Research Points to Drug Option for Hair-Pulling and Skin-Picking Disorders

Summary: Memantine, a drug commonly prescribed to treat symptoms of Alzheimer’s disease, reduces symptoms for adults with hair-pulling and skin-picking disorders.

Source: University of Chicago

New research at the University of Chicago Medicine has found that a drug commonly used to treat symptoms of Alzheimer’s disease effectively reduced symptoms of adults who experience compulsive hair-pulling and skin-picking.

Treatment with the drug memantine was associated with significant improvements compared to a placebo for patients with trichotillomania (a disorder where individuals cannot resist the urge to pull out their hair) and skin-picking disorder (also known as excoriation disorder).

No medication is currently approved by the U.S. Food and Drug Administration for the disorders, which can cause obvious hair loss and skin damage, emotional distress and reduced ability to function socially or at school or work, said lead author Jon Grant, MD, professor of psychiatry and behavioral neuroscience at the University of Chicago Medicine.

“A person’s self-esteem is greatly impacted by these behaviors, so they may not go for interviews for a better job, for example. They may not have the social life they want,” Grant said.

Trichotillomania and skin-picking disorder are regarded as two separate diagnoses, but they have many similarities. Cognitive behavioral therapy is a first-line treatment, but finding therapists well-versed in the disorders can be difficult, he said.

“People often feel that they have to educate the clinician,” Grant said.

Researchers honed in on memantine based on earlier findings by Grant and others that revealed, in individuals with either disorder, disorganized areas of white matter in certain parts of the brain controlling motor habits.

The findings suggested involvement of the neurotransmitter glutamate, a leading theory of the neurobiology behind obsessive-compulsive disorder, Grant said.

When it comes to drugs, “We don’t have a lot of options about what might modulate glutamate in the brain,” he said.

Grant selected memantine, which is approved to address memory loss and deficits in thinking in people with Alzheimer’s disease and has been used off-label for various psychiatric disorders. It is well-tolerated by patients and has few serious side effects, he said.

While Grant was investigating memantine for trichotillomania and skin-picking disorder, another patient of his was prescribed the drug for a separate reason.

“It came kind of serendipitously,” he said. “One day the patient told me, ‘Wow, that stopped me from pulling my hair.’”

The new study at the University of Chicago involved 100 adults with trichotillomania or skin-picking disorder who were enrolled in the double-blind trial of memantine or a placebo for eight weeks.

Researchers assessed patients every two weeks using the National Institute of Mental Health Trichotillomania Symptom Severity Scale, which they modified for skin-picking, because there is no commonly used measurement for the disorder.

They also recorded changes using four other self-reported and clinician-observed accounts of symptoms and behaviors. Patients were seen virtually because of the COVID-19 pandemic.

Seventy-nine participants completed the study. Two dropped out after reporting dizziness while taking the medication.

After eight weeks, 26 of the 43 study participants taking memantine had much improvement or very much improvement, compared to three of the 36 taking a placebo. Six people in the memantine group and one in the placebo group had complete relief of symptoms.

An analysis found that memantine is more effective than other treatments studied thus far, including behavioral therapy, the drug olanzapine (used to treat schizophrenia and bipolar disorder), the drug clomipramine (used to treat obsessive-compulsive disorder), and N-acetylcysteine (an over-the-counter supplement).

The comparisons suggest that memantine might be considered a first-line treatment equal to behavioral therapy in the treatment process for these conditions, according to the study.

Grant said the results point to several additional areas for research, including combining memantine with behavioral therapy or with N-acetylcysteine, which showed promise in previous studies led by Grant. Longer-term use of memantine and different doses also are potential avenues for study, he said.

“The results did show that the medication helped more than the placebo, for which I was very pleased, but it tells me that there’s still a lot more to do,” Grant said. “Even though the results were promising, it was still a very small minority of people in terms of complete remission of symptoms.”

Still, some study participants indicated they intended to seek memantine prescriptions from their primary physicians to continue on the drug, Grant said.

“Some people came in thinking, ‘Nothing has been able to help me.’ Some of them were seeing by the end that this one is different,” he said.

Abstract

Double-Blind Placebo-Controlled Study of Memantine in Trichotillomania and Skin-Picking Disorder

Objective:

Trichotillomania and skin-picking disorder are underrecognized and often disabling conditions in which individuals repeatedly pull at their hair or pick at their skin, leading to noticeable hair loss or tissue damage. To date there is a severe paucity of evidence-based treatments for these conditions. In this study, the authors sought to determine whether memantine, a glutamate modulator, is more effective than placebo in reducing hair-pulling and skin-picking behavior.

Methods:

One hundred adults with trichotillomania or skin-picking disorder (86 women; mean age, 31.4 years [SD=10.2]) were enrolled in a double-blind trial of memantine (dosing range, 10–20 mg/day) or placebo for 8 weeks. Participants were assessed with measures of pulling and picking severity. Outcomes were examined using a linear mixed-effects model. The prespecified primary outcome measure was treatment-related change on the NIMH Trichotillomania Symptom Severity Scale, modified to include skin picking.

Results:

Compared with placebo, memantine treatment was associated with significant improvements in scores on the NIMH scale, Sheehan Disability Scale, and Clinical Global Impressions severity scale in terms of treatment-by-time interactions. At study endpoint, 60.5% of participants in the memantine group were “much or very much improved,” compared with 8.3% in the placebo group (number needed to treat=1.9). Adverse events did not differ significantly between the treatment arms.

Conclusions:

This study found that memantine treatment resulted in statistically significant reductions in hair pulling and skin-picking symptoms compared with placebo, with relatively high efficacy (based on number needed to treat), and was well tolerated. The glutamate system may prove to be a beneficial target in the treatment of compulsive behaviors.