Skin-picking disorder is classified under the head of obsessive-compulsive and related disorders in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition and characterized by excessive and recurrent picking of the skin without a dermatological disease.1 This disorder can be triggered by anxiety and stressful situations, but the precise mechanisms underlying the disorder remain largely unknown.1 A variety of studies showed that selective serotonin reuptake inhibitors (SSRIs) are effective in the treatment of pathological skin picking.2 On the contrary, however, a report by Denys et al3 presented newly developed skin-picking behaviors during SSRI therapy in adults. To our knowledge, young children have not yet been studied in this respect. We present the case of a 5-year-old girl with separation anxiety disorder who displayed skin-picking behaviors and compulsions after fluoxetine therapy.
A 5-year-old girl was referred to the child and adolescent psychiatry outpatient clinic with complaints of inability to fall asleep without her mother and school refusal. Her symptoms have continued for 1 year without any improvement period and increased in time. The patient was diagnosed with separation anxiety disorder according to the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition. Because of the severity of the symptoms and the parents could not apply behavioral advice, fluoxetine 5 mg/d was started and was increased to 10 mg/d after a week. All symptoms decreased markedly after a period of 1 month, and the patient could sleep on her own and could stay without her mother at school. However, the parents described several adverse effects that started a few days after the treatment. She was picking the skin behind her ear many times during the day, and the skin in this area was excoriated. Another complaint of her parents was that she began to ask the same questions over and over again during the day to seek reassurance. Because of these adverse effects, fluoxetine was reduced to 5 mg daily. While the improvements in her initial symptoms continued, her skin-picking and compulsive-asking behaviors reduced by about half during a period of 1 month. At the third month of treatment, fluoxetine was discontinued. Compulsive-asking behaviors of patient completely disappeared within 1 month; however, skin-picking behaviors continued albeit at a diminishing pace.
In this case, it seems that fluoxetine treatment is responsible for the triggering of both the skin-picking and compulsive asking behaviors. We believe that, in the present case, these behaviors were the direct effects of fluoxetine on the grounds that there was no history of such behaviors before the drug and their rapid diminishment or disappearance after the discontinuation. However, this observation is unable to provide a definitive link, and it is possible that the emergence of these behaviors might simply be related to the development of coexisting psychiatric disorders such as skin-picking disorder or obsessive-compulsive disorder (OCD).
Information on the triggering of skin-picking behaviors with SSRIs was limited to adults.3 Denys et al3 reported 2 cases who developed pathological skin-picking behaviors after SSRI treatment and speculated that these behaviors may be related to the effects of serotonin in the brain systems. The fluoxetine has been demonstrated to enhance not only the extracellular concentrations of serotonin, but also the extracellular concentrations of dopamine in prefrontal cortex.4 In the literature, antiparkinsonian dopaminergic agents and methylphenidate were also reported to be related with skin-picking behaviors.5,6 Therefore, the rapid-onset skin picking of our case may be thought to occur as a result of excessive stimulation of both serotonin and dopamine receptors caused by fluoxetine. Serotonergic and dopaminergic systems have also played a role in OCD.7 Thus, fluoxetine-induced compulsive-asking behaviors may share the same mechanism with skin picking in this case. To our knowledge, there are no reports on the triggering effect of SSRIs on the OCD symptoms. However, an animal study demonstrated that dietary elevation of brain serotonin paradoxically induces compulsive behavior.8
In closing, this report suggests clinicians should be aware of the possibility that fluoxetine may induce skin-picking and compulsive behaviors. A trend for high ratio of adverse effects with fluoxetine in very young children has been previously reported,9 and aforementioned adverse effects could be more frequent at early ages. Further studies are needed to determine the frequency and clarify the mechanisms of these adverse effects.
1. Lochner C, Roos A, Stein DJ. Excoriation (skin-picking) disorder: a systematic review of treatment options. Neuropsychiatr Dis Treat
2. Schumer MC, Bartley CA, Bloch MH. Systematic review of pharmacological and behavioral treatments for skin picking disorder
. J Clin Psychopharmacol
3. Denys D, van Megen HJ, Westenberg HG. Emerging skin-picking behaviour after serotonin reuptake inhibitor-treatment in patients with obsessive-compulsive disorder: possible mechanisms and implications for clinical care. J Psychopharmacol
4. Bymaster FP, Zhang W, Carter PA, et al. Fluoxetine
, but not other selective serotonin uptake inhibitors, increases norepinephrine and dopamine extracellular levels in prefrontal cortex. Psychopharmacology (Berl)
5. Tse W, Hälbig TD. Skin picking in Parkinson's disease: a behavioral side-effect of dopaminergic treatment? Psychiatry Clin Neurosci
6. Kara T, Akaltun I. Newly developed skin picking after methylphenidate treatment in attention deficit hyperactivity disorder: possible mechanisms. Clin Neuropharmacol
7. Fonseka TM, Richter MA, Muller DJ. Second generation antipsychotic-induced obsessive-compulsive symptoms in schizophrenia: a review of the experimental literature. Curr Psychiatry Rep
8. Dufour BD, Adeola O, Cheng HW, et al. Nutritional up-regulation of serotonin paradoxically induces compulsive behavior. Nutr Neurosci
9. Lee CS, Williamson LR, Martin SE, et al. Adverse events in very young children
prescribed psychotropic medications: preliminary findings from an acute clinical Sample. J Child Adolesc Psychopharmacol