Delusional disorder. Delusions of parasitosis may result in skin picking, as patients attempt to remove imagined parasites or other vermin from on or under their skin.12
Dermatitis artefacta. Patients may consciously create skin lesions to assume the sick role. Onethird of patients presenting to dermatologists with a disease that is primarily psychiatric may be suffering from dermatitis artefacta.13
TREATMENT RECOMMENDATIONS
Successful clinical care of pathologic skin picking requires perseverance and patience from both patient and clinician.
Treatment begins with a thorough dermatologic examination for medical causes of skin picking (such as atopic dermatitis or scabies) and to treat excoriations (such as with antibiotics for infection). After the dermatologist has ruled out a medical cause, carefully assess the patient’s picking behavior and related psychiatric problems (Table 1).
- If picking is secondary to a psychiatric disorder, begin by providing appropriate treatment for that disorder.
- If picking results from BDD or OCD, we recommend habit reversal therapy combined with medication.
- If picking appears to be an independent impulse control disorder, simultaneous habit reversal therapy and medication is usually necessary to reduce symptoms.
SSRIs are a reasonable first medication because of evidence for their efficacy in reducing skin picking. Higher dosages—comparable to those used in treating OCD—are usually required to improve skin-picking behavior. You may need to try another SSRI if the first trial results in partial or no response.
In our experience, augmenting an SSRI with naltrexone, 50 mg/d, helps reduce intrusive urges to pick and is worth considering if SSRI therapy results in only partial response.
Children or adolescents. Depending upon symptom severity, a trial of habit reversal therapy may be appropriate before you recommend using medication.
EVIDENCE FOR DRUG THERAPY
Although few treatment studies have been done, skin picking does appear to respond to medication (Table 2).
Because no medications are approved to treat skin-picking behavior, inform patients of any “off-label” uses and the scientific or clinical evidence for considering medication treatment.
Case reports and case series. Selective serotonin reuptake inhibitors (SSRIs) appear most effective in patients with picking behavior, including:
- fluvoxamine, 300 mg/d, in one case report8
- fluoxetine, 20 to 80 mg/d, in several case reports.5,14-15
In a series of 33 patients with BDD and compulsive skin picking, one-half (49%) of a variety of SSRI treatment trials improved BDD symptoms and skin picking behavior. The percentage of patients who improved was not examined. Dermatologic treatment alone was effective for only 15% of patients.5
Medications other than SSRIs have also been studied. One patient improved within 3 weeks of taking the tricyclic antidepressant clomipramine, 50 mg/d.3 Another patient picked her skin less often 4 weeks after inositol, 18 grams/d, was added to citalopram, 40 mg/d. Inositol, a nonprescription isomer of glucose, is a precursor in the phosphatidylinositol second-messenger cycle, which may play a role at certain serotonin receptors.16 The patient was given 6 grams dissolved in water three times daily.
Case reports have also suggested that olanzapine, pimozide, doxepin, and naltrexone may be beneficial in reducing skin excoriations. These reports often involved patients with psychiatric and medical comorbidities.17-20
Table 3
Habit reversal: 5 components in patient learning
| Awareness about picking behavior |
| Relaxation to reduce anxiety |
| Competing responses to learn behaviors incompatible with picking (such as fist clenching) |
| Rewarding oneself for successfully resisting picking |
| Generalizing the behavioral control |
Open-label studies. In an open-label study of 28 patients with neurotic excoriation treated in a dermatology clinic, 68% improved within 1 month with sertraline, mean dosage 95 mg/d.9 Similarly, open-label fluvoxamine, mean dosage 112.5 mg/d, was effective in reducing skin excoriation in 7 of 14 patients treated for 12 weeks in a psychiatric setting.21
Double-blind studies. In a double-blind study using fluvoxamine with supportive psychotherapy in patients with psychocutaneous disorders, all five patients with acne excoriee improved after 4 weeks of medication treatment (none was randomized to placebo).22
In a 10-week, double-blind study, 10 patients were assigned to fluoxetine, mean dosage 53.0 ± 16.4 mg/d, and 11 to placebo. A patient self-report visual analog scale showed that fluoxetine was significantly more effective than placebo in reducing picking behavior. Two other measures did not show significant improvement, however, perhaps because of the small sample size.23
In a third study, 8 of 15 patients responded to open-label fluoxetine, 20 to 60 mg/d after 6 weeks. The responders were then randomized to 6 additional weeks of fluoxetine or placebo. All four patients assigned to continue active medication maintained their improvement. Symptoms returned to baseline by week 12 in the four assigned to placebo.24
EVIDENCE FOR HABIT REVERSAL THERAPY
No controlled trials have examined psychosocial treatments for skin picking, but several psychotherapeutic interventions appear promising. Habit reversal has shown promise in three case reports totaling seven patients and appears to reduce picking behavior within a few weeks.25-27