What is the first‑line treatment for dermatillomania in a 69‑year‑old man?

Primary Treatment for Dermatillomania in a 69-Year-Old Man

Cognitive-behavioral therapy (CBT) with habit reversal training is the first-line treatment for dermatillomania in this patient, incorporating exposure with response prevention techniques and self-monitoring tools. 1

First-Line Treatment: Behavioral Interventions

The evidence strongly supports CBT with habit reversal training as the initial approach for dermatillomania across all age groups, including older adults 1, 2, 3. This behavioral intervention has demonstrated the most consistent success in reducing repetitive skin-picking behaviors and should be initiated before considering pharmacological options 3.

Key components of effective CBT for dermatillomania include:

• Awareness training to help the patient recognize triggers and early warning signs of picking episodes 1
• Development of competing responses that physically prevent or replace the picking behavior when urges arise 1
• Self-monitoring tools such as daily logs to track picking frequency, duration, and associated emotional states 1
• Exposure with response prevention (ERP) techniques to reduce avoidance behaviors and build tolerance to picking urges 1

Both individual and group CBT formats are equally effective, allowing flexibility based on patient preference and resource availability 1. Online self-help programs incorporating educational materials and CBT-based exercises have also shown promising results with moderate effect sizes 1.

Second-Line Treatment: Pharmacological Interventions

If CBT alone is insufficient or unavailable, selective serotonin reuptake inhibitors (SSRIs) should be considered as second-line treatment, particularly when moderate to severe functional impairment is present or when comorbid anxiety or depression exists. 1, 4

SSRIs have proven most effective in treating the psychiatric component of dermatillomania 4. The decision to add pharmacotherapy should be made after assessing treatment response at 4 weeks and 8 weeks using standardized measures 1.

Alternative pharmacological option:

• N-Acetylcysteine (1200-2400 mg/day in divided doses) is a well-established glutamatergic agent with minimal side effects that can be considered for skin picking disorder 1

Critical Assessment and Monitoring Requirements

Thorough risk assessment is essential at every visit, including screening for self-harm and suicidal ideation, as dermatillomania carries elevated psychiatric risk. 1 Approximately half of individuals with body-focused repetitive behaviors report self-harm, which may be related to appearance concerns 1.

Assessment should include:

• Functional impairment in self-care, usual activities, and social functioning to guide treatment intensity 1
• Evaluation for comorbid conditions including obsessive-compulsive disorder, anxiety, depression, and substance use 4
• Physical examination of skin lesions for signs of infection, scarring, or tissue damage requiring wound care 4

Adjunctive Supportive Measures

Regular stress management techniques, such as relaxation training, can help reduce picking triggers and should be incorporated into the treatment plan. 1

For acute skin lesions resulting from picking episodes, topical wound care and antibiotics may be necessary to prevent infection 4. The patient should be educated that treatment addresses both the behavioral component and any resulting dermatological complications.

Common Pitfalls to Avoid

• Do not delay behavioral therapy while waiting for medication effects, as CBT with habit reversal training remains the most effective intervention 1, 3
• Avoid using sedating antihistamines long-term, as they may predispose to dementia in older adults 1
• Do not assume the behavior will resolve without intervention, as dermatillomania causes substantial distress and functional impairment requiring active treatment 4, 2

Treatment Algorithm for This 69-Year-Old Patient

1. Initiate CBT with habit reversal training immediately as first-line treatment 1
2. Assess response at 4 weeks and 8 weeks using standardized measures 1
3. If inadequate response after 8 weeks of adherent CBT, add SSRI therapy while continuing behavioral interventions 1, 4
4. Consider N-Acetylcysteine if SSRIs are contraindicated or not tolerated 1
5. Provide wound care and antibiotics for any active skin lesions with signs of infection 4
6. Screen for comorbid psychiatric conditions that may require concurrent treatment 1, 4