Dermatillomania, also known as ‘compulsive skin picking disorder’ or ‘excoriation’, is an anxiety disorder which affects millions of people across the globe. Although conventional medication is not the most common, nor the most effective way to stop skin picking, it can be helpful, especially when combined with Cognitive Behavioural Therapy (CBT). Different people are found to react differently to different types of medication. The most common medications which are prescribed for dermatillomania are anticonvulsant or antiepileptic drugs, dopamine blockers, Inositol, N-Acetyl Cysteine, antidepressants, bipolar medication, Selective Serotonin Reuptake Inhibitors (SSRI’s) and opioid inhibitors.
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A study for trichotillomania found that clomipramine (Anafranil), a medication affecting the brain neurotransmitters serotonin and norepinephrine, was beneficial in treating hair pulling (a body-focussed repeptitive behavior like dermatillomania). Clomipramine has both antidepressant and anti-obsessional properties.
Clomipramine is approved for paediatric OCD and therefore could be used in children with both OCD and trichotillomania. There have been no studies examining the use of clomipramine for dermatillomania sufferers, but given its benefits in hair pulling, this option is being considered. Clomipramine, however, may result in multiple side effects such as dry mouth, constipation, blurred vision, sexual dysfunction and weight gain as well as fine tremor and muscle twitching. Starting at a low dose and slowly titrating the dose over several weeks may reduce the likelihood of side effects.
Selective Serotonin Reuptake Inhibitors (SSRIs) have been examined in treating trichotillomania and skin picking. These include: fluoxetine (Prozac), fluvoxamine (Luvox), sertraline (Zoloft), citalopram (Celexa), escitalopram (Lexapro), and paroxetine (Paxil). These medications are FDA-approved for both depression and OCD. Only fluoxetine (Prozac) has been rigorously studied in dermatillomania sufferers with promising results. Patients may report a range of improvement from sleep, appetite and energy levels to a dramatic reduction in behaviour, though some may report no change at all. In general, the improvement is modest but may only last several months. SSRIs may be helpful in individuals with pulling or picking who also suffer from anxiety, depression or OCD as it may reduce the urge to perform repeated tasks that interfere with daily living. Although well tolerated, they may produce gastrointestinal distress, sedation, constipation, increased urinary frequency, mild anxiety, weight gain, headache and sexual dysfunction. As with other anti-depressants, the potential association between SSRIs and suicidal thoughts and behaviours cannot be ruled out. Other antidepressants have been tried in the treatment of trichotillomania and dermatillomania.
Although the data are sparse, case reports discuss the possible benefits from a range of antidepressants - amitriptyline (Elavil), imipramine (Tofranil), venlafaxine (Effexor), and doxepin (Sinequan). These medications have shown benefit for the treatment of depression, but should not be considered first-line treatment, as there are no extensive studies to prove their efficacy in skin pulling.
Naltrexone (Revia) is an opioid antagonist, approved by the FDA for the treatment of alcohol and opiate dependence. Naltrexone demonstrated potential benefit because it reduces urges to engage in pleasurable behaviours, it may be best for those patients who pull or pick due to strong urges and find the behaviour pleasurable. It should be considered in individuals with trichotillomania or skin picking who suffer from alcoholism, and those with a family history of alcohol use disorders. Although generally well tolerated, naltrexone may cause nausea, insomnia, muscle aches, and headaches. Dopamine-blocking neuroleptics have also been examined in the treatment of trichotillomania and skin picking although they must be prescribed in conjunction with other therapies like Habit Reversal Training. The reasoning for their use is due to a possible link between repetitive behaviours and tic disorders such as Tourette's disorder.
A controlled study of olanzapine (Zyprexa) found that the medication was significantly more effective than a placebo in reducing hair pulling. Neuroleptics may result in a range of side effects: extrapyramidal side effects (Parkinson-like tremor, rigidity), dysphoria, sedation, weight gain, and development of diabetes and high cholesterol. Lithium, a medication approved for the treatment of bipolar disorder, may be beneficial to those who are generally impulsive or have considerable emotional instability as it is effective in controlling mood swings.
Lithium may be an attractive option for patients with trichotillomania or skin picking, who also suffer from bipolar disorder. Lithium can produce significant side effects such as nausea, loss of appetite, mild diarrhoea, dizziness, hand tremors, weight gain, hypothyroidism (low levels of thyroid hormone), increased white blood cell count, acne, and skin rashes. These symptoms may be a sign of having too much lithium in the body, which requires immediate medical attention. With long-term use of lithium, kidney damage may also occur.
Medications that affect the neurotransmitter, glutamate, may be beneficial for sufferers of dermatillomania. Glutamate appears to have a role in the area of the brain involved in compulsive, repetitive behaviours. These medications include lamotrigine (lamictal) (FDA-approved for bipolar disorder), riluzole (Rilutek), and the amino acid N-Acetyl Cysteine. N-Acetyl Cysteine increases the levels of gluthione in the body and has been shown in a study to reduce the skin picking urges when taken in higher dosages. These medications may be beneficial alone or in combination with an SSRI. Controlled studies of these agents are currently lacking. Inositol, a B-vitamin and an isomer of glucose, is broken down by the body into two neurotransmitters which enhances the activity of serotonin in the brain, thus it may also reduce the urge to pull or pick. A controlled study has demonstrated improvement in OCD using inositol, but controlled studies are lacking for hair pulling and skin picking.
Although medication is sometimes used to reduce the sensations and feelings of pleasure that skin picking provides, it must be stressed that no single treatment will work for everyone. In fact a small number of the above medications are only used in extreme situations where skin picking has been triggered by some type of emotional upset. Most doctors prefer to prescribe medication in conjunction with Cognitive Behavioural Therapy where the patient learns to control their urge to pick and works with a therapist to devise steps to alleviate their compulsion.