Narrative Review of Internet-Based Self-Help Tools for Body-Focused Repetitive Behaviors: Recommendations for Clinical Practice

Abstract

Introduction

Body-focused repetitive behaviors (BFRBs), such as skin-picking, hair-pulling, and nail-biting, impair quality of life (QOL). While habit reversal training (HRT) is effective, access is often limited. Internet-based self-help interventions offer an alternative, improving accessibility for patients unable to attend in-person therapy.

Methods

We reviewed randomized controlled trials analyzing self-help or internet-based interventions for BFRBs in adults. PubMed searches yielded 1033 studies, 12 of which met the inclusion criteria, focusing on self-guided interventions for various BFRBs.

Results

The review found that the “Free from BFRB” website was the most studied resource and consistently had high patient satisfaction. Self-guided HRT, decoupling, and decoupling in-sensu consistently reduced symptoms and improved QOL. Decoupling techniques were especially effective for trichotillomania and nail-biting.

Discussion

Internet-based self-help interventions, especially self-help HRT, decoupling, and decoupling in-sensu, offer effective and accessible treatment options for managing BFRBs, particularly for those facing barriers to traditional therapy such as stigma, cost, or location. Engagement and frequency of use are important for the efficacy of self-help options, and therapist-guided treatments may offer more personalized, comprehensive care.

Key Summary Points

Internet-based self-help tools can bridge gaps in care to provide effective treatment for patients facing barriers to traditional therapy.

Interventions such as self-guided habit reversal training (HRT) and decoupling significantly reduced symptoms and improved quality of life (QOL), and the most accessible and studied resource for these interventions was the website “Free from BFRB”.

Engagement and consistent use of self-help tools are closely linked to efficacy and are important in improving treatment outcomes.

While self-help treatments can be effective, therapist-guided interventions may provide more personalized and comprehensive care, leading to better outcomes for some individuals.

Introduction

Body-focused repetitive behaviors (BFRBs) are recurrent self-grooming behaviors, such as skin-picking, hair-pulling, and nail-biting, that can significantly impair quality of life (QOL). Effective behavioral treatments for BFRBs such as therapist-guided habit reversal training (HRT) exist, but time constraints currently limit patient education on HRT techniques [1]. Internet-based self-help interventions may improve access to care by providing self-guided treatment options for patients. In this narrative review, we aim to assess whether these internet-based self-help interventions are effective in treating BFRBs and compile a list of treatment options for patients, as well as a list of resources that outline these self-help treatments.

Methods

Our review focused on randomized controlled trials (RCTs) that analyzed self-help or internet-based interventions on adults with BFRBs. We searched PubMed for studies between the years of 2010 and 2024 using the following terms: body-focused repetitive behaviors OR BFRB OR trichotillomania OR skin picking disorder OR dermatillomania OR excoriation disorder OR nail-biting OR onychotillomania OR onychophagia OR compulsive grooming OR lip biting OR cheek biting; AND self OR online OR internet OR computer OR web OR digital OR manual OR video. The inclusion criteria consisted of 1. RCTs, 2. outcome of interest of one or more BFRBs, and 3. analysis of a self-help or internet-based intervention. Of the 1033 results from the PubMed search, 30 RCTs satisfied the inclusion criteria. Of those 30 studies, 18 were excluded as a result of pharmacological intervention or lack of self-guided intervention. 

This article is based on previously conducted studies and does not contain any new studies with human participants or animals performed by any of the authors.

Results

We identified 12 studies that met our inclusion criteria, including five specific to trichotillomania, two specific to skin-picking disorder, and five describing multiple BFRBs. The self-help treatment options are summarized in Table 1, and internet self-help resources are summarized in Table 2. The “Free from BFRB” psychoeducational website was the most studied internet-based resource and consistently proved effective for patients, particularly when used frequently [2]. Seventy percent of participants reported positive effects, and users experienced significant improvements in QOL and reductions in depression symptoms [3–5]. Self-guided HRT, decoupling, and decoupling in-sensu showed significant symptom reduction across multiple studies, with medium-to-large effects on QOL [2–8]. While no significant differences in efficacy were found between the three techniques for skin-picking, decoupling, and decoupling in-sensu were found to be especially effective for hair-pulling and nail-biting [7, 8]. Habit replacement also showed significant improvement in BFRB symptoms [9]. The stepped care treatment model also showed promise, with high patient satisfaction and notable symptom reduction [10]. Expressive writing showed more modest effects for skin-picking but showed potential in reducing emotional distress, which is linked to BFRBs [11]. The RCT studying the “SaveMySkin” website highlighted the high demand for online self-help treatment, with recruitment exceeding its initial goal of 100 participants in just 18 days. Participants cited a lack of outpatient healthcare options (62.4%) and flexibility in time (79.7%) and location (82%) as key reasons for engagement [12]. However, while self-help manuals were shown to be effective, studies consistently noted that therapist-guided versions of these interventions were likely to yield better outcomes.

Table 1.

Summary of self-help treatment options for BFRB patients

Treatment	Description	Internet resource	Supporting studies and efficacy data
Self-help HRT	Replaces the old automatic behavior through awareness training and competing response training	Free from BFRB website and manual	Showed significant improvement in symptoms and QOL [2–5]. One study’s participants rated self-help HRT and decoupling in-sensu higher than decoupling [4]
Decoupling	The BFRB is unlearned by disrupting the behavior before it is completed and replacing it with a slightly different alternate motion Especially effective for hair-pulling and nail-biting	Free from BFRB website and manual	Showed significant improvement in BFRB symptoms and QOL [2, 8]. Also showed a decrease in depressive symptoms and OCD symptoms [3, 5, 6]. Decoupling was less effective for skin-picking [4], and more effective for hair-pulling and nail-biting [6–8]
Decoupling in-sensu	A variant of decoupling in which the automatic behavior is imagined and replaced by an alternate motion Especially effective for skin-picking, nail-biting, and hair-pulling	Free from BFRB website and manual	Showed significant improvement in symptoms and QOL [2–5]. One study’s participants rated self-help HRT and decoupling in-sensu higher than decoupling [4]
Habit replacement	Replaces the harmful automatic habit with a harmless and unobtrusive behavior	Instructional video as well as a free pdf download: https://www.free-from-bfrb.org/videos/5/	Significantly reduced symptoms and many patients rated the “Free from BFRB” source highly for habit replacement [9]
Stepped care	Less intensive, restrictive, or costly methods are tried first, followed by more intensive ones only if initial results are unsatisfactory	N/A	Results showed that StopPulling.com was only effective in a fourth of the participants, but when used with in-person therapy, the efficacy was extremely high. Engagement was a key factor in success and efficacy [10]
Expressive writing	Personal and emotional writing without regard to form or writing conventions (e.g., spelling, punctuation, grammar)	N/A	Lead to increased feelings of relief, which in turn reduced skin-picking directly after a writing session There was no difference in efficacy between writing on paper and typing [11]

N/A not applicable

Table 2.

Summary of internet-based self-help resources for BFRB patients

Resource	Description	Link	Supporting studies and efficacy data
Free from BFRB website	An informational website on BFRBs that includes instructional videos on different self-help techniques such as self-guided HRT, decoupling, decoupling in sensu, and habit replacement	Free access to the website: www.uke.de/free-from-bfrb	Website and manual rated highly in all studies [2–5, 9]
Free from BFRB manual pdf	This manual teaches self-guided HRT, decoupling, and decoupling in sensu. Proven to be the most effective and easily accessible resource for patients	Free PDF download of the manual: https://ag-neuropsychologie.de/bfrb/	Website and manual rated highly in all studies [2–5, 9]. One study found that participants found the decoupling manual less helpful [4]
SkinPick.com	Personalized professional online behavioral therapy program for skin-picking. A more affordable option for people who cannot afford in-person therapy, at $260 per month. Offers online support groups and webinars for members	https://www.skinpick.com/	N/A
HabitAware.com	Commercial website providing smart bracelets called “Keen” that alter the wearer when performing the BFRB. Helps people become aware of and reduce their BFRBs. Price: $150 Also offers a free app for Apple Watch called “KeenLite” that will also give an alert when they do the BFRB	https://habitaware.com/	N/A
StopPulling.com	A behavior-tracking program to help monitor hair-pulling and identify patterns for when these behaviors occur. Also provides individuals with information on how to change these behaviors. This program is not intended to replace individual behavior therapy but can be used in conjunction with therapy Subscription is $29.95 per month. Coping strategies to help individuals manage their hair-pulling Developed by leading experts in the field of trichotillomania. Directory on website	https://stoppulling.com/	Results showed that it was not sufficient alone, but when used with in-person therapy, the efficacy was very high [10, 13]
StopPicking.com	A behavior-tracking program to help monitor skin-picking and identify patterns for when these behaviors occur. Also provides individuals with information on how to change these behaviors. This program is not intended to replace individual behavior therapy but can be used in conjunction with therapy. Subscription is $29.95 per month Developed by leading experts in the field of skin-picking. Directory on website	https://stoppicking.com/	N/A
BFRB.org	A website aimed to connect people with BFRBs, hosting conferences, events, support groups, and webinars Includes online referral directories for medical and therapeutic providers as well as self-care providers	https://www.bfrb.org/	N/A
SaveMySkin	CBT-based online intervention for skin-picking with several informational modules Study is no longer accessible to the public	Link to information about the study: www.savemyskin.de	Reference [12]

N/A not applicable

Discussion

Our findings suggest that internet-based self-help interventions, particularly self-help HRT, decoupling, and decoupling in-sensu, hold promise as effective and accessible treatment options for individuals with BFRBs, given that studies consistently demonstrated significant symptom reductions and QOL improvement. The convenience of these digital tools, such as the Free from BFRB website and manual, is particularly valuable for patients facing barriers to engaging in traditional in-person therapy, such as stigma, limited geographical access, or financial constraints. By providing a low-barrier alternative, these interventions help to bridge gaps in access to mental health and dermatological services and may serve as a bridge to in-person care for those who are awaiting therapist-guided treatment. Internet-based interventions may also help reduce stigma and encourage individuals to seek treatment who might otherwise feel shame or fear judgment by providing a private and flexible alternative that is still effective in managing symptoms. However, engagement played a critical role in the efficacy of self-guided interventions, as higher frequency of use was associated with better outcomes. Adherence and motivation could be improved in patients through additional support mechanisms, such as regular email check-ins. While many participants benefited from self-guided treatments, studies noted that therapist-guided HRT is likely to be more effective owing to the personalized and comprehensive care that in-person therapy provides, particularly for individuals who do not achieve sufficient improvement with self-help alone. Of the interventions reviewed, the stepped-care model was a promising framework for managing BFRBs, offering a way to maximize the efficiency of treatment delivery while minimizing unnecessary patient burdens. This model allows individuals to begin with lower-intensity interventions, such as internet-based self-help interventions, before progressing to therapist-guided treatments if needed. For many patients, these initial self-help interventions may be sufficient to reduce symptoms, whereas others may require additional support. Future studies should include longitudinal follow-ups on the efficacy of self-guided interventions, given the longest follow-up period in the reviewed studies was 6 months. Further head-to-head comparisons between therapist-guided and self-help versions of interventions, such as HRT, decoupling, and decoupling in-sensu, are necessary to determine the relative efficacy of each format. Furthermore, synthesizing the various approaches in internet-based self-help interventions can be challenging for patients, potentially leading to poorer compliance. Integrating different self-help strategies into a more structured and personalized digital intervention may improve adherence and overall effectiveness. A limitation of our narrative review was that our literature search was conducted solely through PubMed, and relevant articles outside of Pubmed may not have been included in our review.

Author Contributions

Sawye Raygani performed the initial data collection and literature review. Emi M. Murase drafted the manuscript, completed a secondary literature search, and performed the analysis and interpretation of the results. Dr. Jenny E. Murase and Sawye Raygani provided their input and revisions to the manuscript before submission.

Funding

No funding or sponsorship was received for this study or publication of this article.

Data Availability

Data sharing is not applicable to this article as no datasets were generated or analyzed during the current study.

Declarations

Conflict of Interest

Emi M. Murase and Sawye Raygani declare that they have no competing interests. Dr. Jenny E. Murase is on the Editorial Board of Dermatology and Therapy. Dr. Jenny E. Murase was not involved in the selection of peer reviewers for the manuscript nor any of the subsequent editorial decisions.

Ethical Approval

This article is based on previously conducted studies and does not contain any new studies with human participants or animals performed by any of the authors.