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Glutamatergic Dysfunction in Skin-Picking Disorder Treatment of a Pediatric Patient With N-Acetylcysteine To the Editors: S kin-picking disorder (SPD) is charac- terized by repetitive and compulsive picking behaviors that result in skin le- sions. 1 Cognitive behavioral therapy and psychopharmacological agents (ie, selec- tive serotonin reuptake inhibitors, mood stabilizers, typical/atypical antipsychotics, and naltrexone) are generally used to treat SPD, but there is no standardized treatment protocol. 1Y3 N-Acetylcysteine (NAC) is an antiox- idant that modulates glutamate (glu) trans- mission in the brain. 4 N-Acetylcysteine is an effective treatment for patients with obsessive-compulsive disorder (OCD), as glutamatergic dysfunction is known to play a significant role in its pathophysiology. 5Y7 Because of this, NAC has been increasingly prescribed to patients with SPD. 8,9 In this case report, we discuss the clinical course of a 12-year-old female patient diagnosed with SPD that was treated with NAC. CASE REPORT A 12-year-old girl presented to our clinic with symptoms of marked distress, and she had been picking the skin on her face, arms, and legs for nearly 4 years. At first, she began picking the skin on her forehead and cheeks with her fingernails when experiencing stress. At that time, her parents considered this behavior a ‘‘bad habit.’’ However, although the patient’s parents repeatedly reminded her to stop picking her skin, her behaviors persisted. One year after the onset of symptoms, the wounds on the patient’s face began to in- crease and scar. Due to the growing con- cerns of her family, they applied to a dermatological clinic, which found no der- matological pathology. Then, they applied to another clinic, where the child was monitored by a child and adolescent psy- chiatrist. After a failed attempt at habit re- versal therapy, for the next 4 years, the patient was given fluoxetine (40 mg/d), sertraline (200 mg/d), olanzapine (20 mg/d), aripiprazole (20 mg/d), and valproic acid (2000 mg/d) at the maximum tolerated dose for at least 10 to 12 weeks at a time in single or combined form. However, the patient’s symptoms did not regress, and she decided to stop the treatment. The patient believed that she could overcome the problem on her own, and that she did not need a physician. However, she presented to our clinic 6 months later with aggressive skin picking, which caused bleeding on her face, legs, and arms. The patient’s medical and family history did not show any obvi- ous characteristics. There were multiple skin wounds of various sizes and at differ- ent stages of healing on her face, arms, and legs. A physical examination did not reveal any acute source of bleeding. However, we observed wounds that were crusted, which indicated prior mild bleeding. The patient reported that she was moderately de- pressed, and her affect was consistent with her mood. Her perception, thought process, and thought content were all within normal limits. However, during the last 6 months, her skin-picking behaviors progressed, she became increasingly socially isolated, her peer relationships deteriorated, and her academic performance further declined. No substance use was detected. The pa- tient was referred to dermatology for a re-evaluation to determine any possible or- ganic etiologies of her skin condition, but none were found. After ruling out psychi- atric disorders characterized by repetitive and stereotyped behaviors, the patient was diagnosed with SPD according to the Di- agnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-V) criteria. She scored a 5 on the Clinical Global Impression-Severity (CGI-S) scale, which classified her as ‘‘Markedly Ill.’’ Because her previous medical treatments were unsuccessful, we decided to start her on 600 mg/d NAC. During the duration of her NAC treatment, she did not take any other medications. After 2 weeks of treatment, she had fewer compulsions to pick her skin, but when she did feel compelled to pick, she could not stop herself from Letters to the Editors Journal of Clinical Psychopharmacology & Volume 34, Number 6, December 2014 772 www.psychopharmacology.com * 2014 Lippincott Williams & Wilkins Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.