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Introduction: We present a case of a middle age patient with skin excoriation disorder since age 15 who experienced significant improvement with augmentation of her treatment regimen with N-acetyl cysteine. This improvement occurred despite a recurrence of her depression, alcohol use disorder, and stimulant use disorder. Case Presentation: A 59 year-old-female with 44 years of unsuccessful treatment of self-excoriation disorder presented with symptoms of unspecified depression, OCD and stimulant use disorder. She was referred by her surgeon who had to postpone a revision of her hip replacement as she was self-excoriating the right axillary lymphadenectomy site. Initial administration of PHQ-9 revealed a score of 20. She was diagnosed with right breast cancer over 10 years ago, status post radical mastectomy of the right breast. She had episodes of extended sobriety and still had skin picking. She had been using cocaine and alcohol for the past couple of years, even though she was involved in out-patient treatment. It was difficult to cope with her current psychosocial situation which made it difficult for her to maintain sobriety. She continued to pick on her surgical site, which caused her wounds to remain fresh and sore. She self-reported that she struggled with efforts not to pick her skin and even attempted to wear gloves on her hands at bedtime to prevent herself from picking through the night. The patient had been taking paroxetine 60mg per day which she reported had helped. This medication was therefore continued as previously prescribed. We initiated N-acetyl cysteine as it has been shown to have improved skin picking in patients. (1) N-acetyl cysteine was initiated at 1200mg per day, titrating this to 2400mg per day. Also, the patient was referred for CBT and was continued for outpatient cocaine addiction treatment. Given this combination of treatment, the patient showed significant improvement in of her skin picking. She self-reported doing well, going on for months without picking at of her wound. On examination, her wound appeared to be healing significantly and there was noticeable improvement compared to initial examination. There has been significant improvement on the surgical site as observed during the subsequent three monthly follow ups. Conclusion: In light of limited treatment options, the trial of N-acetyl cysteine in patients that suffer from this significantly stressful condition would be beneficial. References: 1. Psychopharmacology: N-Acetylcysteine May Help Patients Resist Urge to Pick Skin Nick Zagorski Published online: April 01, 2016



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