PS51 Attention deficit/hyperactivity disorder treatment and skin picking: help or harm?

Abstract

Body-focused repetitive behaviours (BFRBs), including excoriation disorder and trichotillomania, commonly occur in individuals with attention deficit/hyperactivity disorder (ADHD). ADHD pharmacotherapies are widely used, yet their effects on BFRBs remain poorly characterized. Emerging reports suggest a complex, bidirectional relationship in which medications may either improve or worsen these behaviours, highlighting the need for a clinically focused synthesis across medication classes. A review was carried out to summarize current clinical and case-based evidence on how common ADHD medications influence skin picking and related BFRBs, and to identify patterns of improvement, exacerbation or new-onset behaviours associated with treatment. A literature review was conducted using MEDLINE/PubMed, Embase, Cochrane Library and CINAHL, including studies across all available designs. Eligible publications described children or adults with diagnosed or implied ADHD treated with stimulant or nonstimulant agents (methylphenidate, amphetamine derivatives, atomoxetine, guanfacine, clonidine or bupropion), in whom BFRBs were reported as treatment outcomes or adverse effects. Case reports, small case series, cohort studies, open trials and reviews were included due to the limited evidence base. Across stimulants and atomoxetine, a consistent bidirectional pattern was observed. Skin picking often improved in presentations characterized by automatic or inattentive behaviours, linked to enhanced inhibitory control after medication initiation. However, a minority experienced new or worsened BFRBs after treatment onset or dose escalation, particularly with co-occurring anxiety, obsessive–compulsive disorder or tic disorders. Alpha-2 adrenergic agonists, especially guanfacine extended release, showed the most consistently favourable signal, although data remain limited and primarily nonrandomized. ADHD medications are neither uniformly therapeutic nor uniformly harmful for BFRBs; their impact appears to depend on individual vulnerability rather than drug class alone. Clinicians should treat ADHD as indicated but closely monitor for both benefit and emergent BFRBs, considering alpha-2 agonists where medication-linked behaviours arise, and remain alert to ADHD medication effects when managing BFRBs.