What is the appropriate medication management for a patient with neurotic excoriation, considering their past medical history and potential for underlying psychiatric conditions or skin disorders?

Medication Management for Neurotic Excoriation (Skin Picking Disorder)

Start with cognitive-behavioral therapy (CBT) incorporating habit reversal training as first-line treatment, and add selective serotonin reuptake inhibitors (SSRIs) as second-line pharmacotherapy when CBT alone is insufficient or when moderate-to-severe functional impairment is present. 1, 2

First-Line Treatment Approach

Behavioral interventions should be initiated before medications. CBT with habit reversal training includes awareness training to identify triggers, development of competing responses to replace picking behavior, self-monitoring tools, and exposure with response prevention (ERP) techniques. 1, 2 Family involvement is crucial, particularly for younger patients, to provide support and reinforce behavioral strategies. 1

Second-Line Pharmacological Treatment

SSRIs as Primary Medication Option

SSRIs are recommended when CBT is insufficient, unavailable, or not tolerated, particularly in patients aged 12-18 years with moderate to severe functional impairment. 1, 2 SSRIs should also be considered when comorbid anxiety or depression is present. 1

The evidence base for SSRIs includes fluoxetine and escitalopram, which have demonstrated improvement in skin picking behavior. 3 Case studies and open trials have shown efficacy of selective serotonin reuptake inhibitors in this condition. 4

N-Acetylcysteine as Alternative or Adjunct

N-acetylcysteine (NAC) is a well-established glutamatergic agent with minimal side effects, dosed at 1200-2400 mg/day in divided doses. 1, 2 NAC can be used as an alternative to SSRIs or as an adjunct when SSRIs provide inadequate response. 1

Treatment-Resistant Cases: Augmentation Strategies

When first-line treatments fail, consider the following augmentation approaches:

Atypical Antipsychotics

• Aripiprazole augmentation has shown efficacy when added to venlafaxine (an SNRI) in treatment-resistant cases, with favorable side effect profile. 5
• Olanzapine has been successful in case reports for augmentation. 4, 3

Alternative Antidepressants

• Mirtazapine (a noradrenergic and specific serotonergic antidepressant) has demonstrated remarkable response in severe cases with multiple psychiatric comorbidities, with the additional benefit of antihistaminergic effects that relieve skin itching and pain. 3
• Venlafaxine (SNRI) can be considered, particularly when augmented with aripiprazole. 5

Other Pharmacological Options

• Low-dose naltrexone (4.5 mg daily) has shown efficacy in reducing compulsion to pick and improving lesion healing, though previous reports used higher doses (50 mg). 6
• Clomipramine, doxepin, pimozide, and lamotrigine have been successful in case reports. 4, 3

Monitoring and Assessment Requirements

Assess treatment response at 4 weeks and 8 weeks using standardized measures, adjusting the regimen if symptoms are stable or worsening despite good adherence. 1 Regular monitoring for medication side effects, adverse events, and patient satisfaction is essential at each follow-up. 1

Conduct thorough risk assessment at every visit, including screening for self-harm and suicidal ideation, as approximately half of patients with body-focused repetitive behaviors report self-harm related to appearance concerns. 1, 2 Assess functional impairment in self-care, usual activities, and social functioning to guide treatment intensity. 1

Critical Diagnostic Consideration

Distinguish excoriation disorder from skin picking in body dysmorphic disorder (BDD), as treatment approaches differ significantly. 7 In excoriation disorder, picking is compulsive and may provide temporary relief or occur during boredom/anxiety, whereas in BDD, picking is specifically intended to improve appearance of perceived defects. 7 Carefully assess whether picking is driven by appearance concerns (suggesting BDD) or represents true compulsive behavior to avoid misdiagnosis. 7

Adjunctive Approaches

• Online self-help programs with educational materials and CBT-based exercises show moderate effect sizes. 1, 2
• Regular stress management and relaxation training can help reduce picking triggers. 1, 2
• Both individual and group CBT formats are equally effective, with group therapy offering additional peer support benefits. 1

Important Caveats

Avoid long-term use of sedating antihistamines, as they may predispose to dementia. 1

Assess whether stimulant medications are contributing to or exacerbating skin picking; if so, dose reduction or medication holiday may be warranted. 1

The disorder has a chronic course with fluctuating periods of exacerbation and commonly presents with psychiatric comorbidities including mood disorders, anxiety disorders, obsessive-compulsive disorder, body dysmorphic disorder, and substance use disorders. 4, 3 A multidisciplinary approach involving dermatology, psychiatry, and potentially plastic surgery may be necessary for definitive management. 8