DENVER — Skin-picking and hair-pulling disorders are “underrecognized, understudied, and undertreated,” a dermatologist told colleagues, but medications — especially glutamatergic agents — are showing promise in trials.

“These body-focused repetitive behaviors are frequently misunderstood as just bad habits that can be stopped with willpower,” said Katlein França, MD, PhD, clinical associate professor of dermatology and director of the Psychoneurocutaneous Medicine Center at the University of Miami Miller School of Medicine in Miami, in a presentation at the American Academy of Dermatology (AAD) 2026 Annual Meeting.

In fact, medications are important treatments as follow-ups to behavioral therapy, she said, and dermatologists play a crucial role in providing effective care. “Patients often lack knowledge. If they seek help, dermatologists are usually the first healthcare professionals they approach to discuss their symptoms.”

Grooming Disorders by the Numbers

As a whole, “repetitive self-grooming behaviors can affect skin, hair, and nails and cause physical damage, significant distress, and functional impairment,” said França, a dermatologist, who has a PhD in psychology.

Skin-picking disorder, also known as excoriation disorder or dermatillomania, encompasses the compulsive picking, scratching, rubbing, and pulling of skin. Pimples, scabs, and healthy skin can be affected, França said. People with these disorder may use their fingers or even tweezers.

The disorder is common, estimated to affect 1.4%-5.4% of the population. Cases are only considered pathologic if the condition is chronic and leads to dysfunction or disfigurement.

Hair-pulling disorder, known as trichotillomania, affects an estimated 0.5%-2.0% of the population and can involve the scalp, eyebrows, and eyelashes. Habit-reversal and cognitive-behavioral therapies are first-line treatments, França said, but she focused her presentation on medications.

Skin Picking: Strongest Evidence for Glutamatergic Agents

Pointing to a 2025 scoping review, França highlighted these glutamatergic products for skin-picking disorder:

• N-acetylcysteine: A 2016 double-blind, randomized controlled trial of 66 adults with skin-picking disorder supported this over-the-counter antioxidant supplement, with significant reductions in skin-picking symptoms at 12 weeks among those treated vs those on placebo (doses used were 1200-3000 mg/d).
• While it’s well tolerated, “most people have some GI [gastrointestinal] side effects,” França said. “Pills are 600 mg. There’s also an available liquid version, which might be more tolerable if you have a hard time taking a pill.”
• Memantine: A 2023 double-blind, placebo-controlled trial in patients with skin-picking or hair-pulling disorders showed an impressive number needed to treat of 1.9 for this N -methyl-D-aspartate receptor antagonist used to treat Alzheimer’s disease. In the trial, 60.5% of patients taking the drug rated themselves as “much or very much improved” at 8 weeks compared with 8.3% of those taking placebo.
• Other glutamatergic options with more limited evidence include lamotrigine (it may be helpful when patients have unstable mood), topiramate (watch for cognitive side effects), naltrexone, aripiprazole (not as monotherapy), and mirtazapine (it may be helpful when patients also have insomnia or appetite dysregulation), França said. 

Skin-Picking: The Best of the Rest

França said there’s also evidence for the selective serotonin reuptake inhibitors (SSRI) antidepressants:

• Fluoxetine: It’s the most-studied drug for this condition and considered the first choice at a mean dose of 55 mg/d. “This is when patients start to respond or have a better outcome,” França said.
• Escitalopram: It’s considered the preferred option when obsessive-compulsive disorder or anxiety disorder is a comorbidity.
• Fluvoxamine: This drug had a notable 100% response rate at 12 weeks in a 1999 open-label trial with 14 patients. “It seems to be a good medication, but it’s not still considered the first choice for this condition these days,” França said.
• Sertraline: It’s well tolerated, and doses can go up to 150 or 200 mg/d. “If combined with behavioral therapy, it has superior efficacy,” França said.

Hair-Pulling Disorder: Glutamatergic Agents and SSRI

França noted that glutamatergic agents have stronger evidence than SSRI for hair-pulling disorder. She highlighted a 2025 review and offered her own perspective on these strategies in the presentation and a follow-up interview:

• Memantine: It has strong evidence with a number needed to treat of 1.9 in the 2023 trial. “However, this is based on a single randomized controlled trial, and replication in independent studies is currently lacking,” she said.

• Sertraline and behavioral therapy: A small randomized controlled trial found that combining sertraline with habit-reversal training produced greater improvement than either treatment alone. However, this evidence is preliminary, based on a single small study, and has not been replicated or incorporated into clinical guidelines. Behavioral therapy remains the established first-line treatment, while sertraline may be considered when co-morbid depression or anxiety is present.

• N-acetylcysteine: It has moderate evidence. “A 2026 meta-analysis of body-focused repetitive behaviors reported strong support for efficacy when considering effect size and available replication,” she said, “but the overall evidence base in trichotillomania remains relatively small.”

• Clomipramine: This tricyclic antidepressant has modest evidence, a high relapse rate when the drug is stopped and is not recommended as a first-line medical therapy.

• Fluoxetine and other SSRI: They have limited evidence.

• Olanzapine: This antipsychotic has preliminary-to-moderate evidence. Watch for metabolic side effects.

• Aripiprazole: This antipsychotic has preliminary evidence, “primarily from small open-label studies and case series, with limited controlled trial data.”

Beyond Treatment: Consider Stimulants as a Possible Cause

França urged colleagues to review all medications that patients are taking when they present with psychocutaneous symptoms. As an example of what may come up, she pointed to a systematic review she co-authored that listed 22 case reports of pediatric patients who developed trichotillomania after being prescribed stimulants. 

“After they discontinued the medication, they had a complete resolution of the trichotillomania symptoms. Likely, there was a cause here.”

França disclosed having relationships with Springer, Wiley-Blackwell, and Health.com.