Trichotillomania Treatment & Management

Updated: Aug 05, 2019
  • Author: Dirk M Elston, MD; Chief Editor: William D James, MD  more...
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Approach Considerations

The diagnosis of trichotillomania should be confirmed through a workup.

Determine whether symptoms represent a short-term childhood habit rather than true trichotillomania.

Distinguish whether the patient engages in inattentive automatic pulling or focused pulling in response to stressful emotions, as these pulling styles affect therapy selection.

Determine whether the symptoms indicate a more serious psychological problem through consultation and collaboration with a psychiatrist, developmental-behavioral pediatrician, or licensed clinical psychologist; consultation is recommended and may be required for choosing various treatment options. [27]

Recognize that children with presenting symptoms of trichobezoars may require further evaluation via ultrasonography, magnetic resonance imaging (MRI), or computed tomography (CT).

Currently available evidence suggests that the first line of treatment for trichotillomania is behavioral treatment and intervention, with a focus on affective regulation. [28] No medication has been approved for the treatment of trichotillomania. Drug therapy has largely been disappointing, although some studies have yielded encouraging results. [29, 30, 31]

N-acetyl cysteine may be of benefit, as may behavior modification techniques and psychotherapy. [32, 33]

A psychiatrist should be consulted when a serious psychiatric disorder is suspected. Consultations with other specialists (eg, a psychologist or a developmental-behavioral pediatrics specialist) should be obtained as indicated. A surgeon may be consulted if removal of trichobezoars in the stomach and intestines is under consideration.


Behavioral Interventions

In current practice, behavioral treatment seems to be the most powerful intervention, even for patients older than 16 years. [34] Effective behavioral strategies in the treatment of trichotillomania in children include the following:

  • Habit reversal: This is a set of procedures taught to a child that includes the following components: increasing awareness of the habit; teaching a competing response to practice when the child feels the urge to engage in the habit, in situations in which the habit historically occurs, or for 1 minute after the occurrence of the habit; practicing stress and anxiety reduction procedures daily; and support and encouragement from parents. [35] Studies suggest that traditional habit-reversal therapy is most beneficial in patients with automatic pulling. [7]
  • Self-monitoring: This involves systematically observing and discriminating when the behavior occurs, recording the responses, and evaluating one’s own behavior.
  • Competing reaction training: This is a component of habit reversal that is occasionally used alone; a child is taught a socially appropriate alternative behavior or response and is encouraged to practice it on daily when he or she feels the urge to engage in the habit, in situations in which the habit historically occurs, or for 1 minute after the occurrence of the habit. Recommended behaviors should be inconspicuous and able to be performed in public for 60-90 seconds (eg, holding a clenched fist with both hands).
  • Relaxation training: This involves helping children identify their own bodily sensations associated with tension and then using procedures designed to induce relaxation; typically, it is individualized and may include such procedures as deep-breathing strategies and systematic muscle tensing and relaxation. Targeting anxiety and tension is of particular importance in patients with more focused pulling behavior. [7]
  • Psychotherapy: This process involves direct communication (mainly talking) between a therapist and a child and makes use of various techniques to help solve behavioral and other psychological problems; one of its most popular forms is cognitive-behavioral therapy (CBT).
  • Hypnosis: This is a process of controlling physiologic responses by focusing attention on specific mental images for therapeutic purposes, typically to gain more control over behavior, emotions, or physical well-being; in a hypnotized state, the subject is more open than usual to suggestions (provided by the hypnotist) for subsequent changes in behavior.
  • Elimination of a comorbid behavior: When two seemingly different behaviors occur together (eg, trichotillomania and thumb sucking), a treatment to reduce or change one of them may also reduce or change the other.

In a broad sense, the commonsense approach to stopping the bad habit that makes use of parental involvement is a primitive form of behavioral therapy. It is worth trying first. 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. [36]

In infant patients, provision of loving care with enough maternal skin contact, in conjunction with 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. [7]

Parental involvement should include enough support to ensure that their children grow well not only intellectually but also physically and socially. In many cases, patients’ extracurricular activities are almost solely of an intellectual nature (eg, drawing, mathematics, language lessons) and are not well balanced with social and physical activities.

Shaving or clipping hair close to the scalp may be helpful both for stopping the behavior and for educating the parents regarding the nature of the alopecia. Shaving a circumscribed area weekly (the “hair growth window”) can yield benefits both for diagnosis and for reassurance. It should be kept in mind 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.

If these initial approaches do not work, CBT should be instituted. Trichotillomania is a kind of unwanted automated repetition of hair manipulations, and the awareness gained through CBT can help overcome such unwanted automated activity. Dermatologists who treat these patients should, therefore, be familiar with at least a few of the various CBT methods. Therapeutic success may depend on a firm understanding of the illness and on the cooperation of the family. Several courses of CBT may be needed; each course usually lasts 2 months.

In the authors’ experience, patients referred for psychoanalytical treatment often show disappointing results. 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.

Support groups

Support groups would be very helpful. At present, however, 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.


Pharmacologic Therapy

Few drug studies on trichotillomania in children and adults exist. The majority of studies to date have investigated the efficacy of selective serotonin reuptake inhibitors (SSRIs) because of their role in other obsessive-compulsive disorders. [37] These agents have demonstrated a degree of effectiveness in some patients with trichotillomania, but a positive treatment response is not consistent. [37] In children, SSRIs (eg, fluoxetine, sertraline, fluvoxamine) may be more advantageous as a medication choice than tricyclic antidepressants (TCAs) because of their milder adverse effects.

Although at present, no pharmacotherapy for trichotillomania is consistently effective, several studies show promise. The most compelling data to date are focused on N-acetylcysteine (NAC) and olanzapine. [37]

In a double-blind, placebo-controlled trial, Grant et al assessed whether N -acetylcysteine (1200-2400 mg/day) improved trichotillomania in adults with compulsive behavior. [29] Improvement was measured on the Massachusetts General Hospital Hair Pulling Scale (MGH-HPS), the Clinical Global Impression-Improvement (CGI-I) scale, and the Psychiatric Institute Trichotillomania Scale (PITS). After 9 weeks, significantly greater reduction in hair-pulling symptoms on both the MGH-HPS and the PITS was noted in patients taking N-acetylcysteine. Other authors also have had success. [38]

A study by Bloch et al, however, failed to document a significant improvement with N -acetylcysteine in children with trichotillomania. [39] Their 12-week randomized, double-blinded, placebo-controlled trial was conducted using N -acetylcysteine in children and adolescents aged 8-17 years (N=39) with trichotillomania. The trial did not show a benefit for treatment with N -acetylcysteine when compared with placebo. The authors did note that both groups improved with time, which could be attributed to the patients receiving education and support while being in the study.

Grant et al also assessed the efficacy of the cannabinoid dronabinol for treating trichotillomania in a small open-label treatment study in female subjects, finding that a dosage of 11.6±4.1 mg/day led to a decrease in the mean MGH-HPS from 16.5±4.4 at baseline to 8.7±5.5 at study endpoint. [30] In all, 64.3% of the subjects showed both a decrease in MGH-HPS and a rating of “much or very much” improved on the CGI-I scale, with no adverse effects on cognition.

Van Ameringen et al studied the efficacy of flexible-dose olanzapine for the treatment of trichotillomania in a randomized, double-blind, placebo-controlled trial. [31] A dosage of 10.8±5.7 mg/day showed a significant decrease in the Yale-Brown Obsessive Compulsive Scale for Trichotillomania and the CGI-Severity of Illness scale, with 85% of the subjects who received olanzapine showing improvement on the CGI-I scale. The drug appears to be both safe and effective.

In a study by Golubchik et al, methylphenidate showed limited efficacy in trichotillomania patients with comorbid attention deficit-hyperactivity disorder (ADHD) and a low rate of stressful life events (SLEs). [40]

Case studies suggest that both oxcarbazepine and aripiprazole warrant further study as possible treatments for trichotillomania. [41, 42]

The use of bimatoprost in the treatment of madarosis due to trichotillomania has been described. A 55-year-old woman with trichotillomania was started on bimatoprost 0.03% solution daily. At 2 months, the number and length of eyelashes had doubled compared with the baseline. The medication was stopped at 6 months, and no adverse effects were reported. The patient continued to take amitriptyline to control the urge to pull and fluoxetine for anxiety during the 6 months of treatment. [43]

Whereas drug monotherapy is generally not effective, combination therapy and the addition of other treatment modalities may be helpful.

Antidepressants in pediatric patients

Physicians are advised to be aware of the following information and to use appropriate caution when considering treatment with antidepressants in the pediatric population.

In December 2003, the UK Medicines and Healthcare Products Regulatory Agency (MHRA) issued an advisory stating that most SSRIs are not suitable for use by persons younger than 18 years for treatment of “depressive illness.” After review, this agency decided that the risks SSRIs pose to pediatric patients outweigh the benefits of treatment, except in the case of fluoxetine, which appears to have a positive risk-benefit ratio in the treatment of depressive illness in patients younger than 18 years.

In October 2003, the US Food and Drug Administration (FDA) issued a public health advisory regarding reports of suicidality in pediatric patients treated with antidepressant medications. This advisory reported suicidality (both ideation and attempts) in clinical trials of various antidepressant drugs in pediatric patients. The FDA asked that additional studies be performed, because suicidality occurred in both treated and untreated patients with major depression and thus could not be definitively linked to drug treatment.

However, a subsequent study of more than 65,000 children and adults treated for depression between 1992 and 2002 by the Group Health Cooperative in Seattle found that suicide risk declined, rather than rose, with the use of antidepressants. To date, this is the largest study to address this issue.

Currently, there is insufficient evidence to associate obsessive-compulsive disorder (OCD) and other anxiety disorders treated with SSRIs with an increased risk of suicide.


Diet and Activity

No special diet is required. No activity limitations are suggested. Physical exercise can provide a healthier outlet for stress. In the authors’ experience, many children and adolescents with trichotillomania spend too much time on activities involving little physical exertion (eg, studying at a desk) and not enough on physical activities. If the hair-pulling behavior is associated with a specific activity, however, that activity may require close monitoring. Activities during which patients may engage in hair pulling include the following:

  • Watching television

  • Reading

  • Talking on the phone

  • Lying in bed

  • Driving

  • Writing or doing paperwork