Treatment for Dermatillomania (Skin Picking Disorder)

Behavioral Interventions

• The American Academy of Child and Adolescent Psychiatry recommends cognitive-behavioral therapy (CBT) with habit reversal training, incorporating exposure with response prevention (ERP) techniques, which may be adapted to the individual's developmental level, and family involvement in therapy is recommended, particularly for younger patients, to provide support and reinforce behavioral strategies 1
• CBT should incorporate techniques such as awareness training, development of competing responses, and self-monitoring tools, and family involvement is crucial, especially for younger patients, to support and reinforce behavioral strategies 1

Pharmacological Interventions

• The International Society for the Study of Trauma and Dissociation recommends selective serotonin reuptake inhibitors (SSRIs) as second-line treatment for patients aged 12-18 years with moderate to severe functional impairment who haven't responded to CBT 2
• SSRIs should be considered when there is inadequate response to CBT, particularly when there is moderate to severe functional impairment, and comorbid anxiety or depression is present 1

Special Considerations

• The Journal of Child Psychology and Psychiatry and Allied Disciplines highlights the importance of risk assessment, as skin picking can lead to significant self-harm, including infection, scarring, and tissue damage, and approximately half of young people with body-focused repetitive behaviors report self-harm, which may be related to appearance concerns 1
• Skin picking may be a symptom of an underlying condition, and treatment should be tailored to address the underlying psychological factors, as stated by the Nature Reviews Disease Primers 3

Treatment for Skin Picking Disorder

Understanding Skin Picking Disorder

• Skin picking disorder is distinct from 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 4

First-Line Treatment: Behavioral Interventions

• Components of cognitive-behavioral therapy with habit reversal training include awareness training, development of competing responses, and self-monitoring tools, as recommended by the American Psychological Association 5

Second-Line Treatment: Pharmacological Interventions

• N-Acetylcysteine is a well-established glutamatergic agent for skin picking disorder with minimal side effects, typically dosed at 1200-2400 mg/day in divided doses, according to the American College of Neuropsychopharmacology 5

Adjunctive Approaches

• Online self-help programs, including educational materials, self-monitoring tools, and exercises based on CBT principles, have shown promising results with moderate effect sizes, as reported by the National Institute of Mental Health 5
• Regular stress management techniques, such as relaxation training, can help reduce picking triggers, as recommended by the American Academy of Sleep Medicine 5

Treatment of Skin Picking Disorder

Diagnosis and Characteristics

• Excoriation disorder is characterized by recurrent picking leading to skin lesions with unsuccessful attempts to stop, causing significant distress or functional impairment, as defined by the American Psychiatric Association 6

Medication Considerations

• Stimulants can cause compulsive behaviors, including skin picking, in some patients, according to the American Academy of Child and Adolescent Psychiatry 7
• Topiramate has been mentioned in case reports for severe cases, but lacks robust evidence, as noted in Pediatrics 8

Treatment Approach

• The American Academy of Child and Adolescent Psychiatry suggests considering whether stimulants are contributing to or exacerbating skin picking, and if so, dose reduction or medication holiday may be warranted 7

Treatment for Skin Picking Disorder (Dermatillomania)

First-Line Treatment: Behavioral Interventions

• Exposure with response prevention (ERP) techniques can reduce avoidance behaviors in patients with skin picking disorder, as part of a comprehensive treatment plan 9

Second-Line Treatment: Pharmacological Interventions

• The American Academy of Child and Adolescent Psychiatry recommends selective serotonin reuptake inhibitors (SSRIs) as a second-line treatment for skin picking disorder in patients aged 12-18 years with moderate to severe functional impairment, particularly when cognitive-behavioral therapy (CBT) is insufficient, unavailable, or not tolerated 9

Monitoring Requirements

• The National Comprehensive Cancer Network recommends assessing treatment response at 4 weeks and 8 weeks using standardized measures, and adjusting the regimen if symptoms are stable or worsening despite good adherence 10, 11
• Regular monitoring for medication side effects, adverse events, and patient satisfaction is essential at each follow-up, as recommended by the American Society of Clinical Oncology 10

Critical Assessment and Risk Management

• The American Academy of Dermatology recommends thorough risk assessment, including screening for self-harm and suicidal ideation at every visit, as skin picking disorder carries elevated psychiatric risk 9, 12
• Assessing functional impairment in self-care, usual activities, and social functioning is crucial to guide treatment intensity, as suggested by the National Institute for Health and Care Excellence 10

Treatment Delivery Considerations

• The British Association for Behavioural and Cognitive Psychotherapies suggests that both individual and group CBT formats are equally effective, allowing flexibility based on patient preference and resource availability, with group therapy offering additional benefits through peer support 9
• The use of sedating antihistamines long-term should be avoided, as they may predispose to dementia, according to the British Association of Dermatologists 13