 2
• Do not prematurely conclude treatment failure during the titration phase 2

Behavioral Therapy Integration

Continue and intensify habit reversal therapy for skin picking while optimizing medication. The combination of pharmacotherapy and behavioral intervention produces superior outcomes to either alone. 3

Specific Considerations for Skin Picking

• Skin picking (excoriation disorder) is classified as an obsessive-compulsive related disorder and responds to similar treatments as OCD 3
• Habit reversal therapy is evidence-based for repetitive body-focused behaviors like skin picking 3
• The severe symptoms and likely HS diagnosis create a vicious cycle: HS lesions provide targets for picking, which worsens inflammation and scarring 4

Addressing the Hidradenitis Suppurativa Component

Refer to dermatology urgently if not already involved. HS carries substantial psychiatric burden independent of OCD, with high rates of depression, anxiety, and suicidal ideation. 4

Why This Matters for OCD Treatment

• HS-related pain, discharge, and disfigurement significantly worsen quality of life and may perpetuate obsessive-compulsive symptoms 4
• The inflammatory burden of HS may influence CNS activity and mood 4
• Treating the underlying skin condition removes triggers for compulsive picking behavior 4
• Patients with HS have elevated rates of psychiatric comorbidity that require integrated management 4

Monitoring During Titration

Assess weekly during dose escalation for:

• Gastrointestinal symptoms (nausea is most common, occurring in >10% of patients) 5
• Somnolence, asthenia, headache, dry mouth, or insomnia 5
• Improvement in obsessive-compulsive symptoms using standardized scales (Y-BOCS) 2
• Changes in skin picking frequency and severity 3

Fluvoxamine is generally well tolerated with a low risk of serious adverse events, sexual dysfunction, or withdrawal syndrome compared to other SSRIs. 5

If Inadequate Response After Adequate Trial

Only after 8-12 weeks at 200-300mg should you consider these next steps:

First-Line Augmentation

• Add cognitive-behavioral therapy with exposure and response prevention (ERP) if not already implemented—this has larger effect sizes than medication augmentation alone 2
• Consider atypical antipsychotic augmentation with aripiprazole 10-15mg or risperidone 2, 6

Alternative Strategies

• Switch to a different SSRI (though fluvoxamine has the largest database in OCD treatment) 7
• Consider clomipramine 150-250mg daily (reserve for patients who fail adequate SSRI trials due to inferior tolerability) 2

Critical Pitfalls to Avoid

Do not switch medications prematurely. The most common error is abandoning an SSRI before reaching adequate doses for adequate duration. 2 Your patient has demonstrated good tolerability, which is a green light for dose optimization.

Do not ignore the dermatological component. The HS is not merely a consequence of picking—it is a chronic inflammatory disease requiring its own treatment that will facilitate OCD management. 4

Do not use divided dosing until exceeding 100mg total daily dose. Below this threshold, single bedtime dosing is appropriate. 1

Drug Interaction Considerations

Fluvoxamine is a potent inhibitor of CYP1A2 and moderate inhibitor of CYP2C19 and CYP3A4, but a weak inhibitor of CYP2D6. 5 Review all concurrent medications for potential interactions, particularly:

• Theophylline, caffeine (CYP1A2 substrates)
• Warfarin (CYP2C19 substrate)
• Benzodiazepines metabolized by CYP3A4

Long-Term Management

Plan for 12-24 months of treatment after achieving remission due to high relapse risk with OCD. 2 Premature discontinuation is associated with symptom recurrence in the majority of patients.

When eventually discontinuing, taper gradually rather than stopping abruptly to minimize discontinuation symptoms. 1