lolostock and excoriation disorder: Primary care implications Abstract: Trichotillomania and excoriation disorder are two psychiatric conditions that have similar origins to obsessive compulsive disorder. Both can cause patients signifi cant distress and lead to medical consequences. It is important that primary care NPs identify and refer these individuals for psychiatric treatment.

By Debra A. Scrandis, PhD, CRNP-PMH, CRNP-F, and Ana C. Duarte, PhD, CRNP-PMH

bsessive compulsive disorder (OCD), seen in OCD, while at its essence suggests an anxiety dis- both medical and psychiatric realms, is com- order, is listed in the Diagnostic and Statistical Manual O posed of two distinct types of symptoms. of Mental Disorders, Fifth Edition (DSM-5) as its own Obsessions are thoughts that are recurrent and intru- separate disorder due to the specifi c neurobiological sive in individuals with the disorder. Compulsions are factors involved in its presentation. Two distinct disor- actions taken to gain relief from the obsessive thoughts. ders falling under the OCD umbrella are trichotillo- In combination, the disorder can be debilitating as the (TTM—hair pulling) and excoriation disorder individual continues to have thoughts and a need to (skin picking). The former is specifi c to hair, while the act on these thoughts repetitively. latter is specifi c to skin. Root causes of both are the Keywords: excoriation disorder, obsessive compulsive disorder, psychiatric conditions, trichotillomania www.tnpj.com The Nurse Practitioner • August2021 51

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same, but the symptoms present in different locations pubic and perirectal regions.1,5 Skin picking usually on the body.1 They are both considered under the um- involves the face, but can also include fi ngers, arms, brella of body-focused repetitive behaviors. DSM-5 torso, legs, back, and pubic area.7 Behaviors in skin criteria for TTM include recurrent pulling out of one’s picking include scratching, rubbing, removing skin hair resulting in hair loss, while excoriation disorder parts, and pinching using fi nger nails, fi ngers, and/or includes recurrent skin picking resulting in skin lesions. teeth.7 Inanimate objects such as pins, tweezers, and Both disorders include the criteria of repeated attempts scissors may also be used in repetitive skin picking be- to decrease or stop these behaviors.1 Individuals may haviors.7 Individuals with either or both disorders spend perform these behaviors to help them manage their a significant amount of time doing these behaviors anxiety, , or boredom.2,3 Etiologies are not known, similar to OCD. These behaviors can lead to medical but there may be genetic and environmental problems, such as irreversible hair loss, skin lesions, components.4 keloids, and infections.5 The following scenarios depict actual cases seen in While these disorders are relatively rare, they clinical practice. may present with more frequency in the context of • J.T. is a 30-year-old female who picks at the skin on increased anxiety resulting from the COVID-19 pan- her fi ngers and scalp and is unable to stop these demic.8 Presentation of symptoms may fi rst occur in behaviors. She is experiencing hair loss on her head medical practices, where prompt identifi cation and and excoriations on her fingers, which she finds referral will result in appropriate treatment. distressing and worries that other people will notice these signs. She fi nds that her fi nger picking has ■ Neurobiology increased more recently with her plan to move to a Excoriation disorder and TTM have similar structural new home. and functional brain changes as OCD. Brain changes • B.C. is a 17-year-old female with an . in OCD involve the decision-making functions of the She reports a strong urge to pull the hair on her scalp orbitofrontal cortices and the movement-related and pubic area, which provides relief for her anxiety. functions of the basal ganglia. Reportedly, there are She is distressed by this behavior and wishes she had also reductions in cortical thickness in the parietal the ability to stop. and temporal lobes, which are responsible for so- matosensory and auditory func- tions, respectively. These brain Excoriation disorder and TTM have similar changes may contribute to de- structural and functional brain changes creased control of habit formation as OCD. for which the basal ganglia are responsible.9 Changes are also seen in corti- The prevalence of these disorders is up to 2% co-striato-thalamo-cortical (CSTC) neurocircuitry, for TTM and 2% to 5% for excoriation disorder.5,6 which is involved in the expression of compulsive One study reported that both disorders occur three behaviors.10 The CSTC circuit also plays an important times more in females than males and adolescence as role in reward processing, habit formation, and motor the average time of onset, although it also can begin control. In addition, it contributes to the awareness in childhood.5 can include personality and recognition of signifi cant behavioral stimuli, as disorders, major depressive disorder, generalized anxi- well as regulation of goal-directed behavior. All of ety disorder, and OCD.7 these attributes of the CSTC neurocircuitry suggest can also coexist in these individuals. Individuals may that it is an important area to target in the treatment be conscious or unconscious of the repetitive of TTM and excoriation disorder, as it has been hy- behaviors. pothesized that skin picking/hair pulling is a problem Locations of hair pulling and skin picking vary. Hair with motor inhibition.10 Functional imaging in pa- pulling can occur in any location where there is hair tients with OCD shows CSTC hypoactivation during growth, most commonly the scalp, eyebrows, and eye tasks requiring inhibitory control, and a reduction in lashes.1,5 Less common areas include axilla, face, and functional connectivity between inhibitory control

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Copyright © 2021 Wolters Kluwer Health, Inc. All rights reserved. Trichotillomania and excoriation disorder: Primary care implications and focus during cognitive tasks.9 Functional MRI also suggests an increase in glutamate in the CSTC Common medication classes that can circuit. Glutamate is the body’s main excitatory neu- contribute to hair loss rotransmitter and is abundant in the central nervous medications with Hormone replacement 11 system, making it a novel treatment target. vitamin A therapy Sleep quality is a novel treatment target that is Amphetamines NSAIDs implicated in both TTM and excoriation disorder, but Antibiotics and antifungals Oral contraceptives the effects of poor-quality sleep are noted in the sever- Anticoagulants Parkinson disease ity of hair pulling yet not skin picking. This suggests medications (levodopa) the involvement of separate brain mechanisms in the Antihypertensives (ACEIs, SSRIs (paroxetine, relationship of sleep to each disorder.12 Other emerg- beta-blockers, diuretics) sertraline, fl uoxetine) ing targets include infl ammation and the immune Antiepileptic medications Steroids system and the endocannabinoid system (ECS).13-15 (valproic acid) ECS receptors are located in the same areas of the Chemotherapy Thyroid medications brain involved in OCD, suggesting a link between the Cholesterol-lowering agents ECS and OCD neural circuits. The function of the (clofi brate, gemfi brozil) ECS is largely in maintaining homeostasis. It is also ACEI, angiotensin-converting enzyme inhibitor; SSRIs, selective serotonin reuptake inhibitors; NSAIDs, nonsteroidal anti-infl ammatory drugs involved in immune function, reaction to stress, sleep, Adapted from www.medicalnewstoday.com/articles/326955 pain, rewarding, and arousal.15 The ECS prevents increases in neuronal activation within the central nervous system, thus producing calming and restful Common medication classes that can effects.13-15 contribute to allergic reactions and/or pruritus Antiarrhythmic medications Corticosteroids ■ Assessment Antibiotics medications The NP may fi nd signs of hair loss or cutaneous lesions Antiepileptic drugs Monoclonal antibody on the skin during a physical exam or episodic visit. If therapy there are signs or the patient presents with the complaint Antihypertensives of hair pulling or skin picking, a thorough hair and skin ASA, NSAIDs Statins assessment would be appropriate. The NP should look Chemotherapy Thyroid medications for cutaneous lesions and hair loss such as decreased 5 ASA, aspirin; NSAIDs, nonsteroidal anti-infl ammatory drugs hair density or patches of alopecia. In hair pulling, there Adapted from Reich A, Ständer S, Szepietowski JC. Drug-induced pruritus: a are typically broken hair shafts of different lengths and review. Acta Derm Venereol. 2009;89(3):236-244. doi:10.2340/00015555-0650. the alopecia may not show any scarring.5 It is important to rule out medical conditions, sub- and . Individuals with substance use may pick stance use, and medications as the cause of these behav- or rub their skin due to restlessness, pruritus, or crawling iors (see Common medication classes that can contribute sensations. withdrawal with symptoms including to hair loss and Common medication classes that can con- agitation and piloerection can lead individuals to pick or tribute to allergic reactions and/or pruritus). Actual hair rub their skin.16 of parasitosis, a relatively rare loss from medical conditions, such as thyroid disease, condition in which the individual believes he or she has hormone changes in the postpartum or perimenopausal insects or other organisms embedded in the skin with- periods, alopecia, and tinea capitis, may be considered out any evidence of infestation, is another differential as possible differential diagnosis for TTM. For excoria- diagnosis that may involve pruritus and excoriations.17 tion disorder, scabies, systemic pruritus, and acne may A psychiatric evaluation is appropriate for this suspected be considered as differential diagnoses.7 Other disorders diagnosis. that may involve skin picking include atopic , Screening for underlying anxiety and seasonal or environmental allergic reactions, contact would also be prudent using the Patient Health Ques- dermatitis, basal cell carcinoma, and actinic keratosis. tionnaire 9 (PHQ-9) and the Generalized Anxiety Substance use, such as use of heroin and methamphet- Disorder 7 (GAD-7) questionnaire, since these dis- amine, can cause damage to the skin due to needle marks orders are frequently comorbid with TTM and www.tnpj.com The Nurse Practitioner • August2021 53

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excoriation disorder. Because poor sleep quality is It is important to note that there are no FDA- typically present in both TTM and excoriation dis- approved medications for TTM or excoriation dis- order, it is also wise to do a sleep assessment on in- order. As far as pharmacologic options, underlying dividuals presenting with symptoms of either.13 comorbidities need to be considered in deciding treatment. More studies have been conducted on ■ Management TTM than excoriation disorder. One meta-analysis The course of the disease for TTM and excoriation on TTM found that , N-, disorder can vary but tends to be chronic and diffi cult and had signifi cant benefi ts compared with to treat.5 Individuals may be hesitant or embarrassed placebo.19 A systematic review and meta-analysis on to share their hair pulling and skin picking behaviors. treatment options found some evidence for the use When communicating with these individuals, it is of SSRIs (fl uoxetine, , escitalopram, fl uvox- important to acknowledge their distress and not mini- amine, and sertraline) in the treatment of excoriation mize it. The use of alopecia medications would not be disorder, while other studies found little effi cacy or useful since hair pulling will continue without psychi- signifi cant fi ndings in TTM.4,10,18,19 The evidence for atric interventions. Skin excoriations should be treated lamotrigine has been mixed.4 One meta-analysis found for secondary infections if present, and if needed the large treatment effects for lamotrigine and SSRIs in patient can be referred to . excoriation disorder and made the recommendation There is evidence to support the use of cognitive that individuals seeking treatment for this disorder behavioral therapy and habit reversal therapy and both may experience signifi cant benefi ts regardless of treat- might be the best initial treatment for excoriation dis- ment modality.18 As with anxiety disorders, SSRI doses order and TTM.18,19 Cognitive behavioral therapy in- for OCD may need to be at higher levels than those volves learning about unhealthy patterns of thoughts prescribed for major depression, which may relate to that impact psychologic problems and behaviors. It has TTM and excoriation disorder. Although excoriation disorder Self-care methods to decrease the frequency and TTM are two distinct conditions, of hair pulling and skin picking can include reviews of the literature largely yield support for some of the same treat- wearing hats or head wraps when appropriate ments that would target OCD be- and keeping nails short or manicured. cause of their shared etiologies. In addition to serotonergic agents, phar- been found to be effective in treating anxiety disorders, macotherapies may include medications that target excoriation disorder, and TTM. Habit reversal therapy N-methyl-d-aspartate and .11 includes training the patient on other behaviors that Glutamate studies are promising but not conclusive are not compatible with hair pulling or skin picking, at present. Glutamate modulation in the CSTC can identifying settings or activities that increase hair pull- potentially be treated with noninvasive and invasive ing/skin picking (such as touching face or head) and procedures. Transcranial magnetic stimulation is a altering activities to avoid these pulling/picking situa- noninvasive procedure, while surgical ablation and tions, and conducting positive self-care at pulling and deep brain stimulation are invasive, of which only the picking sites.20 Therefore, it would be important to latter is reversible. Modulation approaches can target provide a therapy referral for these individuals. areas of interest in OCD, likewise they can help to Self-care methods to decrease the frequency of hair further identify affected regions for more precise and pulling and skin picking can include wearing hats or effective therapies.11 head wraps when appropriate and keeping nails short In light of anecdotal reports of OCD symptom or manicured. For individuals with underlying anxiety relief by patients who use cannabis, the ECS is another disorders, other methods for anxiety relief include area worthy of study as a target for novel treatments. meditation, mindfulness, relaxation therapy, and ex- Recent research in the use of cannabidiol for issues ercise. Recognizing stressful situations and using stress such as anxiety and fear response, in addition to FDA balls where the hands are busy may decrease hair pull- approval for two rare epilepsies of childhood, bode ing and skin picking. well for continued research in this area.15

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A few small studies have found immunologic dif- REFERENCES ferences between adults with OCD and healthy controls, 1. American Psychiatric Association. Diagnostic and Statistical Manual of which suggests an immune system role in OCD. The Mental Disorders: DSM 5. 5th ed. 2013. 2. Graham R, Soares NS. What are the DSM-5 diagnostic criteria for exco- antibiotic minocycline and cyclooxygenase-2 (COX-2) riation (skin-picking) disorder? Medscape. 2018. www.medscape.com/ answers/1122042-169038/what-are-the-dsm-5-diagnostic-criteria-for- inhibitors have provided some relief from obsessional excoriation-skin-picking-disorder. symptoms in studies. Also, probiotics, which aim to 3. Elson DM. Trichotillomania. Medscape. 2019. https://emedicine.medscape. decrease infl ammation, have recently become a treat- com/article/1071854-overview#a3. 4. Sani G, Gualtieri I, Paolini M, et al. Drug treatment of trichotillomania ment of interest for this new target. Additional research (hair-pulling disorder), excoriation (skin-picking) disorder, and nail-biting is needed in this area both to understand the mecha- (onychophagia). Curr Neuropharmacol. 2019;17(8):775-786. 13,14 5. Jones G, Keuthen N, Greenberg E. Assessment and treatment of trichotil- nisms and to develop treatments. lomania (hair pulling disorder) and excoriation (skin picking) disorder. More than 100 therapeutic trials for OCD and Clin Dermatol. 2018;36(6):728-736. 6. Grant JE, Chamberlain SR. Prevalence of skin picking (excoriation) disorder. related conditions are currently ongoing worldwide, J Psychiatr Res. 2020;130:57-60. mostly in the areas of neuromodulation and psycho- 7. Torales J, Díaz NR, Barrios I, et al. Psychodermatology of skin picking (exco- therapy. Approximately 20% of these trials are in- riation disorder): a comprehensive review. Dermatol Ther. 2020;33(4):e13661. 8. Pathoulas JT, Olson SJ, Idnani A, Farah RS, Hordinsky MK, Widge AS. vestigating new pharmacologic therapies targeting Cross-sectional survey examining skin picking and hair pulling disorders glutamate and the immune system. Additionally, novel during the COVID-19 pandemic. J Am Acad Dermatol. 2021;84(3):771-773. 9. Grant JE, Chamberlain SR. Exploring the neurobiology of OCD: clinical therapies such as psychedelics, catechol-o-methyl- implications. Psychiatr Times. 2020;2020. transferase inhibitors, and endocannabinoid modula- 10. Fineberg NA, Apergis-Schoute AM, Vaghi MM, et al. Mapping compulsiv- tors are being studied. In addition to new medication ity in the DSM-5 obsessive compulsive and related disorders: cognitive domains, neural circuitry, and treatment. Int J Neuropsychopharmacol. 2018; options, authors of one review recommend that 21(1):42-58. continued studies narrow focus even further, toward 11. Goodman WK, Storch EA, Sheth SA. Harmonizing the neurobiology and treatment of obsessive-compulsive disorder. Am J . 2021;178(1) biomarkers for more personalized and effective :17-29. doi:10.1176/appi.ajp.2020.20111601. treatment.13 12. Cavic E, Valle S, Chamberlain SR, Grant JE. Sleep quality and its clinical associations in trichotillomania and skin picking disorder. Compr Psychiatry. Overall, there is no single-line treatment for TTM or 2021;105:152221. excoriation disorder. Though some of these new treat- 13. Grassi G, Cecchelli C, Vignozzi L, Pacini S. Investigational and experimental ments are promising for OCD, and possibly TTM and drugs to treat obsessive-compulsive disorder. J Exp Pharmacol. 2021;12:695-706. 14. Marazziti D, Mucci F, Fontenelle LF. Immune system and obsessive-compulsive excoriation disorder, it is still prudent to refer patients disorder. Psychoneuroendocrinology. 2018;93:39-44. to a psychiatric specialist to ensure best outcomes. 15. Kayser RR, Snorrason I, Haney M, Lee FS, Simpson HB. The endocan- nabinoid system: a new treatment target for obsessive compulsive disorder? Cannabis Cannabinoid Res. 2019;4(2):77-87. ■ Conclusion 16. Lipman ZM, Yosipovitch G. Substance use disorders and chronic itch. J Am J.T. is unable to take SSRIs due to elevated hepatic Acad Dermatol. 2021;84(1):148-155. 17. Ansari MN, Bragg BN. Delusions of parasitosis. In: StatPearls. Treasure enzymes and presented with a rash with lamotrigine. Island, FL: StatPearls Publishing; 2020. www.ncbi.nlm.nih.gov/books/ She currently gets manicures and found her picking NBK541021/. 18. Selles RR, McGuire JF, Small BJ, Storch EA. A systematic review and meta- decreased once she relocated to the new home. She is analysis of psychiatric treatments for excoriation (skin-picking) disorder. currently receiving cognitive behavioral therapy. Gen Hosp Psychiatry. 2016;41:29-37. 19. Farhat LC, Olfson E, Nasir M, et al. Pharmacological and behavioral treat- B.C. was prescribed an SSRI for her anxiety with ment for trichotillomania: an updated systematic review with meta-analysis. minimal improvement in her hair pulling. She received Depress Anxiety. 2020;37(8):715-727. 20. Himle JA, Bybee D, O’Donnell LA, et al. Awareness enhancing and monitor- a referral for habit reversal therapy and was advised to ing device plus habit reversal in the treatment of trichotillomania: an open work on methods such as exercise and nutrition to feasibility trial. J Obsessive Compuls Relat Disord. 2018;16:14-20. improve her anxiety. TTM and excoriation disorder can have a detri- Debra A. Scrandis is an associate professor at the University of Maryland School mental impact on patients. It is important for primary of Nursing, Baltimore, Md. care NPs to identify these disorders, as well as allow individuals to share their distress and refer them to Ana C. Duarte is an assistant professor at the University of Maryland School of Nursing, Baltimore, Md. providers, such as psychiatric mental health NPs and therapists. Several self-care techniques, The authors and planners have disclosed no potential confl icts of interests, such as exercise, can be recommended for patients fi nancial or otherwise. empowering them to take some control over these symptoms. DOI-10.1097/01.NPR.0000753840.44209.51 www.tnpj.com The Nurse Practitioner • August2021 55

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