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- Presentation
Pharmacologic and Behavioral Treatments for Body-Focused Repetitive Behaviors in Psychocutaneous Disease
Description
The presentation reviews body-focused repetitive behaviors, especially skin picking disorder and trichotillomania, as under-recognized psychocutaneous diseases that cause physical damage, distress, and functional impairment. These conditions are often stigmatized and patients frequently first seek help from dermatologists, making education and support essential. Behavioral therapy is presented as first-line treatment, with habit reversal training and acceptance-enhanced CBT as key approaches. Pharmacologic options are discussed as adjuncts or alternatives when behavioral treatment is unavailable or insufficient. For skin picking disorder, SSRIs such as fluoxetine, fluvoxamine, escitalopram, and sertraline are commonly used, while emerging evidence supports glutamatergic agents like N-acetylcysteine and memantine; smaller studies or case reports also mention topiramate, lamotrigine, lithium, naltrexone, and mirtazapine. For trichotillomania, antidepressant evidence is more limited, but memantine and N-acetylcysteine may help, especially in adults; antipsychotics and benzodiazepines are used in practice but lack strong supporting evidence. The talk also warns that stimulant medications, including prescribed or online-obtained neurostimulants, can trigger trichotillomania or other psychocutaneous problems, and symptoms may resolve after discontinuation. Additional supportive strategies include digital tools, apps, wearable reminders, internet-delivered therapy, nutritional counseling, vitamin D supplementation, and transcranial magnetic stimulation for refractory cases. Overall, the talk emphasizes no FDA-approved pharmacotherapy, the promise of glutamatergic agents and digital health, and the importance of reducing stigma, improving access, and providing holistic care.
View moreConclusions
- Body-focused repetitive behaviors are serious, chronic, and underrecognized conditions that should not be dismissed as mere bad habits.
- Dermatologists are often the first clinicians to see these patients, so education, stigma reduction, and supportive care are essential.
- Behavioral therapy is the first-line treatment, with habit reversal training and acceptance-enhanced CBT offering the strongest practical foundation.
- There is still no FDA-approved pharmacotherapy for skin picking disorder or trichotillomania, so medication use remains off-label and evidence-driven.
- For skin picking disorder, SSRIs can help, but glutamatergic agents such as N-acetylcysteine and memantine appear especially promising.
- For trichotillomania, medication evidence is more limited overall, but memantine and N-acetylcysteine may be among the better-supported options.
- Real-world prescribing for trichotillomania often does not match expert recommendations, indicating a need for clearer standards and better clinician education.
- Prescription stimulants can trigger psychocutaneous adverse effects, including trichotillomania, and stopping the offending drug can resolve symptoms.
- Digital and internet-delivered therapies are effective and can expand access to evidence-based treatment.
- Transcranial magnetic stimulation is an emerging option for refractory cases, though the optimal protocols and durability of benefit remain uncertain.
- Lifestyle factors such as diet, vitamin D status, and broader health behaviors may influence symptoms and deserve clinical attention.
- Long-term recovery is likely to depend on a combination of treatment, motivation, empowerment, social support, and ongoing patient education.
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