From the Guidelines
Excoriation disorder should be treated with a combination of cognitive-behavioral therapy (CBT) and medication, such as selective serotonin reuptake inhibitors (SSRIs), to reduce skin picking behaviors and improve quality of life. Excoriation, also known as skin picking disorder, is a condition where individuals repeatedly pick at their skin, causing tissue damage 1. According to the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5), excoriation disorder is characterized by recurrent picking of one’s skin leading to skin lesions, accompanied by unsuccessful attempts to decrease or stop the behavior 1.
Treatment Approaches
- Cognitive-behavioral therapy (CBT) is the most effective psychotherapeutic approach, helping patients identify triggers and develop alternative coping strategies 1.
- For medication, selective serotonin reuptake inhibitors (SSRIs) like fluoxetine (20-80 mg daily) or sertraline (50-200 mg daily) are commonly prescribed for 12-16 weeks initially, with treatment often continuing for 6-12 months.
- N-acetylcysteine (1200-2400 mg daily) has shown promise as an alternative treatment.
- Practical management includes keeping nails short, using fidget toys for distraction, covering affected areas with bandages, and maintaining a skin care routine with gentle cleansers and moisturizers to promote healing.
Pathophysiology
Excoriation disorder is related to obsessive-compulsive spectrum disorders and involves dysregulation of the brain's reward system, particularly affecting dopamine and serotonin pathways, which explains why SSRIs can be effective in reducing picking behaviors 1. The obsessive–compulsive and related disorders (OCRDs) chapter in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) includes excoriation (skin-picking) disorder, as well as other conditions such as body dysmorphic disorder, trichotillomania, and hoarding disorder 1.
Clinical Considerations
It is essential to address excoriation disorder promptly to prevent further tissue damage and improve the patient's quality of life 1. A comprehensive treatment plan should be individualized to the patient's needs and may involve a combination of psychotherapy, medication, and practical management strategies.
From the Research
Definition and Characteristics of Excoriation
- Excoriation disorder is a condition characterized by the repetitive scratching or picking of skin, leading to physical damage, distress, and functional impairment 2.
- It has been associated with impulsivity and problems with inhibition, and may be a disease severity marker 2.
- The disorder is clinically recognized and was recently included in the Diagnostic and Statistical Manual of the American Psychiatric Association (DSM) - fifth edition, as an OCD-related disorder 3.
Prevalence and Epidemiology
- Epidemiological surveys show a prevalence of 3% to 5% for the general population, with heterogeneous gender and age distribution 3.
- Excoriation disorder is most common in females, and its course is chronic, characterized by fluctuating and frequent periods of exacerbation 4.
Treatment Options
- Treatment of excoriation disorder may be pharmacological and/or psychological, with some evidence for the benefit of SSRI agents and N-Acetyl-Cysteine 3.
- Various psychological treatments have been investigated, including cognitive behavioral protocols, some of which have been developed specifically for this disorder 3.
- Other pharmacological therapies include lamotrigine, opioid antagonists, and mirtazapine, which has been shown to be effective in a case report 4.
- Augmentation strategies using antipsychotics, such as olanzapine and aripiprazole, have also been used to treat excoriation disorder 4, 5.
Management Considerations
- Optimal management of excoriation disorder includes individualized treatment plans consisting of psychotherapies, behavioral and pharmacologic interventions 6.
- Older adults require unique management considerations due to increased risk of poor outcomes, such as infection and hospitalization, and age-related changes to the skin and underlying medical and psychiatric comorbidities 6.