Review Article

Skin Appendage Disord 2022;8:1–7 Received: May 20, 2021

Accepted: June 25, 2021
DOI: 10.1159/000518191 Published online: September 1, 2021

Trichotillomania: What Do We Know So

Far?
Daniel Fernandes Melo a Caren dos Santos Lima b, c Bianca Maria Piraccini d, e
Antonella Tosti f

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aDermatology
Department, University of State of Rio de Janeiro (UERJ), Rio de Janeiro, Brazil; bDermatology
Department, University of State of Pará (UEPA), Belém, Brazil; cDermatology Department, University Center of Pará
(CESUPA), Belém, Brazil; dDepartment of Experimental, Diagnostic and Specialty Medicine (DIMES) Alma Mater
Studiorum University of Bologna, Bologna, Italy; eIRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna,
Italy; fPhillip Frost Department of Dermatology and Cutaneous Surgery, University of Miami School of Medicine,
Miami, FL, USA

Keywords comply with this treatment strategy. Pharmacotherapy can

Trichotillomania · Hair pulling · Impulse-control disorder · be necessary, especially in adolescents and adult patients.
Alopecia Options include tricyclic antidepressants, selective sero-
tonin reuptake inhibitors, and glutamate-modulating
agents. Glutamate-modulating agents such as N-acetylcys-
Abstract teine are a good first-line option due to significant benefits
Trichotillomania is defined as an obsessive-compulsive or re- and low risk of side effects. Physicians must emphasize that
lated disorder in which patients recurrently pull out hair the role of psychiatry-dermatology liaison is extremely nec-
from any region of their body. The disease affects mainly fe- essary with concurrent support services for the patient and
male patients, who often deny the habit, and it usually pres- parents, in case of pediatric patients. In pediatric cases, par-
ents with a bizarre pattern nonscarring patchy alopecia with ents should be advised and thoroughly educated that nega-
short hair and a negative pull test. Trichoscopy can reveal the tive feedback and punishment for hair pulling are not going
abnormalities resulting from the stretching and fracture of to produce positive results. Social support is a significant pil-
hair shafts, and biopsy can be necessary if the patient or par- lar to successful habit reversal training; therefore, physicians
ents have difficulties in accepting the self-inflicted nature of must convey the importance of familial support to achieving
a trichotillomania diagnosis. Trichotillomania requires a remission. This is a review article that aims to discuss the lit-
comprehensive treatment plan and interdisciplinary ap- erature on trichotillomania, addressing etiology, historical
proach. Physicians should always have a nonjudgmental, aspects, clinical and trichoscopic features, main variants, dif-
empathic, and inviting attitude toward the patient. Behav- ferential diagnosis, diagnostic clues, and psychological and
ioral therapy has been used with success in the treatment of pharmacological management. © 2021 S. Karger AG, Basel
trichotillomania, but not all patients are willing or able to

karger@karger.com © 2021 S. Karger AG, Basel Correspondence to:

www.karger.com/sad Daniel Fernandes Melo, danielfernandesmelo @ yahoo.com.br
 Introduction We limited the search to articles available in English and consid-
ered those mentioning the dermatological aspects of this condi-
tion, its trichoscopic features, diagnostic criteria, and treatment
Trichotillomania, also called hair-pulling disorder, is options. The references of these articles were reviewed to identify
defined by the Diagnostic and Statistical Manual of Men- additional resources. After excluding duplicate titles, we had a to-
tal Disorders (DSM-V) as an obsessive-compulsive or re- tal of 13 relevant articles.
lated disorder in which subjects recurrently pull out hair
from any region of their body, resulting in hair loss [1–3].
The psychosocial aspects of trichotillomania are greatly Discussion
underestimated, but recent literature suggests an in-
creased interest in this neglected area [2]. Trichotillomania has been discussed in the medical lit-
Although extensive epidemiological studies are lacking, erature for over a century. Nevertheless, it was officially
the estimated prevalence data suggest that 0.5–2% of the gen- introduced as a mental illness in DSM in 1987, when it
eral population suffers from this disorder [2]. However, as was classified as an impulse control disorder. DSM-V in-
some people who suffer from trichotillomania feel ashamed cluded trichotillomania in the chapter on obsessive-com-
of their condition, real prevalence may be higher [3]. pulsive and related disorders, along with excoriation dis-
Epidemiologic data in pediatric population are rela- order, body dysmorphia, hoarding disorder, and obses-

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tively scarce, but lifetime prevalence is estimated to be sive-compulsive disorder [3].
around 1–3%. The most common sites of hair removal are The etiology of trichotillomania is not well understood
the scalp, eyebrows, eyelashes, and pubic region [4]. yet. However, it is likely to be the result of the interaction
Limbs, underarms, and chest hair can also be involved [2]. of several factors on a single patient (genetic, psychologi-
In adults, trichotillomania appears to have a large fe- cal, social, and neurobiological) [2].
male preponderance, with a female-to-male ratio of 4:1 While trichotillomania may be triggered by stress, the
[3]. Regarding pediatric trichotillomania, the disorder habit itself also causes significant distress, low self-es-
most often affects female children between 9 and 13 years teem, guilt, and shame. Most people report that pulling is
old, who generally deny the habit [5]. painless, if not pleasurable. It has been proposed that hair
Trichotillomania is a highly comorbid disorder, with a pulling creates “counterirritation” to reduce the stress
lifetime prevalence of concomitant psychiatric disease as perception by the brain [2].
high as 80%. The most common associated disorders are Two types of hair pulling have been described for
anxiety, major depression, substance misuse, eating dis- trichotillomania: automatic and focused. Automatic oc-
orders, posttraumatic stress disorder, personality disor- curs outside of one’s awareness, while focused pulling
ders, and body dysmorphic disorder [6]. It has been re- happens in awareness and in response to negative emo-
ported to overlap with skin-picking and nail-biting [1]. tional states, such as stress, sadness, anger, or anxiety [1].
Over 20% of patients may concomitantly suffer from Pulling may occur in private, leading parents to believe
trichophagia, when patients consume the pulled hair cre- the hair is falling out in pediatric cases. Younger children
ating trichobezoars, or hairballs, which can lead to sig- more often fall in the automatic category; therefore, they
nificant gastrointestinal complications and the need for do not recall actual pulling but may admit to “play with
further surgical intervention [3, 4]. A rarer presentation hair.” On the other hand, older children and over 75% of
of the trichobezoar is the “Rapunzel syndrome,” in which adults tend to manifest focused pulling in response to
the tail of the hairball extends into the intestines and may stressful events [1, 4]. Focused hair pullers tend to pull out
cause intestinal obstruction [2]. The aim of this article is hair that feels different from the rest (kinky, white, or odd
to review the literature on trichotillomania, addressing texture), and they may also have other associated rituals
etiology, historical aspects, clinical and trichoscopic fea- such as chewing, hair licking, or trichophagia [2].
tures, main variants, diagnostic clues, and management. Clinically, trichotillomania presents with a diffuse or
bizarre-shaped pattern, irregular nonscarring patchy alo-
pecia (shown in Fig. 1, 2) [1, 7, 8] and can present with 1
Methods and Results or 2 patches or with diffuse scalp involvement. The fron-
toparietal region is more often affected, and eyebrows,
A literature search in the scientific database MEDLINE through
PubMed was performed in January 2021, using the keywords upper eyelashes, and pubic area are also commonly in-
“trichotillomania” AND “alopecia,” “trichotillomania” AND “hair volved. Less commonly, face, limbs, underarms, and chest
pulling,” and “trichotillomania” AND “impulse control disorder.” hair are also affected. The shape of the patches is bizarre

2 Skin Appendage Disord 2022;8:1–7 Melo/Lima/Piraccini/Tosti

DOI: 10.1159/000518191
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Fig. 1. Small irregular-shaped patch of hair loss in the frontal re- Fig. 2. A 9-year-old girl with a bizarre-shaped alopecia patch in the
gion of a 50-year-old woman diagnosed with depression and anx- frontotemporal region.
iety.

with angular or irregular borders. Sometimes the alopecia considered as a highly-specific trichoscopic finding asso-
of the crown is surrounded by a rim of unaffected hair at ciated with trichotillomania [5].
the periphery, resembling tonsures of Christian monks Trichotillomania can be difficult to distinguish from
(“Friar Truck” sign) [2, 3, 9]. The hair shafts have various alopecia areata at dermoscopy. Clinically, a negative hair
lengths due to different fracture points of the hair shafts pull test and absence of hypopigmented regrowing vellus
or the hair being pulled several times, producing a rough hair favor a diagnosis of trichotillomania [5, 8].
feeling when touching the scalp[7]. Recently, an article reported pediatric cases of tricho-
The differential diagnosis for trichotillomania in- tillomania without patches (trichotillomania incognito),
cludes alopecia areata, tinea capitis, traction alopecia, and in which the patients clinically presented focal low hair
telogen effluvium [4]. Trichoscopy reveals abnormalities density and negative pull test in the affected area associ-
resulting from the stretching and fracture of hair shafts. ated with trichoscopic findings of trichotillomania. The
Common trichoscopic signs include black dots, broken absence of patches, with no specific complaint, makes the
hair shafts of different lengths, and yellow dots [5, 8]. diagnosis even more challenging. In these cases, trichos-
Many other signs, all variants of broken hairs, have copy is essential to allow early recognition of the disease.
been described, including longitudinal split ends of hairs Trichoscopy is also useful to demonstrate the signs of
(short hairs with trichoptilosis), coiled hairs, flame hairs plucking to the parents of children with trichotillomania
(semitransparent, wavy, and cone-shaped hair residues, [1, 8]. Histopathology on horizontal sections shows a
resembling a fire flame), V-signs (2 or more hairs emerg- noninflammatory nonscarring alopecia in which the
ing from 1 follicular unit and broken at the same length), morphological changes are those of follicular damage sec-
tulip hairs (short hairs with a tulip leaf-like hyperpigmen- ondary to the external insult, with distortion of the hair
tation at the distal end), and sprinkled hairs (only a sprin- follicle anatomy and with perifollicular and intrafollicu-
kled “hair powder,” resulting from hair damage) [8, 9] lar hemorrhage. Additional findings include melanin pig-
(Fig. 3, 4). ment casts, loss of hair shafts, and trichomalacia, where
Hook hairs or question mark hairs are partially coiled the hair shaft is dysmorphic, with incomplete cornifica-
hairs due to a contraction of the remaining hair fixed to tion and irregular pigmentation. The number of hair fol-
the scalp after the distal shaft has been pulled. They are licles is normal, with an increased occurrence of catagen

Trichotillomania Skin Appendage Disord 2022;8:1–7 3

DOI: 10.1159/000518191
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Fig. 3. Trichoscopy of the eyelashes (a) and
scalp (b) of a patient with trichotillomania
presenting black dots (yellow circles), bro-
ken hairs with multiple lengths (red ar-
a b
rows), and V-sign (blue circle) (×20).

or telogen hair follicles and without significant inflamma- pulsive need to remove hair from the affected areas
tion [7]. followed by feelings of gratification. Due to the meth-
The main variants of trichotillomania include trichot- od of hair removal, the scalp is not involved in tricho-
eiromania, trichotemnomania, trichodaganomania, telo- daganomania, and affected areas are generally acces-
gen mania, and trichophobia [10, 11]. sible sites such as the dorsal forearms. Microscopic
1. Trichoteiromania refers to the compulsive action of features of examined hair may show a smooth blunted
scratching and rubbing of the scalp, which results in shaft at the bite site and a lack of attached root sheaths
fracture of the hair shafts. This is usually associated or hair bulbs, as would be seen in trichotillomania [10].
with skin dryness and itching conditions, such as li- 4. Telogen mania represents obsessive-compulsive fits of
chen simplex chronicus. Clinically, it presents as single fierce hair brushing in women [11].
or multiple irregular patches of alopecia, with scaling, 5. Trichophobia denotes plucking of hair based on the
lichenification, and hair breakage [10, 12]. Tricho- delusion of having to pull something out of the hair
scopic findings of trichoteiromania include proximal roots [11].
trichorrhexis nodosa and “broom hairs” which are Although trichotillomania is considered a psychiatric
broken hair shafts longitudinally split into 2 or 3 parts. diagnosis, most patients will initially present to a derma-
Broken hair shaft with different lengths, perifollicular tologist for evaluation. Therefore, dermatologists should
scaling, and erythema can also be seen [10]. be aware of the peculiarities of this disease to provide ap-
2. Trichotemnomania is hair loss due to cutting or shav- propriate advice and treatment for their patients [4]. The
ing. Patients with this condition show signs of shaving diagnostic criteria for trichotillomania are listed in Ta-
or hair-cutting in the affected areas with an otherwise ble 1 [3]. Although the course of illness may vary, tricho-
healthy-appearing scalp. Trichoscopic examination of tillomania is commonly a chronic disorder with fluctua-
trichotemnomania may show short, broken, nonvellus tions in intensity over time [3].
hairs, without a decrease in follicle density, exclama- As there is currently no gold-standard treatment for
tion mark hairs, yellow dots, or black dots [10]. trichotillomania, disease management is challenging. It
3. Trichodaganomania is the process of biting one’s own consists of both psychotherapeutic and pharmacological
hair on accessible sites resulting in hair loss in the af- options. Treatment recommendations may vary according
fected areas. This condition shares some features with to the patient’s age. In prescholar children, trichotillomania
other variants of trichotillomania, including a com- is considered a habit disorder that is expected to disappear

4 Skin Appendage Disord 2022;8:1–7 Melo/Lima/Piraccini/Tosti

DOI: 10.1159/000518191
 a b

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c d

Fig. 4. a–d Trichoscopic features of trichotillomania, showing trichoptilosis (blue circles), black dots (yellow
circles), flame hairs (green circles), tulip hair (red circle), and micro-exclamation mark hair (black circle) (×20).

on its own, and parental education and support is usually Recently, the invention of electronic devices that mon-
enough to control the symptoms. However, in older chil- itor habits may improve the effectiveness of HRT. One
dren and adolescents, behavioral approaches combined example device unit consists of an electronic necklace
with pharmacotherapy offer more clinical benefits due to that casts inaudible sound waves around the head and
the high incidence of associated psychiatric disorders [10]. communicates to a bracelet that vibrates when crossing
into the head region for longer than 3 s. This type of tech-
Nonpharmacological Treatments nology may present an opportunity to target therapy at
Significant benefits are usually obtained with cogni- the unconscious pulling predominantly seen in the pedi-
tive-behavioral therapy (CBT), currently the most empir- atric population [4]. Stimulus control training is a tech-
ically validated treatment option [9]. Habit reversal train- nique that modifies the person’s environment to make it
ing (HRT), a type of CBT, involves helping patients ac- less favorable to hair-pulling behavior [10].
quire awareness of their hair-pulling behavior and then Other psychotherapy methods include dialectical be-
replacing that behavior with other activities that patients havioral therapy, exposure and ritual prevention therapy,
can perform with their hands whenever they feel the urge metacognitive therapy, acceptance and commitment
to pull out their hair [4, 9–11]. therapy, and support group therapy [10]. Support groups

Trichotillomania Skin Appendage Disord 2022;8:1–7 5

DOI: 10.1159/000518191
 Table 1. Diagnostic criteria for trichotillomania according to the Diagnostic and Statistical Manual of Mental
Disorders

DSM-V diagnostic criteria for trichotillomania

Recurrent pulling out of one’s hair, resulting in hair loss

Repeated attempts to decrease or stop hair pulling
The hair pulling causes significant distress or impairment in social or occupational functioning
The hair pulling or hair loss is not attributable to another medical condition
The hair pulling is not better explained by the symptoms of another mental disorder

are common in many medical conditions to bring togeth- in reducing the urge to tear hairs, time spent on pulling
er individuals to sharing challenges and successes of their hairs, and number of torn hairs [9].
illness management. A small study comparing group be- A small study showed benefit with doses of up to 80
havioral therapy to supportive therapy in adults demon- mg daily. However, since other psychiatric conditions
strated short-term improvement in those in group behav- such as depression and anxiety are common in patients

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ioral therapy, suggesting that this could play an adjunc- with trichotillomania, and SSRIs have shown efficacy in
tive role in trichotillomania [4]. these conditions, it is reasonable to include this medica-
Alternative behavioral intervention approach, such as tion in the patient’s regimen [10].
hypnotherapy, has been utilized to sensitize and alert pa-
tients to impending pulling behaviors. The lack of con- Antipsychotics
trolled trials of hypnotherapy makes it difficult to ascer- Olanzapine is the most studied antipsychotic for the
tain the true efficacy of this therapy [4]. treatment of trichotillomania. Although dosages of 2.5–
10 mg daily revealed significant improvement, olanzap-
Pharmacological Treatment ine has many side effects, including metabolic dysfunc-
No medications are specifically approved for the treat- tion and extrapyramidal symptoms, which should be
ment of trichotillomania. However, some drugs, like selec- weighed against potential benefit [9].
tive serotonin reuptake inhibitors (SSRIs) and the tricyclic
antidepressant clomipramine, may help control the symp- N-Acetylcysteine
toms. It has likely more to do with psychiatric comorbidity NAC is a modulator of glutamic acid action, which has
than the efficacy for trichotillomania itself [5, 10]. been recently used in psychodermato logical conditions
such as onychotillomania, skin-picking disorders, pruri-
Tricyclic Antidepressant go, trichoteiromania, and trichotillomania [9, 10, 12].
Clomipramine blocks the reuptake of norepineph- The mechanism of action of NAC for neurologic and psy-
rine and serotonin and also blocks muscarinic cholin- chiatric disorders is not fully understood, but it is possibly
ergic, adrenergic, H1, and 5HT2 receptors [10]. Studies related to its action on the glutamate system. Glutamater-
showed successful responses in clomipramine mono- gic hyperactivity leading to excitotoxicity and oxidative
therapy at 125 mg/day and dual therapy at 50 mg/day stress has been implicated in the pathogenesis of impulse
combined with behavioral therapy. When compared control disorders, such as trichotillomania. The decrease
with CBT and placebo, clomipramine was significantly in glutamate levels, being the main excitatory neurotrans-
less effective than CBT but showed more benefits than mitter in the nucleus accumbens, would explain NAC ef-
placebo [10]. Adverse effects are relatively frequent and ficacy in controlling compulsive behavior [10, 12].
include dry mouth, constipation, drowsiness, and seda- While NAC demonstrated significant effect in adults
tion [10, 13]. with trichotillomania using 1,200 mg twice daily, data
from the pediatric trial did not show any benefit [4, 10].
Selective Serotonin Reuptake Inhibitors Possibly, children do not respond to NAC as adults react
Although SSRIs are the most often chosen treatment because children are more likely to engage predominant-
option for trichotillomania, evidence of benefit is weak. ly in an automatic pattern of pulling, and NAC may be
Studies comparing fluoxetine and placebo in patients better for focused pulling by reducing urges to pull hair
with trichotillomania showed no significant differences [13]. Due to its relative safety and tolerability compared

6 Skin Appendage Disord 2022;8:1–7 Melo/Lima/Piraccini/Tosti

DOI: 10.1159/000518191
to other pharmacological treatments for trichotillomania, Trichotillomania requires a comprehensive treatment
NAC has the potential to be an important option, espe- plan and interdisciplinary approach. During the treatment
cially for refractory cases [4, 10]. process, the physician should always have a nonjudgmen-
tal, empathic, and inviting attitude toward the patient. The
Opioid Antagonists role of psychiatry-dermatology liaison is essential in addi-
Naltrexone is the opioid antagonist most studied for tion to patient and parent support services [2]. The pro-
the treatment of trichotillomania. It reduces the dopa- vider should educate the patient and their family, highlight-
mine levels in the nucleus accumbens, which seems to be ing psychosocial effects and triggers, discussing available
involved in the brain’s reward pathway [10]. It showed treatment options, among which CBT is currently the first-
effectiveness in trichotillomania in some case reports by line treatment, especially in children [4].
reducing the hair-pulling urge. However, in a double-
blind randomized controlled trial using naltrexone 150
mg daily, there was no significant difference in reducing Statement of Ethics
hair pulling between drug and placebo[9, 10].
Written informed consent was obtained from the patients for
publication of any accompanying images.
Dronabinol

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Dronabinol is a cannabinoid agonist that seems to have
potential benefits in the treatment of trichotillomania by Conflict of Interest Statement
diminishing glutamate cytotoxicity in the striatum. In a
small study, using dronabinol at the dosage of 2.2–15 mg/ Dr. Tosti reports being a consultant – DS Laboratories, Monat
day, the drug showed significant benefits in reducing hair- Global, Almirall, Tirthy Madison, Eli Lilly, Bristol Myers Squibb,
pulling behavior in 75% of the subjects. Furthermore, at and P&G.
this dosage, the medication was generally well tolerated,
with no significant deleterious effects on cognition [9, 10].
Funding Sources

This research did not receive any specific grant from funding
Conclusion agencies in the public, commercial, or not-for-profit sectors.

Trichotillomania is a poorly understood disorder that

can be extremely disabling with evident impact on qual- Author Contributions
ity of life and social and psychological functioning of af- A.T., D.F.M., and C.D.L. conceived the study. D.F.M. and
fected patients. Factors that suggest progression include C.S.L. wrote the manuscript. A.T. and B.M.P. reviewed the final
an increase in the reported number of pulling sites, fre- manuscript.
quency of urges, and amount of focused pulling.

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DOI: 10.1159/000518191