Bridging the Gap between Dermatology and Psychiatry: Prevalence and Treatment of Excoriation Disorders Secondary to Neuropsychiatric Medications

Round 1

Reviewer 1 Report

This is an excellent paper.  As an expert in BFRBs, I've been looking for a well-written paper to discuss this phenomenon of medication induced excoriation disorders.  It's fascinating that in some instances, "SSRIs and atypicals may be used to correct BFRD, when in other cases, they are the offending agents."  Well said!  The authors also expound about why this may be happening- I like their theory on the relationship between serotonin and excess dopamine.

This paper would be a wonderful contribution to the literature.

I’ve read a few case reports on medication-induced trichotillomania and seen it in my practice.  Most of these reports are on stimulants causing BFRDs.  This is the first extensive literature search and case series I’ve read on the topic.  I did a quick google scholar search and nothing this comprehensive came up.  As such, the originality and scientific content of this article are both sound and worth publishing.

This is a well-written paper.   The flow and quality of English are excellent.

I have a few minor suggestions: When I read a paper, I may occassionally get stuck on a sentence.  These are sentences I have to read more than once to understand them.  The authors may consider a slight tweak in the content/structure of the sentence:

Table 1, case 4, page 4:

Change: "Two month following initiation" to "Two month(s) following (ropinirole) initiation"
Change "continued hair pulling"  to "hair pulling continued"

Table 1, case 7, page 4:
Make it explicit " Atomoxetine was discontinued "and skin picking stopped".

Table 1, case 8, page 5

Make it explicit "Skin picking continued and was accepted as a reasonable 'adverse event,' given the benefits of Clozaril"

Page 5, line 108-109,  I would consider adding the following sentence:

More than half of patients (5 patients) discontinued the offending agent with complete relief of dermatillomania symptoms. "Of these 5 patients, one patient's skin picking resurfaced 2 months later, for reasons unknown, despite being off the offending agent."  One patient was given a reduced dosage of the offending agent and dermatillomania decreased but persisted. 

Other than these minor edits, which you can take or leave, I think it is ready for publishing.

Author Response

Thank you so much for your thorough review of my manuscript. I appreciated all of your corrections in helping me to make this a stronger paper. I will be uploading the new manuscript this week which will include all four suggested changes highlighted in yellow.

Reviewer 2 Report

Manuscritp is interesting, well written and it covers a topic with few literature available. 

I've only two suggestions:

1) [results section] the population of patients is very small (9 patients) so, in my opinion is not worth of report median age and so on (line 76 - 78)

2) [discussion section] from line 139 to line 174 authors describe pharamcological and non pharmacological treatment for skin-picking and trichotillomania. In my opinion this section is out of topic and too long. Here we are talking about secondary disorders and in 7 out of 9 patients the tratment was or no treatment or stop of medication suspected to have elicitated the disorder. Authors should shorten this section.

Author Response

Thank you so much for your review of my paper and suggestions to make this a stronger manuscript. 

As for your first suggestion, we are removing the sentence presenting the median age, standard deviation, and range of the ages. We have instead included a sentence in its place that states that since we only followed 9 patients, we are unable to comment on the overall distribution of these disorders amongst age groups and genders. This change will be highlighted for you in yellow in the results section of the updated manuscript I plan to submit over the weekend.

As per your second suggestion however, we feel it is important to include these sections. We have not removed them and are providing justification below.

One patient who needed to continue their offending agent received an additional pharmacological treatment for their symptoms. However, 3 other patients who continued their offending agents and continued to see skin picking or hair pulling symptoms would have likely benefitted from an additional medication to help manage their symptoms. Trial of a medication to improve outcomes would have at least given them a shot at remission of symptoms versus letting the dermatillomania or trichotillomania remain. Removal of the offending agent, while it is the best for resolution of symptoms, is not always possible. We included this brief section as we believe it is important that pharmacological agents be considered in these cases as excoriation disorders can be extremely debilitating. This is why we feel the section on pharmacological agents as treatments is relevant.

Additionally, for patients who have to continue their pharmacological offending agents out of necessity as in the case of the 26/M receiving clozapine for schizophrenia, it may be beneficial to additionally refer these patients to nonpharmacological treatments. These would include cognitive behavioral therapy, habit reversal therapy, and psychoeducation which is why we included the brief 5 sentence paragraph on nonpharmalogical therapies that have been used for dermatillomania and trichotillomania. We feel this highlights the need for healthcare providers to realize when referrals to mental health specialists could be indicated.

To best address your comment I have included an additional section explaining the relevance of both of these sections in the piece of the discussion that presents the results. This section will be highlighted in yellow on the new submission of the revised manuscript this week. I hope this aids in tying the concepts together and improved the understanding of the relevance of the indication section.

It is also important to note we are unable to shorten the manuscript any further at risk of not meeting the minimum length requirements for the journal.