What medication can help a female patient with dermatillomania, considering her past medical history and demographic information?

Medication Treatment for Dermatillomania (Skin Picking Disorder)

N-acetylcysteine should be initiated as the first-line pharmacological treatment for this patient with dermatillomania, starting at 1200-2400 mg daily, as it has demonstrated superiority over placebo in three out of five randomized controlled trials and carries minimal side effects. 1

Treatment Algorithm

Step 1: First-Line Behavioral Therapy (Always Initiate)

• Habit reversal training is the primary treatment modality and should be started immediately for all patients with dermatillomania 1
• Deliver 10-20 sessions of cognitive-behavioral therapy, either in-person or internet-based 1
• Awareness training helps identify triggers, situations, and early warning signs preceding picking episodes 1
• Competing response training teaches alternative behaviors when urges emerge 1
• Patient adherence to between-session homework is the strongest predictor of treatment success, so emphasize this heavily 1

Step 2: Add Pharmacotherapy (When Behavioral Therapy Alone Is Insufficient)

First-Line Medication: N-Acetylcysteine

• Start N-acetylcysteine at 1200 mg daily, titrating up to 2400 mg daily as tolerated 1
• This is preferred over other medications due to significant benefits with low side effect risk 1
• Monitor response over 8-12 weeks before declaring treatment failure

Second-Line Medication: Clomipramine (If N-Acetylcysteine Fails)

• Initiate clomipramine only after N-acetylcysteine trial 1
• Requires 8-12 weeks at maximum tolerated dose before declaring treatment failure - do not discontinue prematurely 1
• Monitor for serious adverse effects including seizures, cardiac arrhythmias, and serotonergic syndrome, especially when combined with other serotonergic agents 1

Alternative Options: SSRIs

• Selective serotonin reuptake inhibitors (fluoxetine, sertraline, others) have shown effectiveness in treating the psychiatric component of dermatillomania 2, 3
• Consider when comorbid depression, anxiety, or OCD is present 2
• Fluoxetine inhibits CYP2D6 and may interact with other medications; initiate at low doses if combining with drugs metabolized by this pathway 4

Special Consideration: Atomoxetine

• If comorbid ADHD is present, atomoxetine (selective noradrenaline reuptake inhibitor) may address both conditions simultaneously 5
• This represents a targeted approach when ADHD symptoms coexist with skin picking

Treatment Duration and Maintenance

• Continue successful interventions for at least 12-24 months after achieving remission, given the chronic nature of dermatillomania 1
• Develop a relapse prevention plan identifying triggers, warning signs, and action steps 1
• Some patients may require longer-term or indefinite treatment depending on severity and response

Concurrent Management of Skin Lesions

• Treat active wounds with topical wound care and antibiotics if infected 2, 6
• Address pruritus if present with topical antipruritics containing menthol 0.5% or topical corticosteroids (mometasone furoate 0.1% or betamethasone valerate 0.1%) 7
• Apply moisturizers to prevent dry skin, which can trigger picking behavior 7

Critical Pitfalls to Avoid

• Do not discontinue clomipramine before completing 8-12 weeks at maximum tolerated dose - premature discontinuation is a common error 1
• Do not overlook comorbid psychiatric conditions (OCD, anxiety, depression, ADHD, borderline personality disorder) that require concurrent treatment 2
• Do not rely solely on medication without behavioral therapy - the combination is superior to either alone 1, 2
• Monitor for serious complications including deep tissue infections, osteomyelitis, or epidural abscess in severe cases with chronic wounds 6

Multidisciplinary Approach

• Coordinate care between dermatology and psychiatry for optimal outcomes 8
• Consider referral to specialized CBT programs for OCD and anxiety disorders 2
• Support groups and habit reversal exercises are well-tolerated adjuncts 2