Newly Developed Skin Picking After Methylphenidate Treatment in Attention Deficit Hyperactivity Disorder: Possible Mechanisms

Characteristics of trichotillomania and excoriation disorder across the lifespan

Trichotillomania (hair-pulling disorder) and excoriation (skin-picking) disorder are body-focused repetitive behaviors, which often first present in adolescence and cause distress and impairment into adulthood. Few studies have examined the clinical characteristics of the co-occurrence of these conditions across the lifespan. We examined cross-sectional survey responses collected from April 2018-February 2020 to evaluate the relationship between trichotillomania, excoriation disorder, and their co-occurrence. Responses from individuals with trichotillomania (n = 50), excoriation disorder (n = 52), and both conditions (n = 50) ages 4-67 years old were compared for co-occurring conditions and current symptoms. Self-report measures of hair-pulling and skin-picking severity and subtypes were assessed. Gender, race, and co-occurring conditions were generally similarly distributed across the three groups with high rates of self-reported anxiety (63-82%), depression (34-50%), obsessive-compulsive disorder (16-29%), and attention-deficit/hyperactivity disorder (12-32%). Among individuals with both trichotillomania and excoriation disorder, significant positive correlations were observed between hair-pulling and skin-picking severity scores as well as hair-pulling and skin-picking subtypes. Hair-pulling and skin-picking severity peaked at the transition from adolescence to adulthood and hair-pulling/skin-picking styles appeared to shift across the lifespan. Our results support several similarities between trichotillomania and excoriation disorder, providing new insight into the clinical characteristics of these conditions.

Trigeminal trophic syndrome in a pediatric patient with diffuse intrinsic pontine glioma

A 13-year-old girl with a history of diffuse intrinsic pontine glioma (DIPG) suffered from progressively worsening facial ulcerations secondary to paresthesia-induced self-excoriation. She was diagnosed with trigeminal trophic syndrome (TTS) induced by DIPG and struggled to heal her lesions in the background of this excoriation disorder. A multidisciplinary approach that included mood disorder management with sertraline and amitriptyline helped diminish paresthesia, improve her quality of life, and promote healing of the ulcers despite the progression of her DIPG. This case highlights the multifactorial complexity of TTS in pediatric patients and the need for successful management strategies.

Skin Picking Successfully Treated With Atomoxetine in Comorbid Skin Picking and Attention-Deficit/Hyperactivity Disorder: A Case Report

"Skin picking disorder" (SPD: also known as neurotic excoriation, psychogenic excoriation, or dermatillomania) is classified in the "obsessive-compulsive and related disorders" category in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, and characterized by unintentional, repetitive skin picking behaviors. Atomoxetine is a selective noradrenaline reuptake inhibitor used in the treatment of attention-deficit/hyperactivity disorder (ADHD). In this case report, we present a 9-year-old girl with the comorbid diagnosis of ADHD and SPD treated successfully with atomoxetine. To our knowledge, this is the first report of skin picking treated with atomoxetine in a patient with ADHD. We discussed possible explanations of mechanisms. Further studies are required on the effectiveness of atomoxetine for the treatment of SPD in the presence and absence of comorbid ADHD.

Atomoxetine Induced Skin Picking: A Case Report

"Skin picking disorder," also known as "dermatillomania" or "psychogenic excoriation," is classified in the "Obsessive Compulsive and Related Disorders" category in Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition and characterized by repetitive skin picking behaviors resulting in skin lesions. Atomoxetine (ATX) is a selective norepinephrine (noradrenaline) reuptake inhibitor commonly used in the management of attention-deficit/hyperactivity disorder. Atomoxetine is considered to increase levels of noradrenaline and dopamine by inhibiting norepinephrine transporters. In this case report, we present an 8-year-old male attention-deficit/hyperactivity disorder patient with skin picking behavior due to ATX treatment. We discussed possible explanations of skin picking behavior with ATX in the light of the current literature. To our knowledge, this is the first report of skin picking due to ATX in literature, and further studies are needed to investigate the frequency and mechanisms of skin picking with ATX.

Drug Treatment of Trichotillomania (Hair-Pulling Disorder), Excoriation (Skin-picking) Disorder, and Nail-biting (Onychophagia)

BACKGROUND

Trichotillomania (TTM), excoriation (or skin-picking) disorder and some severe forms of onychophagia are classified under obsessive-compulsive and related disorders. There are different interacting neurotransmitter systems involved in the pathophysiology of impulse-control disorders, implicating noradrenaline, serotonin, dopamine, opioid peptides and glutamate, hence investigators focused on drugs able to act on these transmitters. Our aim was to critically review the efficacy of the drugs employed in impulse-control disorders.

METHODS

We searched for controlled drug trials to treat TTM, excoriation, and/or nail-biting six databases (PubMed, Cochrane, Scopus, CINAHL, PsycINFO/PsycARTICLES, and Web of Science), using the search strategy: (trichotillomania OR "excoriation disorder" OR "face picking" OR "skin picking" OR "hair pulling" OR onychophagia OR "nail-biting") AND drug treatment on 12 March 2018 for all databases. We followed in our method of identifying relevant literature the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement.

RESULTS

SSRIs and clomipramine are considered first-line in TTM. In addition, family members of TTM patients are often affected by obsessive-compulsive spectrum disorders. Other drugs used in the treatment of TTM are lamotrigine, olanzapine, N-Acetylcysteine, inositol, and naltrexone.

CONCLUSION

The treatment of TTM, excoriation disorder and nail-biting is still rather disappointing. Conjectures made from preclinical studies and the relative pathophysiological hypotheses found poor confirmations at a clinical level. There is a need for further studies and the integration of pharmacological and psychotherapeutic. Our results point to the need of integrating personalised medicine principles in the treatment of these patients.

Guanfacine Extended Release for the Reduction of Aggression, Attention-Deficit/Hyperactivity Disorder Symptoms, and Self-Injurious Behavior in Prader-Willi Syndrome-A Retrospective Cohort Study

Objective: To examine the role of Guanfacine Extended Release (GXR) in the management of behavioral disturbances in patients with Prader-Willi Syndrome (PWS). Methods: Twenty from a total of 27 individuals with genetically confirmed PWS, 6-26 years of age, with the following symptoms were identified: significant aggression/agitation, skin picking, and/or symptoms of attention-deficit/hyperactivity disorder (ADHD). Response to GXR for the above noted symptoms was categorized as improved, worsened, or unchanged, while assessing for side effects and tolerability. Results: Eleven of the 20 individuals reported skin-picking, 17 reported aggression/agitation, and 16 reported symptoms of ADHD. Nine (81.8%), 14 (82.3%), and 15 (93.7%) individuals showed an improvement in skin-picking, aggression/agitation, and ADHD, respectively, while on GXR treatment. Two patients with prior complaints of psychotic symptoms did not respond to GXR. Of note, no abnormal weight gain or significant adverse reaction was observed in this group, while on GXR. Conclusions: In this study, GXR demonstrated improvement in symptoms of skin picking, aggression/agitation, and ADHD in patients with PWS. GXR was not effective in reducing psychosis or agitation related to psychotic symptoms. Future studies are warranted to further establish the utility of GXR in PWS patients.

Fluoxetine-Induced Skin Picking and Compulsive Behaviors in a Preschool Girl

Skin-picking disorder is regarded as a type of obsessive-compulsive and related disorders according to the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition. Selective serotonin reuptake inhibitors (SSRIs) are reported to be effective in the treatment of skin-picking disorder. However, these agents can cause opposite effects in some cases. There is a report on SSRI-induced skin-picking disorder in adults. However, to our knowledge, there are no data regarding SSRI-induced skin picking in children. We present the case of a preschool girl with separation anxiety disorder who displayed skin-picking and compulsive-asking behaviors after fluoxetine therapy.