Habit reversal training for excoriation disorder: Differential outcomes of telehealth versus in-person treatments

Excoriation disorder (ED) is characterized by the presence of compulsive skin-picking behaviors and resulting distress/impairment. First-line psychotherapeutic for ED is habit reversal training (HRT). This intervention is designed develop awareness and skills to better tolerate urges to engage in picking behaviors and replace with more benign behaviors. While effective, limited work has directly compared in-person and telehealth HRT for ED. Here, we describe an adult male diagnosed with ED, highlighting differential outcomes associated with HRT following telehealth and in-person treatment. Symptom severity was recorded using the Skin Picking Scale (SPS-R) at pre-treatment and every 3-weeks until treatment completion. Treatment was initially delivered via telehealth with the patient scoring 19/32 on the SPS-R and only completing three virtual visits due to marked frustration with the virtual context and limited treatment progress. The patient presented again to clinic after one year with SPS-R score of 20/32 and successfully completed 16 in-person visits (SPS-R = 8). Discussion of this case highlights important factors that may contribute to these differential outcomes, including familiarity with telehealth technology, limited field of view with telehealth, and limited family involvement, as well as relevant considerations for providers when offering telehealth services. While the case presentation does highlight important differences, side-by-side clinical trials should be conducted before more stringent treatment recommendations are developed.