Treatment for Self-Excoriation (Skin-Picking Disorder)
Start with habit reversal training as the primary treatment for all patients with excoriation disorder, delivered as 10-20 sessions of cognitive-behavioral therapy either individually or in groups. 1
First-Line Treatment: Habit Reversal Training
Habit reversal training should be the initial intervention for excoriation disorder, following the same evidence-based approach proven effective for trichotillomania and other body-focused repetitive behaviors. 1 This behavioral approach has demonstrated the strongest evidence base across multiple studies and should be implemented before considering pharmacological options. 2
The core components include:
- Awareness training to help patients identify specific triggers, high-risk situations, and early warning signs that precede skin-picking episodes 1
- Competing response training to practice alternative behaviors when the urge to pick emerges, such as clenching fists, sitting on hands, or engaging in tactile substitutes 1
- Self-monitoring tools to track picking episodes, triggers, and progress throughout treatment 3
- Exposure with response prevention techniques adapted to the individual's developmental level 3
Deliver 10-20 sessions with patient adherence to between-session homework exercises being the most robust predictor of both short-term and long-term treatment success. 1 Both individual and group formats are equally effective, allowing flexibility based on patient preference and resource availability, with group therapy offering additional peer support benefits. 3
Family involvement is crucial, particularly for younger patients, to provide support and reinforce behavioral strategies throughout the treatment process. 3, 4
Pharmacological Treatment Options
First-Line Medication: N-Acetylcysteine
N-acetylcysteine is the preferred first-line pharmacological treatment due to significant benefits and low risk of side effects, with three out of five randomized controlled trials demonstrating superiority to placebo. 1 This glutamatergic agent has minimal side effects and is well-established for skin picking disorder. 3, 4
Dose at 1200-2400 mg daily in divided doses, following evidence from controlled trials. 1, 3, 4
Second-Line Medication: SSRIs
SSRIs (fluoxetine, escitalopram) have demonstrated improvement in skin picking and show the most promising pharmacological results in terms of mitigating severity and frequency of symptoms. 1, 5 SSRIs are increasingly being used in combination with psychotherapy when patients present with excoriation disorder. 5
Higher doses are typically required for body-focused repetitive behaviors compared to depression treatment, and at least 8-12 weeks at maximum tolerated dose should be allowed before declaring treatment failure. 1 SSRIs should be considered as second-line treatment for patients aged 12-18 years with moderate to severe functional impairment who haven't responded to CBT. 3
Treatment Algorithm
Start with habit reversal training (10-20 sessions) if the patient is motivated for behavioral therapy and has no severe comorbidities requiring immediate medication. 1 This follows the recommendation that cognitive-behavioral therapy should be the initial treatment before pharmacotherapy. 4
Start with N-acetylcysteine plus habit reversal training if moderate-to-severe symptoms are present or if the patient prefers a combined approach. 1 This combination addresses both the neurobiological and behavioral components of the disorder simultaneously.
Add SSRIs when CBT alone is insufficient, particularly with moderate-to-severe functional impairment, or when comorbid anxiety or depression is present. 3, 4 The dosage and treatment plan should be tailored to the individual patient's needs. 4
If SSRIs fail, consider augmentation with antipsychotics (often combined with antidepressants) or naltrexone, though these have less robust evidence. 5 Other options that have been studied include antiepileptics (lamotrigine, topiramate), lithium, and mirtazapine, though additional studies are needed to definitively establish their role. 5
Maintenance and Monitoring
Continue successful interventions for at least 12-24 months after achieving remission, given the chronic, fluctuating nature of excoriation disorder. 1, 3 This extended treatment duration is critical to prevent relapse.
Provide monthly booster CBT sessions for 3-6 months after acute response to prevent relapse, and develop a relapse prevention plan identifying triggers, warning signs, and action steps. 1
Monitor for medical complications including infection, scarring, and tissue damage at each visit, as skin picking can lead to significant self-harm. 1, 3 Approximately half of patients with body-focused repetitive behaviors report self-harm related to appearance concerns, indicating substantial psychiatric burden. 4
Screen for emergence or worsening of depression, anxiety, and suicidal ideation at every visit, as excoriation disorder carries elevated psychiatric risk. 1, 3 Thorough risk assessment including screening for self-harm is essential. 3
Assess treatment response at 4 weeks and 8 weeks using standardized measures, and adjust the regimen if symptoms are stable or worsening despite good adherence. 3 Regular monitoring for medication side effects, adverse events, and patient satisfaction is essential at each follow-up. 3
If using antipsychotics, monitor metabolic parameters including weight, glucose, and lipids, and assess for serotonin syndrome if combining serotonergic medications. 1
Adjunctive Approaches
Online self-help programs with educational materials, self-monitoring tools, and exercises based on CBT principles have shown promising results with moderate effect sizes. 3, 4 These can be particularly useful for patients with limited access to in-person therapy or as supplements to standard treatment. 2
Regular stress management techniques, such as relaxation training, can help reduce picking triggers as part of a comprehensive treatment plan. 3, 4
Critical Pitfalls to Avoid
Do not confuse excoriation disorder with skin picking in body dysmorphic disorder, where picking is driven by attempts to improve appearance of perceived defects, whereas in excoriation disorder, picking is not primarily motivated by appearance concerns. 3, 4 This distinction is critical for appropriate treatment selection.
Assess whether stimulants are contributing to or exacerbating skin picking, and if so, dose reduction or medication holiday may be warranted, as stimulants can cause compulsive behaviors including skin picking in some patients. 3
Avoid long-term use of sedating antihistamines, as they may predispose to dementia and do not address the underlying disorder. 3
Assess functional impairment in self-care, usual activities, and social functioning to guide treatment intensity, as this is crucial for determining the appropriate level of intervention. 3