Non-Pharmacological Treatments for Skin Picking Disorder

In the 2024 study by Loftus et al, “A Systematic Review of Non-Pharmacological Treatment Options for Skin Picking Disorder (SPD),” the authors found cognitive behavioral therapy (CBT), habit replacement therapy (HRT), acceptance and commitment therapy, enhanced group behavior therapy (AE-GBT), online self-help modules, and expressive writing were non-pharmacological treatment interventions that reduced skin picking symptoms and severity in patients with SPD.¹

Background 

SPD is a compulsive, body-focused repetitive disorder that involves chronic urge to scratch and pick at the skin, which leads to lesions, crusts, and changes in pigmentation at the healed picking site.¹ The disorder impacts patient quality of life by interfering with work or school and by creating feelings of shame.¹ There are currently no FDA-approved pharmacological interventions for SPD but given the high comorbidity of SPD with other neuropsychiatric conditions such as major depressive disorder, generalized anxiety disorder, and obsessive-compulsive disorder, non-pharmacological interventions are a flexible and promising treatment option to improve SPD symptoms.1 Recent studies have explored the efficacy and impact of non-pharmacological interventions on SPD, which are reviewed here, and demonstrate reduction in SPD symptoms and severity.¹

Objective 

To evaluate the efficacy and feasibility of different non-pharmacological treatment interventions on SPD symptoms and severity.¹

Methods

PubMed, EBSCO, and Scopus databases were reviewed using keywords such as “skin picking,” “excoriation,” “psychiatry,” and “psychodermatology.”¹ Articles published between 2017 and 2023 that assessed a non-pharmacological treatment for SPD were selected and reviewed independently by at least two blinded authors.¹ Every author of this study then read all potential papers to ensure the papers met the inclusion criteria.1 Eleven studies were selected based on inclusion criteria to be included in the systematic review.¹

Outcomes and Measures

The most common primary outcome measure was self-reported decrease in skin picking symptoms and severity based on the Skin Picking Scale-Revised (SPS-R).¹ This scale measures frequency of picking urges, intensity of urges, time devoted to skin picking, control over picking urges, distress from skin picking, functional impairment due to skin picking, avoidance due to skin picking, and skin damage; scores can range from 0 to 32.^2,3 Another common primary outcome measure was the Skin Picking Impact Scale (SPIS), which measures psychosocial impact of skin picking behaviors on the patient’s daily life (total score range from 0 to 50).⁴ The final common primary outcome was Clinical Global Impression Scale (CGI), which is a self-report measure of symptom severity on a scale of 1 to 7 and treatment-induced symptom change on a scale of 1 to 7.5 For all outcomes, lower scores were associated with decreased symptoms and severity.¹

Results

Several non-pharmacological intervention studies were reviewed and demonstrated a significant reduction in skin picking symptoms and severity.¹ Both individual and group CBT decreased skin picking symptoms and lesion severity based on a CGI pre-treatment mean score of 4.7 that decreased to 2.89 post-treatment.¹ HRT similarly demonstrated a significant reduction in skin picking behaviors up until 3-months post-intervention.¹ Group HRT-ACT therapy led to significant symptom improvement and reduction in SPS-R scores for a year after treatment.1 Internet-delivered behavior therapy included online, self-paced modules and access to an assigned therapist, and demonstrated a statistically significant symptom reduction based on SPS-R scores (17.22 pre-treatment, 11.00 post-treatment, P < 0.001).¹ Other similar internet-based treatments demonstrated significant reduction in symptoms and symptom severity.1 Expressive writing therapy, which involves personal writing to confront difficult feelings, decreased patients' skin picking urges (P < 0.001).¹ A reduction was seen in both control (writing about a picture instead of their own emotions) and emotional writing groups (P = 0.003), likely because writing interferes with skin picking, thus reducing symptoms and severity.¹

KeyTakeaway

This study demonstrates that there are several potentially effective non-pharmacological interventions available for patients with SPD.¹ Many options are internet-based, which increases access for patients without health insurance or the ability to see a healthcare provider in person.¹

Limitations

The study is limited by its use of studies with small sample sizes and short follow-up periods.¹ In addition, many of the studies involved a high percentage of female patients, so studies in male patients need to be done in the future.¹ 

Conclusion and Future Directions

In a systematic review of 11 non-pharmacological interventions for SPD, several options including CBT, HRT, and internet-based modalities were effective at decreasing skin picking urges, symptoms, and symptom severity.¹ This provides many options for patients to choose an intervention that best fits their lifestyle and preferences while also increasing access to treatment.¹

1. Loftus H, Cassidy C, Mun L, Jafferany M. A Systematic Review of Non-Pharmacological Treatment Options for Skin Picking Disorder (SPD). Clin Exp Dermatol. 2024 Aug 31:llae366. doi: 10.1093/ced/llae366. Epub ahead of print.

2. Snorrason I, Keuthen NJ, Lee H, Beard C, Björgvinsson T. Skin Picking Scale-Revised: Diagnostic accuracy and optimal cut-off scores in university and psychiatric settings. J Obsessive-Compuls Relat Disord. 2022;34:100743, ISSN 2211-3649. doi: 10.1016/j.jocrd.2022.100743.

3. Rautio D, Andrén P, Bjureberg L, Silverberg-Mörse M, Mataix-Cols D, Fernández de la Cruz L. Body-Focused Repetitive Behavior Disorders in Children and Adolescents: Clinical Characteristics and Treatment Outcomes in a Naturalistic Setting. Behav Ther. 2024;55(2):376-390. doi: 10.1016/j.beth.2023.07.010. Epub 2023 Jul 27.

4. Keuthen NJ, Deckersbach T, Wilhelm S, Engelhard I, Forker A, O’Sullivan RL, Jenike MA, Baer L. The Skin Picking Impact Scale (SPIS): scale development and psychometric analyses. Psychosomatics. 2001;42(5):397-403. doi: 10.1176/appi.psy.42.5.397.

5. Busner J, Targum SD. The clinical global impressions scale: applying a research tool in clinical practice. Psychiatry (Edgmont). 2007;4(7):28-37.

Dr. Lio reports research grants/funding from AbbVie, AOBiome; is on the speaker bureau for AbbVie, Arcutis, Eli Lilly, Galderma, Hyphens Pharma, Incyte, La Roche-Posay/L’Oreal, MyOR Diagnostics, ParentMD, Pfizer, Pierre-Fabre Dermatologie, Regeneron/Sanofi Genzyme, Verrica; reports consulting/advisory boards for Alphyn, AbbVie, Almirall, Amyris, Arcutis, ASLAN, Boston Skin Science, Codex Labs, Concerto Biosci, Dermavant, Eli Lilly, Galderma, Janssen, LEO Pharma, L’Oreal, Merck, Micreos, MyOR Diagnostics, Regeneron/Sanofi Genzyme, Skinfix, Theraplex, UCB, Unilever, Verrica Yobee Care; stock options with Codex, Concerto Biosciences and Yobee Care. In addition, Dr. Lio has a patent pending for a Theraplex product with royalties paid and is a Board member and Scientific Advisory Committee Member of the National Eczema Association.