Abstract
To the Editor:
Case Report
A 16-year-old, obese white female was in treatment for depression with anxiety and obsessive compulsive behaviors complicated by repetitive running away from home and high- risk sexual activities. Skin manipulation began at age 5, with rubbing, digging, squeezing, and scratching. It progressively worsened in her teens. The common sites of skin picking were face, extremities, and groin. She picked on normal areas or on scabs of previously healed lesions and ate the scabs. Itching was not a concern, but nail biting was another problem. She excoriated her skin daily to the point of bleeding. Psychotherapy had been ongoing since she was of kindergarten age.
The patient counted numbers and sat on her hands to diminish picking. She wore gloves and long sleeves to cover the lesions and applied makeup for cosmesis. Nevertheless, peers made fun of her because of the sores; therefore, she avoided social situations, even school. Drug or alcohol use and body dysmorphic symptoms were denied. She felt embarrassed about her behaviors. After two cutaneous infections that required antibiotic therapies and surgical drainage, her primary care physician recommended psychiatric treatment.
Over the years, prescribed medications included fluoxetine, fluvoxamine, paroxetine, divalproex, gabapentin, lamotrigine, oxcarbazepine, aripiprazole, olanzapine, quetiapine, risperidone, and ziprasidone. Current medications were divalproex 1000 mg, fluvoxamine 250 mg, and ziprasidone 80 mg daily.
Topiramate was prescribed at 100 mg per day. Within 1 month, the intensity and frequency of skin manipulation significantly decreased; depression, anxiety, and aggression improved also. Once topiramate was increased to 200 mg daily, continued progress included even fewer skin picking urges. Some weight loss was noted. Running away from home and high-risk sexual behaviors stopped. Despite one depression relapse requiring hospitalization, the compulsive cutaneous manipulations were diminished in frequency for >6 months and the other risky behaviors did not occur.
Discussion
Compulsive skin manipulation is a complex condition of varying etiologies. Pharmacological treatments target serotonin (Pukadan et al. 2008), dopamine (Luca et al. 2012), and glutamate (Grant et al. 2007) receptors. Topiramate, a γ-aminobutyric acid enhancing agent, may offer an alternative strategy.
Pathologic skin picking does not respond well to many pharmacotherapies (Denys et al. 2003; Grant et al. 2007; Pukadan et al. 2008; Jafferany et al. 2010). In this case, topiramate quickly induced and maintained progress for >6 months. Topiramate may be a useful adjunctive agent to consider for adolescents with compulsive skin manipulation, comorbid with other psychiatric disorders. Skin picking lessened even during a depressive relapse. This suggests that the effects of topiramate were primarily focused on diminishing compulsive behaviors. Weight loss was clinically desirable.
Our clinical vignette is inconsistent with a previous report that topiramate was documented as not effective in treating Prader-Willi syndrome patients with skin picking (Jaffrany et al. 2010). The various etiologies of this behavior in addition to coadministration of different pharmacotherapies may contribute to conflicting results. Nevertheless, a significant reduction in skin pathology and frequency was reported.
Footnotes
Disclosures
No competing financial interests exist.