Treatment Choice and Sequencing of Treatment
If untreated, Excoriation Disorder is a chronic illness that often results in substantial psychosocial dysfunction and may lead to medical complications. Control of the skin picking is therefore critical for maintaining long-term health and quality of life. Based on our clinical experience and research findings, we suggest the following management strategies:
- • Begin with a thorough psychiatric assessment to establish an accurate diagnosis of Excoriation Disorder and to assess for co-occurring psychiatric disorders;
- • Thorough evaluation from a dermatologist with knowledge about Excoriation Disorder to assess for underlying dermatological conditions that may cause or worsen skin picking;
- • Maintain collaboration between internal medicine and psychiatric management teams for monitoring and rapid intervention if serious medical sequelae result from the picking;
- • Provide education about the disorder to the patient, including possible etiologies, and treatment risks and benefits; and
- • Provide CBT (including habit reversal or acceptance-enhanced behavior therapy) as first-line treatment for Excoriation Disorder.
Given the relative paucity of information regarding a treatment of choice for Excoriation Disorder, medications (serotonin reuptake inhibitors, n-acetylcysteine, or naltrexone) or techniques used in CBT may be used as monotherapies or in conjunction with one another. Choice of medication should be informed by the existence of co-occurring disorders and patient history. SSRIs may be the first choice if the patient has co-occurring depression or anxiety whereas NAC may be the first choice for someone with no co-occurring disorders. Naltrexone may be the choice for someone with a personal or family history of addictions.
Consultation with Other Disciplines
Dermatologic consultation should occur where significant inflammation of the skin occurs at the site of picking, or where there is diagnostic uncertainty as to the cause of the skin picking. Consultation with dermatological colleagues can also be helpful where an individual endorses sensations on the skin that prompt picking episodes.