Treatment for Excoriation Disorder

First-Line Treatment

The American College of Psychiatrists recommends habit reversal training as the primary treatment modality for all patients with excoriation disorder, following the same evidence-based approach proven effective for trichotillomania and other body-focused repetitive behaviors 1
Habit reversal training should include awareness training to help patients identify triggers, situations, and early warning signs that precede skin-picking episodes, and competing response training to practice alternative behaviors when the urge to pick emerges 1
Deliver 10-20 sessions of individual or group cognitive-behavioral therapy, either in-person or via internet-based protocols, with patient adherence to between-session homework exercises being the most robust predictor of both short-term and long-term treatment success 1

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
Typical dosing ranges from 1200-2400 mg daily, though specific dosing protocols should follow the evidence from trichotillomania trials 1
SSRIs (fluoxetine, escitalopram) have demonstrated improvement in skin picking, with higher doses 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 3, 4

Start with habit reversal training (10-20 sessions) if patient is motivated for behavioral therapy and has no severe comorbidities requiring immediate medication, as recommended by the American Psychiatric Association 1
Start with N-acetylcysteine plus habit reversal training if moderate-to-severe symptoms or if patient prefers combined approach, with a treatment duration of at least 12-24 months after achieving remission 1
Consider 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, 3

Continue successful interventions for at least 12-24 months after achieving remission, given the chronic, fluctuating nature of excoriation disorder, as recommended by the American College of Psychiatrists 1
Monitor for medical complications including infection, scarring, and tissue damage, and screen for emergence or worsening of depression, anxiety, and suicidal ideation 4
If using antipsychotics, monitor metabolic parameters including weight, glucose, and lipids, and assess for serotonin syndrome if combining serotonergic medications 4