What is dermatillomania?
Dermatillomania, also known as Excoriation Disorder or skin-picking disorder, is a mental health condition marked by an obsessive desire to pick at one’s skin. This behavior can cause physical harm, such as open wounds, scarring, and infections. Individuals with dermatillomania frequently focus on perceived skin imperfections, such as bumps, scabs, or irregularities, which they may pick at repeatedly. In many cases, this behavior is triggered by stress, anxiety, or boredom, and it provides a brief sense of relief or satisfaction, but it is frequently followed by guilt or shame.
Dermatillomania, classified in the DSM-5 as Obsessive-Compulsive and Related Disorders, is similar to trichotillomania (hair-pulling disorder) and obsessive-compulsive disorder (OCD). Individuals suffering from dermatillomania may spend an inordinate amount of time picking at their skin, resulting in severe skin damage, social embarrassment, and avoidance of certain activities. Dermatillomania is estimated to affect 1% to 5% of the population and usually starts in adolescence.
Though many people with dermatillomania are aware of the harm they are doing to their skin, they often struggle to stop the behavior. This disorder can cause significant physical and psychological distress, and its chronic nature necessitates early detection and treatment to prevent long-term skin damage and improve quality of life.
Traditional Treatments for Dermatillomania
Cognitive Behavioral Therapy (CBT): The Gold Standard
Dermatillomania has long been treated primarily with cognitive-behavioral therapy (CBT). CBT focuses on altering the negative thought patterns and behaviors that lead to compulsive picking. This therapeutic approach targets both the cognitive (thought) and behavioral (action) aspects of the disorder, assisting patients in developing healthier coping mechanisms and managing their urges.
CBT for dermatillomania frequently includes habit reversal training (HRT), which is one of the most effective strategies for managing body-focused repetitive behaviors (BFRBs) such as skin picking. HRT typically consists of the following components:
- Awareness training: Patients learn to identify the triggers, sensations, and emotions that lead to a picking episode. This awareness helps them become more aware of their actions, allowing for intervention before they escalate.
- Competing response: Once patients understand their triggers, they are taught to engage in a less harmful behavior whenever they feel compelled to pick. Rather than picking, they may squeeze a stress ball, clench their fists, or apply a soothing cream to their skin.
- Stimulus control: This aspect of CBT focuses on changing the environment to reduce the opportunity for skin-picking. Patients may be advised to cover mirrors, wear gloves, or use physical barriers such as bandages to prevent access to their skin. Furthermore, eliminating triggers, such as keeping the skin moisturized or avoiding stressful situations, may be part of the treatment strategy.
- Cognitive restructuring: CBT also addresses the thoughts and beliefs that drive the picking behavior. Patients are encouraged to question negative self-perceptions and distorted beliefs about their skin. For example, they may be encouraged to replace perfectionistic thoughts with more realistic and compassionate ones, thereby alleviating the emotional distress that frequently leads to picking.
Acceptance & Commitment Therapy (ACT)
Acceptance and Commitment Therapy (ACT) is another type of psychotherapy that has demonstrated promise in treating dermatillomania. Unlike CBT, which focuses on changing thoughts and behaviors, ACT emphasizes acceptance of unwanted thoughts and feelings while committing to actions that are consistent with one’s values. ACT in dermatillomania treatment helps people accept their urges to pick without acting on them, by using mindfulness techniques to observe these urges without judgment.
ACT can be especially useful for patients who are dealing with the emotional consequences of their picking behavior, such as guilt, shame, or frustration. ACT encourages patients to accept their emotions without being controlled by them, resulting in a healthier relationship with their skin and a greater sense of self-compassion.
Medications: Pharmaceutical Interventions
While the FDA has not approved any medications specifically for the treatment of dermatillomania, certain pharmacological interventions are used off-label to help manage symptoms, especially when the disorder co-occurs with anxiety, depression, or OCD.
Selective serotonin reuptake inhibitors (SSRIs)
Selective Serotonin Reuptake Inhibitors (SSRIs), such as fluoxetine (Prozac) and sertraline (Zoloft), are frequently prescribed to patients with dermatillomania who also suffer from significant anxiety or depression. SSRIs increase the levels of serotonin, a neurotransmitter involved in mood regulation and impulse control. SSRIs can help some people reduce their compulsive picking behavior by improving emotional regulation and lowering overall anxiety.
While SSRIs are not a cure for dermatillomania, they can be an effective addition to psychotherapy, particularly for people whose picking behavior is motivated by emotional distress. However, SSRIs have potential side effects, such as nausea, fatigue, and sexual dysfunction, which should be discussed with a doctor.
N-acetylcysteine (NAC)
One of the more promising pharmacological interventions for dermatillomania is an over-the-counter supplement called **N-acetylcysteine (NAC). NAC is an antioxidant that has been shown to regulate glutamate levels, a neurotransmitter involved in compulsive behaviors. Several studies have found that NAC can reduce the frequency and intensity of picking episodes in people who have body-focused repetitive behaviors (BFRBs), such as dermatillomania.
NAC is generally considered safe and well-tolerated, though it can cause gastrointestinal discomfort in some people. The typical dosage used in studies ranges from 1200 mg to 2400 mg per day, and it is frequently combined with psychotherapy for best results.
Group Therapy and Support Groups
Many people with dermatillomania find that the social isolation and shame associated with the disorder exacerbate their symptoms. Group therapy and support groups offer patients a valuable opportunity to connect with others who have similar experiences, reducing feelings of isolation and stigma.
Individuals who participate in group therapy can learn from the experiences of others, gain practical tips for managing urges, and receive validation for their struggles. Many people find comfort in knowing that they are not alone in their experiences, and group therapy provides a supportive environment that promotes personal growth and accountability.
Support groups, whether in person or online, provide ongoing encouragement and a sense of belonging. In the case of dermatillomania, these groups can be an important part of a comprehensive treatment plan, especially for those who do not have access to one-on-one therapy.
Dermatological Interventions.
In addition to psychological treatments, many people suffering from dermatillomania benefit from dermatological care to address the physical consequences of their picking behavior. Dermatologists can treat wounds, prescribe medications to relieve itching or inflammation, and recommend skincare routines to help prevent future damage.
Individuals with scarring may benefit from dermatological interventions such as laser treatments or chemical peels to improve the appearance of their skin. These treatments can help to boost self-esteem and decrease the desire to pick at flaws.
Innovations in Dermatillomania Treatment
Digital Therapeutics and Mobile Health Apps.
One of the most exciting advances in dermatillomania treatment is the rise of digital therapeutics and mobile health apps. These tools provide individuals with real-time support, behavioral tracking, and cognitive-behavioral exercises that are accessible at any time and from any location. Digital platforms, such as NOCD and Keystone, are specifically designed to assist people with body-focused repetitive behaviors (BFRBs), including dermatillomania.
These apps use Cognitive-Behavioral Therapy (CBT) techniques, such as habit reversal training and exposure therapy, to assist individuals in tracking their urges and managing their picking behaviors. Daily check-ins, progress tracking, mindfulness exercises, and educational resources for managing BFRBs are all possible features. Furthermore, some apps provide telehealth services, which connect users with licensed therapists who specialize in treating dermatillomania.
By making evidence-based treatments more accessible, mobile apps enable people to take control of their condition and actively participate in their recovery. For those who do not have access to in-person therapy, digital therapeutics are a convenient and effective alternative.
Transcranial Magnetic Stimulation(TMS)
Transcranial Magnetic Stimulation (TMS) is a non-invasive brain stimulation technique that has sparked interest as a treatment for a variety of mental health conditions, including depression and OCD. In recent years, researchers have begun to investigate its application in body-focused repetitive behaviors such as dermatillomania.
TMS uses magnetic fields to stimulate specific brain areas involved in mood regulation and impulse control, such as the prefrontal cortex. TMS may reduce the compulsive urges associated with skin-picking by modulating brain activity in these regions, while also improving overall emotional regulation.
Early research has yielded promising results, with some people experiencing a decrease in picking behaviors following a series of TMS sessions. While TMS is still in the experimental stages for dermatillomania, its non-invasive nature and low side effects make it a promising treatment option for those who have not responded to traditional therapies.
Virtual reality exposure therapy (VRET)
Virtual Reality Exposure Therapy (VRET) is a novel approach that combines virtual reality technology with traditional exposure therapy techniques, providing an immersive and controlled environment for people to confront and manage their skin-picking triggers. In VRET, patients are shown virtual simulations of situations that trigger their picking urges, such as the sight of skin imperfections or the sensation of stress and anxiety. Individuals can gradually develop resilience to these triggers by practicing behavioral interventions in the safe confines of virtual reality.
VRET has been shown to be effective in treating a variety of anxiety and obsessive-compulsive disorders, and its use in body-focused repetitive behaviors (BFRBs), such as dermatillomania, is gaining traction. Patients who are repeatedly exposed to the discomfort that drives their picking behavior can learn to tolerate it without engaging in the destructive habit. VRET can be especially helpful for people who struggle to address their triggers in real-life situations, as it provides a controlled environment in which they can practice healthier responses.
Psychedelic-Assisted Psychotherapy.
Psychedelic-assisted psychotherapy is a growing field of study that investigates the use of psychedelics, such as psilocybin and MDMA, to treat mental health disorders, including compulsive behaviors like dermatillomania. While still in the experimental stage, preliminary research suggests that psychedelic substances, when combined with guided psychotherapy, may help people gain deep emotional insights, reduce anxiety, and break repetitive behavioral cycles.
Psilocybin, the active compound in magic mushrooms, has been studied for its ability to increase neuroplasticity, or the brain’s ability to form new neural connections. This increased neuroplasticity may aid in behavioral change by allowing individuals to reconsider their compulsive tendencies and adopt healthier coping mechanisms. By allowing patients to engage with their emotions in a profound and often transformative way, psychedelic-assisted therapy may provide a novel approach to reducing the compulsive urges associated with dermatillomania.
While psychedelic therapies are still not widely available, ongoing clinical trials show promise in treating conditions such as depression, PTSD, and OCD. Dermatillomania shares some underlying mechanisms with these disorders, particularly obsessive-compulsive behaviors, making psychedelic-assisted therapy a promising treatment option for the future.
Deep Brain Stimulation (DBS).
Deep Brain Stimulation (DBS) may provide new relief options for people suffering from severe, treatment-resistant dermatillomania. DBS involves surgically implanting electrodes into specific areas of the brain that are thought to be involved in the regulation of compulsive behaviors, such as the nucleus accumbens or the prefrontal cortex. These electrodes are linked to a pulse generator, which sends electrical impulses to control neural activity in specific brain regions.
Although DBS is more commonly used to treat movement disorders such as Parkinson’s disease, it has shown promise in treating treatment-resistant cases of OCD and depression, both of which have compulsive elements similar to dermatillomania. Early case studies indicate that DBS may help regulate the brain’s reward system, lowering the desire to engage in skin-picking and other compulsive behaviors.
While DBS is a highly invasive procedure that is typically used as a last resort, it represents a cutting-edge option for people who have exhausted all other treatment options. Further research will determine its long-term efficacy and safety in treating compulsive disorders such as dermatillomania.
N-acetylcysteine (NAC) and Glutamate Modulation
Based on its traditional use, N-acetylcysteine (NAC) remains one of the most promising pharmacological treatments for dermatillomania. NAC, an antioxidant that regulates glutamate, a neurotransmitter linked to compulsive behaviors, is thought to help normalize brain chemistry that drives repetitive skin-picking.
Recent research has expanded on previous findings, indicating that NAC may be especially effective when combined with cognitive-behavioral therapy (CBT). As researchers investigate new glutamate-modulating compounds, NAC remains an important component of emerging pharmacological treatments for body-focused repetitive behaviors (BFRBs) such as dermatillomania.
Ongoing research is also looking into other compounds that target glutamate pathways, which could lead to new, more targeted treatments for dermatillomania. These advancements may improve the efficacy of pharmacotherapy for people who haven’t responded to SSRIs or other conventional treatments.
Holistic and Alternative Treatments for Dermatillomania
Mindfulness and Meditation Practices
Mindfulness and meditation are increasingly being recognized as effective tools for treating a variety of mental health conditions, including dermatillomania. These practices encourage people to focus on the present moment and observe their thoughts and urges without judgment, rather than reacting impulsively to them. Individuals suffering from dermatillomania can gain greater awareness of their picking behaviors and begin to intervene before they escalate by practicing mindfulness.
Mindfulness-Based Cognitive Therapy (MBCT), which combines traditional cognitive-behavioral techniques with mindfulness exercises, has shown especially promising results for people who engage in body-focused repetitive behaviors. MBCT teaches patients how to recognize and tolerate discomfort, which helps them resist the urge to pick. Regular meditation practice can also help to reduce overall stress and anxiety, which are common causes of dermatillomania.
Yoga and Physical Activity
Yoga and physical exercise can also be effective tools for treating dermatillomania. Regular physical activity has been shown to reduce anxiety, improve mood, and aid in overall emotional regulation. Yoga, in particular, combines physical movement with breath control and mindfulness, assisting individuals in developing a deeper connection with their bodies while also reducing the stress that frequently leads to skin-picking behavior.
Yoga is especially beneficial for people who suffer from dermatillomania because it promotes body awareness and self-compassion. Patients who practice yoga may learn to appreciate their bodies and treat themselves with kindness, reducing the desire to engage in harmful behaviors such as picking.
Nutritional Interventions
New research suggests that nutrition is important for mental health and may influence compulsive behaviors. Diets high in omega-3 fatty acids, antioxidants, and B vitamins have been associated with improved brain function and emotional regulation. Addressing nutritional deficiencies in people with dermatillomania may improve overall mental health and reduce the frequency of picking episodes.
Some people with dermatillomania may benefit from working with a nutritionist or dietitian to create a balanced diet that promotes mental health. Furthermore, avoiding dietary triggers like caffeine or sugar, which can heighten anxiety and exacerbate compulsive behaviors, may be beneficial.
Acupuncture and TCM
Acupuncture, a practice based on Traditional Chinese Medicine (TCM), is being studied for its ability to treat dermatillomania symptoms. Acupuncture involves inserting thin needles into specific points on the body to balance energy flow, or Qi. While the exact mechanisms by which acupuncture affects compulsive behaviors are still being investigated, some research suggests that it may help regulate neurotransmitter levels and reduce stress, both of which are important triggers for skin-picking behavior.
In addition to acupuncture, TCM approaches such as herbal remedies and Qi Gong (a movement-based meditation practice) are being investigated for mental health benefits. Individuals with dermatillomania may benefit from these holistic treatments in terms of stress management, anxiety reduction, and emotional balance.
