Skin picking disorder is only a recent new entity in the psychiatric classification system of the Diagnostic and Statistical Manual of Mental Disorder (DSM) 5th edition (1). It is described as recurrent picking of skin leading to skin lesions, repeated attempts to decrease or stop skin picking, and it is associated with significant distress or functional impairment. It is listed in the section of obsessive-compulsive and related disorders and has significant overlap with other classified disorders such as trichotillomania (hair-pulling disorder).
Historically, there has been limited research in this specific disorder and treatment efficacy has often been poor in severe cases. Ultimately, only a small portion of patients seek help, noted to be due to reasons such as embarrassment, stigma, belief that it is a “bad habit”, or that it is untreatable (2). In addition, many of the patients initially present to a general practitioner/family physician or a dermatologist before ever being consulted to a psychiatrist (2). A recent systematic review of treatment options found that current management options included both a behavioural approach (habit reversal or cognitive-behavioural therapy, specifically acceptance-enhanced behaviour) and medication management (selective serotonin reuptake inhibitor [SSRI] or N-acetyl cysteine [NAC] (3). The severity of skin-picking disorder can range from mild-severe; and not all cases need medication treatment.
Despite a less than comprehensible approach to treatment or presentation of skin picking disorder, it remains a relatively common disorder, with prevalence estimating to range between 1.4–5.4% (4). It may present itself at any age, but most commonly coincides with the onset of puberty during adolescence (5). It may be triggered by other dermatological conditions such as acne or eczema, but is often multifactorial in terms of triggers and can include stress, anger, anxiety, boredom among others (6). Most common areas observed for skin picking is the face, followed by hands, fingers, arms and legs.
In more severe cases, if patients are not help-seeking, they likely will be unable to stop picking despite repeated efforts. This may lead to furthering of shame, isolation and ultimately even development of an anxiety disorder or major depressive disorder. The functional impact on these patients should not be underestimated as they may spend an impressive amount of time hiding this behaviour or performing the repetitive behaviour of picking. This can have subsequent psychosocial, personal and professional consequences. Medically, this can also have significant morbidity and mortality, including infections, scaring, and even serious physical disfigurement (7). Psychiatrically, it is also associated with other comorbid conditions, such as mood and anxiety disorders.
Recent reviews studied the clinical efficacy but also the tolerability of a number of pharmacological agents for treating or reducing skin-picking disorders. This has included Serotonin Selective Reuptake Inhibitors (SSRI’s), lamotrigine, glutamateric agents such as NAC, opioid antagonists such as naltrexone (3, 8) and augmentation strategies. SSRI’s have been identified as the foundation of pharmacotherapy for skin-picking disorder, supported by a randomized controlled trial that suggested NAC should also be considered as a possible option (9). There was no systematic studies investigating the efficacy and tolerability of augmentation agents, but case studies supported atypical and typical antipsychotic agents in reducing skin picking. Augmentation agents included Olanzapine, Haloperidol and Aripiprazole as potential adjuncts (3).