Dermatillomania: Strategies for Developing Protective Biomaterials/Cloth

Dermatillomania or skin picking disorder (SPD) is a chronic, recurrent, and treatment resistant neuropsychiatric disorder with an underestimated prevalence that has a concerning negative impact on an individual’s health and quality of life. The current treatment strategies focus on behavioral and pharmacological therapies that are not very effective. Thus, the primary objective of this review is to provide an introduction to SPD and discuss its current treatment strategies as well as to propose biomaterial-based physical barrier strategies as a supporting or alternative treatment. To this end, searches were conducted within the PubMed database and Google Scholar, and the results obtained were organized and presented as per the following categories: prevalence, etiology, consequences, diagnostic criteria, and treatment strategies. Furthermore, special attention was provided to alternative treatment strategies and biomaterial-based physical treatment strategies. A total of six products with the potential to be applied as physical barrier strategies in supporting SPD treatment were shortlisted and discussed. The results indicated that SPD is a complex, underestimated, and underemphasized neuropsychiatric disorder that needs heightened attention, especially with regard to its treatment and care. Moreover, the high synergistic potential of biomaterials and nanosystems in this area remains to be explored. Certain strategies that are already being utilized for wound healing can also be further exploited, particularly as far as the prevention of infections is concerned.

This survey included questions related to body focussed repetitive behaviours (BFRBs). The survey link was posted in two closed Facebook groups related to BFRBs on 1st March 2020 and was kept open for responses until 30th April 2020. These two Facebook groups were chosen with an assumption that individuals joined these private groups in order to share their experiences or stories of living with BFRBs and to seek community support from other individuals with the same struggles.

Results
A total of 112 respondents have given their consent to be a part of this survey. The first 61 responses were excluded from being analysed as Question "what kind of BFRB you have?" did not show the option Dermatillomania due to a technical glitch which was later corrected, so the remaining 51 responses were analysed that were received post correction.       About 42.2% reported that they enjoy doing it but just don't like the harm it does to their body while 42.2% reported that they don't seem to like or enjoy engaging in the behaviour. About 86.7% of the individuals think that there should be better treating facility than that already exists for the treatment of BFRBs.

Conclusions
There is a need for alternative treatment strategy as the need is represented by 86.7% of the individuals with skin picking in this survey. It is very important to consider opinions of individuals with SPD when designing treatment strategies. In this survey that we conducted about 42.2% reported that they enjoy engaging in the behaviour but don't like the harm it does to their bodies. Another 42.2% reported that they don't seem to either like or enjoy engaging in skin picking behaviour ( Figure S7). Considering these answers, response substitution and response prevention methods seemed to be more apt and which is why physical barrier strategies have been proposed and discussed in this review.

Limitations
It is a self-reported survey. Most of the individuals are not officially diagnosed by a psychiatrist. Survey was conducted to understand all body focussed repetitive behaviours and not just Dermatillomania. Discontinuation caused recurrence [2][3][4] Sertraline SSRI Case report *Partial improvement in psychogenic excoriation in one individual [5] No data [6][7][8] Fluvoxamine SSRI 12-week open label trial 7 completers out of 14 participants showed improvement on YBOCS scale and significant reduction in skin picking [9] No data [10] Trazodone SARI Case report Not effective at all (50 mg at night for 6 months) [11] No data [11] Paroxetine SSRI Case report 40mg/day for 4months -skin picking completely stopped [11] No skin picking for one year [10] Citalopram SSRI Case reports No reduction or improvement in skin picking [5,12] - [5,12] Venlafaxine SNRI Case Report Skin picking behavior was aggravated [5] - [5] Doxepin SNRI

Case Report
Symptomatic and clinical improvement in neurotic excoriation in two individuals [13] Effects Maintained even after two months [14] -Case Report Doxepin + HRT was helpful [14] Escitalopram SSRI weeks reduced skin picking [27] Complete cessation of skin picking at 6week follow-up [27] Case Report Risperidone with Citalopram given for a month reduced methylphenidate induced skin picking [28] No Recurrence at subsequent follow up [28] Haloperidol Case Report 100 mg twice daily with 40 mg twice daily of fluoxetine decreased SPIS score in a month [43] --