Recovery from pathological skin picking and dermatodaxia using a revised decoupling protocol

OBJECTIVE: Pathological skin picking (PSP) is characterized by repetitive scratching, biting, and picking of the skin. The disorder is subsumed under the section "obsessive-compulsive and related disorders" in the DSM-5. A related body-focused repetitive disorder, which has received less empirical attention so far, is dermatophagia or dermatodaxia (eating or biting/gnawing of the skin). Habit reversal training (HRT) is regarded as the treatment of choice demonstrating improvement at a medium effect size relative to control conditions.

METHODS: The present case report describes a 50-year-old man with a lifetime history of PSP and dermatodaxia of the fingertips who stopped excessive nail-biting approximately 10 years ago using a treatment method known as decoupling. Yet, his PSP and dermatodaxia remained treatment-refractory after treatment with both decoupling (conventional protocol) and HRT.

RESULTS: Using a revised protocol of decoupling, the man was able to fully stop PSP and dermatodaxia; only the tendency to fidget nervously with his hands remained. The case report describes the revised protocol. Scores on the Skin Picking Scale Revised (SPS-R) dropped from 15 to 0.

DISCUSSION: The revised decoupling protocol is an easy to use technique that holds promise in this underdiagnosed and undertreated condition. Yet, rigorous randomized controlled studies are needed to ascertain its efficacy.