Habit Reversal Training for Trichotillomania, Excoriation Disorder, and Itch

San Diego, California — Of the various comorbidities associated with dermatologic conditions, psychological issues are common. Study data from 2017 published in the Asian Journal of Psychiatry found that 34.2% of patients receiving treatment at an outpatient dermatology facility met ICD-10 criteria for psychiatric disorders such as depression, anxiety disorder, and obsessive-compulsive disorder.¹

The intersection of dermatology and psychiatry is evident in the body-focused repetitive behavior (BFRB) disorders. BFRBs are “psychiatric disorders that involve recurrent pulling and picking one’s own body resulting in skin lesions with varying degrees of severity,” wrote Daniela Sampaio, MD, of the department of psychiatry and behavioral neuroscience, University of Chicago, Pritzker School of Medicine, Illinois, and colleagues  in a 2018 paper published in Clinics in Dermatology.² “For that reason, the interface with dermatology is important.”

Body-Focused Repetitive Behavior Disorders

Trichotillomania (hair-pulling) and excoriation disorder (skin-picking) are classified in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) in the category of Other Specified Obsessive Compulsive and Related Disorders.³ Other types of BFRBs include nail biting, cheek chewing, and lip biting.

The scalp is the main site of presentation of trichotillomania and various patterns of alopecia may be present.² Eyebrows and eyelashes are other commonly involved sites, although many body areas may be involved including legs, armpits, and the pubic region.⁴

Excoriation disorder most commonly involves the face and “frequently starts with picking at an underlying dermatologic condition such as acne but can continue after dermatologic treatment,” according to Sampaio, et al.² “The dermatologic findings and distribution are atypical and will help the clinician differentiate from other dermatologic conditions.”

Although estimates have shown varying rates of BFRBs, emerging findings suggest a higher prevalence than previously believed. In a 2018 study of 4335 college students, approximately 12% of patients met diagnostic criteria for these disorders and nearly 60% of the sample reported engaging in subclinical BFRBs.⁵

Despite the psychological nature of BFRB disorders, many “patients are unlikely to seek mental health treatment for their condition [and] will instead seek dermatologic help due to the cosmetic damage incurred,”² the researchers wrote. In addition to dermatologic assessment of the affected areas, the optimal management strategy for BFRBs should include psychological treatment and, when indicated, pharmacotherapy.²

Habit Reversal Training (HRT)

In a presentation at the second annual Integrative Dermatology Symposium held October 3-5, 2019 in San Diego, California, Katlein França, MD, PhD, discussed the use of the behavior therapy technique “habit reversal training” (HRT) for the treatment of trichotillomania, excoriation disorder, and itch. Dr França is a clinical assistant professor in the department of dermatology and cutaneous surgery, and faculty in the department of psychiatry and behavioral sciences at the University of Miami Miller School of Medicine in Florida.

HRT was developed in the 1970s by Azrin, et al, as a treatment strategy for tics and other habitual behaviors.⁴ HRT typically includes the following core components: