There have been some studies that support medication as a treatment for body-focused repetitive behaviours (BFRBs). However, each person’s biological makeup is different and therefore must be treated uniquely by a medical professional.

Here, we will go through some examples of using medication to successfully treat BFRBs, particularly those that target the body’s glutamate system. The glutamate system includes receptors and pathways in the brain and spinal cord that use glutamate as a neurotransmitter (how your body sends messages to the brain). Glutamate is the main chemical that stimulates nerve activity in the central nervous system, and it is needed for healthy brain function, learning, and memory. Glutamate also creates other neurotransmitters that allow healthy sleep, anxiety regulation, and muscle function. Having too much glutamate can cause conditions such as dementia and fibromyalgia, while issues in producing or using glutamate can lead to mental health disorders such as depression and obsessive-compulsive disorder (OCD) (Cleveland Clinic, 2022).

Vitamin Supplements

BFRBs are categorised under Obsessive-Compulsive Related Disorders in the DSM-5 (American Psychiatric Association, 2022). Baratzedah et al. (2021) suggest that oxidative stress – where the body has too few antioxidants causing cell damage and inflammation – damages the brain, contributing to OCD symptoms, including BFRBs.

N-Acetylcysteine (NAC)

N-acetylcysteine (NAC) is a supplement that replenishes glutathione (the body’s main antioxidant) in the brain and is known for reducing oxidative stress (Tenório et al., 2021). NAC targets the glutamate system by modulating, or controlling, glutamate levels in the brain.

NAC has also been associated with reducing cortisol levels, which is often described as “the stress hormone,” though its role in the body is far more complex. Cortisol naturally increases in the morning to kickstart the day – called the ‘cortisol awakening response’ (CAR) – and lowers in the evening to allow sleep. Many people with BFRBs experience a reversed effect, feeling extremely low in energy on waking and only beginning to feel alert by the time most people go to bed (Kluge et al., 2007). High cortisol levels are linked to an increased risk of BFRBs (Graubard et al., 2021), so this unnatural reversal can exacerbate symptoms.

Researchers from Stanford University School of Medicine (George et al., 2015) developed a study of NAC and glutathione to prevent skin picking and hair pulling, based on evidence that oxidative stress causes neurological inflammation and damage leading to BFRBs. Laboratory mice who showed excessive grooming (similar to skin picking and hair pulling in humans) were supplemented with NAC and glutathione. This supplement led to decreased grooming; most mice given NAC were cured after 6-8 weeks, and around half of the mice given glutathione were cured in 2-3 weeks. However, the other half of the mice given glutathione showed no improvement at all, which highlights how individual biology affects medication responses.

A later study by Jones et al. (2018) recommends using NAC for human BFRBs, and an updated literature review by Lee and Lipner (2022) details successful cases, though they warn that larger studies are needed to draw robust conclusions. A recent case study (Khan et al., 2024) also highlights how the correct dose of NAC can effectively treat skin picking.

Many people find NAC helpful in reducing their BFRBs, but ideally, a full nutritional programme should be tailored to the individual by qualified personnel.

Medications

Memantine

A February 2023 study explored the use of a dementia medication, memantine, for trichotillomania and dermatillomania. Grant et al. (2023) found that most people with BFRBs were referred to psychiatrists rather than dermatologists. This appears to make good clinical sense, as the study also found that memantine significantly reduced skin picking and hair pulling compared with a placebo.

Memantine, originally prescribed for moderate to severe dementias such as Alzheimer’s and Huntington’s diseases, targets the glutamate system. The study found that 60.5% of participants in the memantine group were “much or very much improved,” compared with 8.3% in the placebo group. This research opens up an exciting future for treating BFRBs with medication that has already been tested for side effects and use alongside other medications.

Selective Serotonin Reuptake Inhibitors (SSRIs)

SSRIs are commonly used to treat depression and anxiety and have been explored for BFRBs. However, evidence regarding their effectiveness is mixed. While some individuals experience benefits, larger studies are needed to draw definitive conclusions (JDD Online, 2023).

Clomipramine (Anafranil)

Clomipramine, a tricyclic antidepressant, has shown potential in treating trichotillomania by affecting serotonin and norepinephrine levels. While it may benefit those with concurrent depression or OCD, possible side effects include dry mouth, constipation, and weight gain. Starting with a low dose and gradually increasing can help manage these effects (BFRB.org, 2023).

Other Considerations

Glutamatergic Agents

Research into medications affecting the glutamate system, such as riluzole and topiramate, is ongoing. These agents aim to address the underlying neurochemical aspects of BFRBs, but more robust clinical trials are necessary to establish their efficacy and safety (JDD Online, 2023).

Comprehensive Behavioural Treatment (ComB)

While not a medication, it is important to highlight that behavioural therapies, particularly the Comprehensive Behavioural Model (ComB), have demonstrated effectiveness in managing BFRBs. Combining behavioural interventions with pharmacological treatments may offer enhanced benefits (CTV Veeva, 2023).

References

American Psychiatric Association (2022) Diagnostic and statistical manual of mental disorders (5th ed., text rev.). Available at: https://doi.org/10.1176/appi.books.9780890425787 (Accessed: February 2025).

Baratzadeh et al – Baratzadeh, F., Elyasi, S., Mohammadpour, A. H., Salari, S., & Sahebkar, A. (2021) ‘The role of antioxidants in the management of obsessive-compulsive disorder’, Oxidative Medicine and Cellular Longevity, 2021(1), p. 6661514. Available at: https://doi.org/10.1155/2021/6661514 (Accessed: February 2025).

Cleveland Clinic (2022) Glutamate. Available at: https://my.clevelandclinic.org/health/articles/22839-glutamate (Accessed: February 2025).

George et al – George, N. M., Whitaker, J., Vieira, G., Geronimo, J. T., Bellinger, D. A., Fletcher, C. A., & Garner, J. P. (2015) ‘Antioxidant therapies for ulcerative dermatitis: A potential model for skin picking disorder’, PloS One, 10(7), e0132092. Available at: https://doi.org/10.1371/journal.pone.0132092 (Accessed: February 2025).

Grant et al – Grant, J. E., Chesivoir, E., Valle, S., Ehsan, D., & Chamberlain, S. R. (2023) ‘Double-blind placebo-controlled study of memantine in trichotillomania and skin-picking disorder’, American Journal of Psychiatry, 180(5), pp. 348–356. Available at: https://doi.org/10.1176/appi.ajp.20220737 (Accessed: February 2025).

Graubard et al – Graubard, R., Perez-Sanchez, A., & Katta, R. (2021) ‘Stress and skin: An overview of mind-body therapies as a treatment strategy in dermatology’, Dermatology Practical & Conceptual, 11(4), e2021091. Available at: https://doi.org/10.5826/dpc.1104a91 (Accessed: February 2025).

Jones et al – Jones, G., Keuthen, N., & Greenberg, E. (2018) ‘Assessment and treatment of trichotillomania (hair pulling disorder) and excoriation (skin picking) disorder’, Clinics in Dermatology, 36(6), pp. 728–736. Available at: https://doi.org/10.1016/j.clindermatol.2018.08.008 (Accessed: February 2025).

Khan et al – Khan, S., Hughes, S., & Hill, O. (2024) ‘N-acetyl Cysteine supplementation to alleviate skin picking disorder: A case report’, Cureus, 16(2), e53440. Available at: https://doi.org/10.7759/cureus.53440 (Accessed: February 2025).

Kluge et al –  Kluge, M., Schüssler, P., Künzel, H. E., Dresler, M., Yassouridis, A., & Steiger, A. (2007) ‘Increased nocturnal secretion of ACTH and cortisol in obsessive-compulsive disorder’, Journal of Psychiatric Research, 41(11), pp. 928-933. Available at: https://doi.org/10.1016/j.jpsychires.2006.08.005 (Accessed: February 2025).

Lee et al – Lee, D. K., & Lipner, S. R. (2022) ‘The potential of N-acetylcysteine for treatment of trichotillomania, excoriation disorder, onychophagia, and onychotillomania: An updated literature review’, International Journal of Environmental Research and Public Health, 19(11), p. 6370. Available at: https://doi.org/10.3390/ijerph19116370 (Accessed: February 2025).

Tenório, M. C. D. S., Graciliano, N. G., Moura, F. A., Oliveira, A. C. M., & Goulart, M. O. F. (2021) ‘N-acetylcysteine (NAC): Impacts on human health’, Antioxidants (Basel, Switzerland), 10(6), p. 967. Available at: https://doi.org/10.3390/antiox10060967 (Accessed: February 2025).