Medication Summary
Excoriation (skin-picking) disorder is treated with a variety of psychotropic medications. Attempts to treat it with a variety of psychotropic medication classes include antipsychotic agents, antianxiety agents, antidepressant agents, topical cortisone agents, and antiepileptic agents.
A two-center randomized, double-blind trial with 66 adults with excoriation disorder assessed N-acetylcysteine against placebo for 12 weeks, with 47% of N-acetylcysteine group reporting improvement compared to 19% receiving placebo. N-acetylcysteine, an amino acid that appears to restore extracellular glutamate concentration in the nucleus accumbens, has been shown to significantly reduce skin-picking symptoms, and it is well tolerated. [17]
In 2005, Krishnan and Koo reported that pathology of the opioid neurotransmitter system and the central nervous system (CNS) is the neurologic basis for neurotic excoriations, which suggested that psychiatric medications that can normalize CNS pathology can abate neurotic excoriations. [18] In line with this, glutamate, an excitatory CNS neurotransmitter, has been reported as being potentially helpful for treating picking disorders when other conventional therapies fail. [19] Adding venlafaxine to a treatment regimen of aripiprazole abated a case of treatment-resistant excoriation disorder. [30]
Antidepressants, TCAs
Class Summary
Antipsychotic agents decrease the urge to scratch and relieve anxiety.
Doxepin
For its sedating and antipsychotic effects, doxepin (10-25 mg orally at bedtime) is a useful medication in treating neurotic excoriations. Doxepin inhibits histamine and acetylcholine activity and has proved useful in the treatment of various forms of depression associated with chronic and neuropathic pain.
Anxiolytics, Nonbenzodiazepine
Class Summary
Antianxiety agents are used to reduce the level of anxiety in patients who experience pruritus.
Buspirone (BuSpar)
The mechanism of action of buspirone is unknown. It has high affinity for serotonin 5-HT1A and 5-HT2 receptors and moderate affinity for dopamine D2 receptors. It does not affect benzodiazepine-GABA receptors.
Antidepressant, SSRIs
Class Summary
Antidepressants may be used to improve mood and to restore normal sleep patterns in patients who experience pruritus.
Fluoxetine (Prozac)
Fluoxetine selectively inhibits presynaptic serotonin reuptake, with minimal or no effect on reuptake of norepinephrine or dopamine.
Paroxetine (Paxil, Paxil CR, Pexeva)
Paroxetine (Paxil, Paxil CR, Pexeva)
Paroxetine is a potent selective inhibitor of neuronal serotonin reuptake. It has a weak effect on norepinephrine and dopamine neuronal reuptake. For maintenance therapy, make dosage adjustments to maintain the patient on the lowest effective dosage, and reassess the patient periodically to determine the need for continued treatment.
Fluvoxamine (Luvox CR)
Fluvoxamine is a potent selective inhibitor of neuronal serotonin reuptake. It does not significantly bind to alpha-adrenergic, histamine, or cholinergic receptors and, thus, has fewer adverse effects than tricyclic antidepressants (TCAs).
Citalopram (Celexa)
Citalopram enhances serotonin activity by selective reuptake inhibition at the neuronal membrane. Although citalopram is not FDA approved for use in children, various clinical trials have shown efficacy in the treatment of moderate-to-severe major depressive disorder (MDD) in children and adolescents.
Escitalopram (Lexapro)
Escitalopram is the S-enantiomer of citalopram. It may have a faster onset of depression relief (1-2 wk) in comparison with other antidepressants.
Corticosteroids, Topical
Class Summary
Topical corticosteroids have anti-inflammatory properties and cause profound and varied metabolic effects. They modify the body’s immune response to diverse stimuli.
Triamcinolone topical (Kenalog, Triderm, Trianex, Oralone)
Topical triamcinolone treats inflammatory dermatosis that is responsive to steroids. It decreases inflammation by suppressing the migration of polymorphonuclear leukocytes and reversing capillary permeability.
Hydrocortisone topical (Westcort, U-Cort, Ala-Cort, Caldecort)
Topical hydrocortisone is an adrenocorticosteroid derivative that is suitable for application to skin or external mucous membranes and is used to treat inflammatory dermatoses that are responsive to steroids. It decreases inflammation by suppressing the migration of polymorphonuclear leukocytes (PMNs) and reversing capillary permeability.
Betamethasone topical (Diprolene, Luxiq)
Topical betamethasone is used to treat inflammatory dermatoses responsive to steroids. It decreases inflammation by suppressing migration of PMNs and reversing capillary permeability. It affects production of lymphokines and has an inhibitory effect on Langerhans cells.
Clobetasol (Temovate, Temovate E, Olux, Olux-E)
Clobetasol is a class I superpotent topical steroid. It suppresses mitosis and increases synthesis of proteins that decrease inflammation and cause vasoconstriction.
Anticonvulsants, Other
Class Summary
Antiepileptic agents decrease impulsiveness.
Topiramate (Topamax, Topiragen)
Topiramate is a sulfamate-substituted monosaccharide with a broad spectrum of antiepileptic activity that may have state-dependent sodium channel blocking action. It potentiates the inhibitory activity of gamma-aminobutyric acid (GABA) and may block glutamate activity.
Monitoring of plasma concentrations is not necessary for optimizing therapy. On occasion, addition of topiramate to phenytoin may necessitate adjustment of the phenytoin dosage to achieve optimal clinical outcome.
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A picker's nodules with no crust and a scarred appearance.
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A picker's nodule with crusted lesions.
