An overview of nonpharmacological treatments for skin picking disorder

A review of nonpharmacological treatments for skin picking disorder from 2017 to 2023 has identified effective interventions and they include various forms of group and exposure therapies. Cognitive behavioural therapy (CBT), acceptance and commitment therapy (ACT), ACT-enhanced group behavioural therapy (AE-GBT), habit reversal therapy, online self-help modules and expressive writing may produce the optimal results in treating skin picking disorder (SPD). SPD is a well-described neuropsychiatric disorder. However, there are no clear protocols for treating patients. The review, published in Clinical and Experimental Dermatology, summarizes and compares recent publications and provides an up-to-date guide of current nonpharmacological treatments for SPD. The researchers conducted a literature review of all nonpharmacological SPD treatment studies published between 2017 and 2023 using PubMed, CINAHL Plus with Full Text (EBSCO) and Scopus. This study evaluated the prevalence of skin picking disorder, and its associations, in an epidemiologically representative community sample of 10,169 people. The researchers found that skin picking disorder had a point prevalence of 2.1%, and lifetime prevalence of ~3.1%. However, it has received very little research study in terms of neurobiology and treatments. The study showed individuals with SPD reported extremely high rates of mental health comorbidities. Most of them reported comorbid generalized anxiety disorder and/or depression. Around a quarter reported having panic disorder, PTSD, OCD or ADHD.Dr. Rosanne Paul, who is an assistant professor of dermatology at the School of Medicine at Case Western Reserve University in Ohio, said the best treatments depend upon why a patient is picking: Are they itching? Do they pick at any scab or bump on their body just because it is out of habit? Do they have a delusion that there is something on their skin that they need to remove? There are many therapies to target itching. There is typically a stepwise approach involving topical anti-itch creams or lotions, topical corticosteroids and calcineurin inhibitors. “If the patient is not improving, systemic therapies may be warranted. In the cases where they have a psychiatric impulse or obsessive compulsive component it is best managed with behaviour therapy with a psychologist, psychiatrist or neuropsychiatric specialist," Dr. Paul told the Medical Post.Meryl Da Costa, a counsellor and chief community officer for SkinPick.com, said the most effective treatments for SPD or excoriation disorder are evidence-based behavioural interventions that help individuals understand and gently interrupt the patterns maintaining the behaviour over time. “Habit Reversal Training (HRT) remains one of the most well-established approaches. It supports individuals in building awareness of when and where picking occurs, and in developing alternative responses that are physically incompatible with picking,” Da Costa told the Medical Post. “For many, this provides an important behavioural foundation.”SPD is rarely just a habit in isolation. Da Costa said for many individuals it serves a functional role, such as regulating anxiety, releasing tension, managing boredom or responding to perceived imperfections in the skin. She said treatments to help individuals not only change the behaviour itself, but also understand and respond differently to the internal experiences that drive it. “For example, CBT can support individuals in identifying and shifting unhelpful thought patterns, while ACT and mindfulness-based approaches focus on changing one’s relationship with urges, learning to notice them without immediately acting, and to respond with greater psychological flexibility and self-compassion,” said Da Costa.It may be important to consider the SPD within a collaborative framework. Dermatologists can play an important role in treating underlying skin conditions, such as acne or other dermatological triggers that may contribute to picking. “However, Skin Picking Disorder itself is not a primary dermatological condition. It is a mental health condition with a strong focus on behavioural change. Treating the skin alone does not address the underlying behavioural and emotional mechanisms that maintain the picking cycle. As such, optimal care often involves coordination between dermatological and behavioural health interventions” said Da Costa.Perhaps most importantly, effective treatment is not about “stopping a bad habit.” It is about understanding why the behaviour is occurring in the first place, and supporting individuals in developing safer, more sustainable ways of responding to both internal and external triggers. An often under-recognized, but clinically significant component of treatment is that SPD is frequently done in secrecy. Many individuals go to great lengths to hide the behaviour, sometimes for years. “This secrecy can intensify shame, and shame, in turn, often perpetuates the cycle of picking. When individuals feel ashamed, they are more likely to withdraw, delay help-seeking, and continue engaging in the behaviour as a means of coping," said Da Costa.Supportive communities and group-based interventions, whether in-person or through structured online platforms can play a meaningful role in disrupting this cycle. When individuals recognize they are not alone, and that others share similar experiences, the behaviour becomes easier to talk about and the associated shame often begins to soften. Da Costa said it is often observed that as shame reduces, the intensity and frequency of urges can also decrease not because the behaviour resolves immediately, but because the emotional drivers underlying it are less acute and less isolating. “Ultimately, the most effective treatment is one that is structured, evidence-based, and responsive to the individual addressing both the observable behaviour and the underlying psychological experience,” said Da Costa.A significant unmet needDespite being relatively common (2%-to-3% prevalence), it remains under-recognized and frequently misunderstood, including within healthcare settings. Many individuals go years, sometimes decades without receiving an accurate diagnosis or being offered evidence-based treatment. In some cases the behaviour is attributed solely to dermatological concerns, without recognition of the underlying behavioural and psychological processes.Access to appropriately trained providers is another significant barrier. There are relatively few clinicians with specialized training in body-focused repetitive behaviours (BFRBs), which contributes to a gap between those in need of care and those able to access evidence-based interventions. “In my opinion there is an overwhelming amount of psychiatric patients who need care and likely a deficit of providers to help assist them. There is also a shortage of psychiatrists who may specialize in cutaneous manifestations of psychiatric disease,” said Dr. Paul. An important development in recent years has been the expansion of digital, therapist-supported interventions. These programmes can help address gaps in access by providing structured, evidence-based care to individuals who may not otherwise have access to specialized treatment. “While the core principles of treatment have remained relatively stable, the way in which care is conceptualized, personalized, and delivered has improved in meaningful ways. That said, there is still considerable progress to be made in increasing awareness, improving access to trained providers, and reducing stigma,” said Da Costa.The strongest evidence currently supports behavioural interventions, particularly HRT, often delivered within a broader cognitive behavioural framework. These approaches help individuals become more aware of picking triggers and develop alternative responses. “However, in practice, treatment often needs to go beyond behaviour alone. Skin picking is frequently linked to emotional regulation. People may engage in it to manage anxiety, tension or distress. So, effective interventions tend to include strategies that address underlying emotional processes,” said Marta Isibor, an assistant psychologist in Addictions in Edinburgh.Classic cognitive-behavioural therapies despite effectiveness in-treatment are associated with a high relapse rate post-treatment. Therefore, accepting the behaviour and working to minimise its role is often more productive long-term. “Pharmacological options, for example SSRIs or N-acetylcysteine, may be helpful for some individuals, but it is crucial to stress the evidence is weaker compared to behavioural therapies, and medication is usually most effective when combined with psychological support. Currently there are no formally recommended medications for body-focused repetitive behaviours,” Isibor told the Medical Post.Reference:Loftus H, Cassidy C, Lisa Mun L, et al. A systematic review of nonpharmacological treatment options for skin picking disorder. Clinical and Experimental Dermatology, Volume 50, Issue 2, February 2025, Pages 299–306, https://doi.org/10.1093/ced/llae366

An overview of nonpharmacological treatments for skin picking disorder

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