eMedicine Specialties > Dermatology > Diseases of the Adnexa

Trichotillomania: Treatment & Medication

Author: Chull-Wan Ihm, MD, Professor, Department of Dermatology, Chonbuk National University, Korea
Contributor Information and Disclosures

Updated: Aug 31, 2009

Treatment

Medical Care

In current practice, behavioral treatment seems to be the most powerful treatment, even with the patients older than age 16 years.16

In a broad sense, the common sense approach to stop the bad habit using parental involvement is a primitive form of behavioral therapy. It is worth trying first. In order to achieve the level of parental involvement necessary to aid in treatment, the physician should ensure that parents fully understand the entire nature of the alopecia. Some parents who have not witnessed episodes of hair pulling by their child refuse to believe that the condition is self-inflicted.17

In infant patients, loving care with enough maternal skin contact plus available transitional objects such as dolls or other toys would work well. For this purpose, parent-infant psychotherapy in combination with behavioral guidance may be needed.3

Parental involvement for the children should include enough support so that they grow well intellectually, physically, and socially. The author has found that in many cases, patients' extracurricular activities are almost solely of an intellectual nature (eg, drawing, math, language lessons) rather than balanced with social and physical activities.

Shaving or clipping hair close to the scalp may be helpful to stop the behavior and to assure the parents of the nature of the alopecia. Shaving a circumscribed area weekly (the "hair growth window") can have both diagnostic and reassurance benefits. Remember that the shaved (clipped) hairs are not all in the actively growing anagen stage and that a couple of months may be required before total regrowth is noted.

Professional cognitive behavior therapy (CBT) should be instituted if the above initial approaches do not work. The rationale for CBT is that awareness helps to overcome unwanted automated activity, and trichotillomania is a kind of unwanted automated repetition of hair manipulations. The author recommends that dermatologists be familiar with at least a few of the many different methods of CBT. The success of therapy may depend on firm understanding of the illness and the cooperation of the family members to help the patient maintain the treatment procedures. The duration of a course of CBT is usually 2 months. Several courses may be needed.

The 3 essentials of cognitive behavioral therapy are as follows16,18,19 :

  • Self-monitoring: The patient keeps records of hair-touching behavior. To help the patient comply, the author recommends a basic, not a fine detailed, recording plan. Patients simply record the daily frequency of hair touching by putting a stroke on a sheet of paper each time they touch their hair each day. Thus, the daily records are used to give the patient awareness of the habit and help the patient reduce the frequency. In the author’s experience, this very simple procedure alone is quite effective.20
  • Habit-reversal training: The patient should institute competing responses. The competing response should be incompatible with hair pulling (eg, making tight fists and holding for 2 min).
  • Stimulus control (organizing the patient's environment): Because hair manipulations usually occur when the patient is engaged in sedentary activities and is alone, performing daily physical exercise and being around people are helpful. Other activities that may be helpful to keep hands busy or away from the head include needlework, taking a walk, or wearing bandages on the fingers, among others.
CBT is typically effective in highly motivated and compliant patients; however, with various modifications it can be successfully applied even in patients in very early childhood.21

No medication has been approved for the treatment of trichotillomania. Drug therapy has largely been disappointing, although a recent study by Grant et al is encouraging (see Medication). Only a minority of patients receive temporary help from the currently available pharmacotherapy. The primary agents are selective serotonin reuptake inhibitors (eg, clomipramine),22 but a positive treatment response is not consistent. While drug monotherapy is generally not effective, combination therapy and other treatment modalities may be helpful.

In the author's experience, patients referred for psychoanalytical treatment have always shown disappointing results, which seems to back up the poor prognosis of adult patients. However, patients whose trichotillomania is largely of the focused type should be referred for psychiatric evaluation because this type shows comorbidity with systemic psychiatric disorders.

A clinical guideline summary from the American Academy of Child and Adolescent Psychiatry, Practice parameter for the assessment and treatment of children and adolescents with anxiety disorders,23 may be of interest.

Support groups
Support groups would be very helpful; however, currently, setting up and maintaining a support group for patients with trichotillomania is only a remote possibility in most countries because of the general lack of understanding of the disorder and because patients themselves are usually secretive about their behavior. An abundant amount of helpful information and educational tools can be found through the Trichotillomania Learning Center.

Consultations

Consult a psychiatrist when a serious psychiatric disorder is suspected.

Activity

Trichotillomania is primarily a psychiatric disorder. Physical exercise is always advisable. The author has found that many of the childhood and adolescent patients with trichotillomania spend too much time in study for examinations in school, sitting at a desk, rather than participating in physical activities.

Medication

In a 12-week, double-blind, placebo-controlled trial, Grant et al assessed whether N -acetylcysteine improved trichotillomania in adults (n = 50) with compulsive behavior. The dosage ranged from 1200 mg/d to 2400 mg/d. Improvement was measured by the Massachusetts General Hospital Hair Pulling Scale, the Clinical Global Impression scale, and the Psychiatric Institute Trichotillomania Scale. After 9 weeks of treatment, significantly greater reduction in hair-pulling symptoms (P = .001) was observed in patients taking N -acetylcysteine in both the Massachusetts General Hospital Hair Pulling Scale and the Psychiatric Institute Trichotillomania Scale. N -acetylcysteine restores extracellular glutamate concentration in the nucleus accumbens and therefore may be effective in reducing compulsive behavior. This study is thought to be the first to examine the effect of a glutamatergic agent for the treatment of trichotillomania.24

More on Trichotillomania

Overview: Trichotillomania
Differential Diagnoses & Workup: Trichotillomania
Treatment & Medication: Trichotillomania
Follow-up: Trichotillomania
Multimedia: Trichotillomania
References
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References

  1. Chamberlain SR, Odlaug BL, Boulougouris V, Fineberg NA, Grant JE. Trichotillomania: neurobiology and treatment. Neurosci Biobehav Rev. Jun 2009;33(6):831-42. [Medline].

  2. Salaam K, Carr J, Grewal H, Sholevar E, Baron D. Untreated trichotillomania and trichophagia: surgical emergency in a teenage girl. Psychosomatics. Jul-Aug 2005;46(4):362-6. [Medline].

  3. Keren M, Ron-Miara A, Feldman R, Tyano S. Some reflections on infancy-onset trichotillomania. Psychoanal Study Child. 2006;61:254-72. [Medline].

  4. Stein DJ, Christenson GA. Trichotillomania:Descriptive characteristics and phenomenlogy. In: Stein DJ, Christenson GA, Hollander E. Trichotillomania. 1. 1st. Washington,DC: American Psychiatric Press,Inc.; 1999:1-41/1.

  5. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition. 4th ed. Washington, DC: American Psychiatric Publishing; 2000.

  6. Christenson GA, Pyle RL, Mitchell JE. Estimated lifetime prevalence of trichotillomania in college students. J Clin Psychiatry. Oct 1991;52(10):415-7. [Medline].

  7. Mansueto CS, Thomas AM, Brice AL. Hair pulling and its afftective correlates in an African-American university sample. J Anxiety Disord. 4/2007;21:590-9.

  8. Diefenbach GJ, Tolin DF, Hannan S, Crocetto J, Worhunsky P. Trichotillomania: impact on psychosocial functioning and quality of life. Behav Res Ther. Jul 2005;43(7):869-84. [Medline].

  9. Murphy C, Redenius R, O'Neill E, Zallek S. Sleep-isolated trichotillomania: a survey of dermatologists. J Clin Sleep Med. Dec 15 2007;3(7):719-21. [Medline].

  10. Radmanesh M, Shafiei S, Naderi AH. Isolated eyebrow and eyelash trichotillomania mimicking alopecia areata. Int J Dermatol. May 2006;45(5):557-60. [Medline].

  11. Reeve EA, Bernstein GA, Christenson GA. Clinical characteristics and psychiatric comorbidity in children with trichotillomania. J Am Acad Child Adolesc Psychiatry. Jan 1992;31(1):132-8. [Medline].

  12. Lee YJ, Ihm CW. Clinical observation of 69 cases of trichotillomania. Korean J Dermatol. 2005;43:567-75.

  13. Koblenzer CS. Psychoanalytic Perspectives on Trichotillomania. In: Stein DJ, Christenson GA, Hollander E. Trichotillomania. 1. 1st. Washington,DC: American Psychiatric Press,Inc.; 1999:125-145/5.

  14. Randall W. Grooming reflexes in the cat: endocrine and pharmacological studies. Ann N Y Acad Sci. 1988;525:301-20. [Medline].

  15. Ihm CW, Han JH. Diagnostic value of exclamation mark hairs. Dermatology. 1993;186(2):99-102. [Medline].

  16. Bloch MH, Landeros-Weisenberger A, Dombrowski P, Kelmendi B, Wegner R, Nudel J. Systematic review: pharmacological and behavioral treatment for trichotillomania. Biol Psychiatry. Oct 15 2007;62(8):839-46. [Medline].

  17. Papadopoulos AJ, Janniger CK, Chodynicki MP, Schwartz RA. Trichotillomania. Int J Dermatol. May 2003;42(5):330-4. [Medline].

  18. Rothbaum BO, Ninan PT. Manual for the cognitive-behavioral treatment of trichotillomania. In: Stein DJ, Chistenson GA, Hollander E, eds. Trichotillomania. Washington, DC: APA Press; 1999:263-84.

  19. Keuthen NJ, Aronowitz B, Badenoch J. Behavioral treatment for trichotillomania. In: Stein DJ, Chistenson GA, Hollander E, eds. Trichotillomania. Washington, DC: APA Press; 1999:147-66.

  20. Anthony WZ. Brief intervention in a case of childhood trichotillomania by self-monitoring. J Behav Ther Exp Psychiat. 1978;9:173-5.

  21. Rahman O, Toufexis M, Murphy TK, Storch EA. Behavioral Treatment of Trichotillomania and Trichophagia in a 29-Month-Old Girl. Clin Pediatr (Phila). May 29 2009;[Medline].

  22. Swedo SE, Leonard HL, Rapoport JL, Lenane MC, Goldberger EL, Cheslow DL. A double-blind comparison of clomipramine and desipramine in the treatment of trichotillomania (hair pulling). N Engl J Med. Aug 24 1989;321(8):497-501. [Medline].

  23. [Guideline] Connolly SD, Bernstein GA. Practice parameter for the assessment and treatment of children and adolescents with anxiety disorders. J Am Acad Child Adolesc Psychiatry. Feb 2007;46(2):267-83. [Medline].

  24. [Best Evidence] Grant JE, Odlaug BL, Kim SW. N-acetylcysteine, a glutamate modulator, in the treatment of trichotillomania: a double-blind, placebo-controlled study. Arch Gen Psychiatry. Jul 2009;66(7):756-63. [Medline].

  25. Azrin NH, Nunn RG. Habit Control in a Day. New York, NY: Simon & Schuster; 1978.

  26. Begotka AM, Woods DW, Wetterneck CT. The relationship between experiential avoidance and the severity of trichotillomania in a nonreferred sample. J Behav Ther Exp Psychiatry. Mar 2004;35(1):17-24. [Medline].

  27. Christenson GA, Mackenzie TB, Mitchell JE. Characteristics of 60 adult chronic hair pullers. Am J Psychiatry. Mar 1991;148(3):365-70. [Medline].

  28. Flessner CA, Conelea CA, Woods DW, Franklin ME, Keuthen NJ, Cashin SE. Styles of pulling in trichotillomania: exploring differences in symptom severity, phenomenology, and functional impact. Behav Res Ther. Mar 2008;46(3):345-57. [Medline].

  29. Mannino FV, Delgado RA. Trichotillomania in children: a review. Am J Psychiatry. Oct 1969;126(4):505-11. [Medline].

  30. Mansueto CS, Stemberger RM, Thomas AM, Golomb RG. Trichotillomania: a comprehensive behavioral model. Clin Psychol Rev. 1997;17(5):567-77. [Medline].

  31. Muller SA. Trichotillomania: a histopathologic study in sixty-six patients. J Am Acad Dermatol. Jul 1990;23(1):56-62. [Medline].

  32. Muller SA, Winkelmann RK. Trichotillomania. A clinicopathologic study of 24 cases. Arch Dermatol. Apr 1972;105(4):535-40. [Medline].

  33. Song IM, Ihm CW. Clinicohistopathologic analysis of 28 cases of trichotillomania. Korean J Dermatol. 1997;35(6):1101-9.

  34. Sperling LC, Lupton GP. Histopathology of non-scarring alopecia. J Cutan Pathol. Apr 1995;22(2):97-114. [Medline].

  35. Tay YK, Levy ML, Metry DW. Trichotillomania in childhood: case series and review. Pediatrics. May 2004;113(5):e494-8. [Medline].

  36. Woods DW, Flessner C, Franklin ME, et al. Understanding and treating trichotillomania: what we know and what we don't know. Psychiatr Clin North Am. Jun 2006;29(2):487-501, ix. [Medline].

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Further Reading

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Keywords

trichotillomania, hair pulling, morbid hair pulling, hair-related psychosis, alopecia, psychotic alopecia, self-induced primary psychiatric disorders, self-induced psychiatric disorder, traumatic alopecia, hair loss, trichotillosis, trichomalacia

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Contributor Information and Disclosures

Author

Chull-Wan Ihm, MD, Professor, Department of Dermatology, Chonbuk National University, Korea
Chull-Wan Ihm, MD is a member of the following medical societies: American Academy of Dermatology and American Society of Dermatopathology
Disclosure: Nothing to disclose.

Medical Editor

Leonard Sperling, MD, Chair, Professor, Department of Dermatology, Uniformed Services University of the Health Sciences
Leonard Sperling, MD is a member of the following medical societies: American Academy of Dermatology
Disclosure: Nothing to disclose.

Pharmacy Editor

David F Butler, MD, Professor of Dermatology, Texas A&M University College of Medicine; Chair, Department of Dermatology, Director, Dermatology Residency Training Program, Scott and White Clinic, Northside Clinic
David F Butler, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Dermatology, American Medical Association, American Society for Dermatologic Surgery, American Society for MOHS Surgery, Association of Military Dermatologists, and Phi Beta Kappa
Disclosure: Nothing to disclose.

Managing Editor

Edward F Chan, MD, Clinical Assistant Professor, Department of Dermatology, University of Pennsylvania School of Medicine
Edward F Chan, MD is a member of the following medical societies: American Academy of Dermatology, American Society of Dermatopathology, and Society for Investigative Dermatology
Disclosure: Nothing to disclose.

CME Editor

Catherine M Quirk, MD, Clinical Assistant Professor, Department of Dermatology, University of Pennsylvania
Catherine M Quirk, MD is a member of the following medical societies: Alpha Omega Alpha and American Academy of Dermatology
Disclosure: Nothing to disclose.

Chief Editor

Dirk M Elston, MD, Director, Department of Dermatology, Geisinger Medical Center
Dirk M Elston, MD is a member of the following medical societies: American Academy of Dermatology
Disclosure: Nothing to disclose.

 
 
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