Treatment Strategies for Pediatric Trichotillomania: State‐of‐the‐Art Review on Progress and Persistent Challenges

ABSTRACT

Trichotillomania (TTM) is a condition characterized by recurrent hair pulling, often resulting in hair loss and functional impairment. The disorder remains underreported in the pediatric population, despite high rates of psychiatric comorbidities. Moreover, diagnosing and treating TTM among children remains challenging due to a lack of standardized guidelines. Hence, this systematic review aims to evaluate the current treatment approaches for pediatric TTM. A comprehensive search was conducted of five databases, using the search concepts of trichotillomania, pediatric populations, and treatments/interventions. Studies were included if they (1) directly addressed the topic, (2) were of an appropriate study type (e.g., clinical trials, case–control studies, cohort studies, cross‐sectional studies, or interview studies), (3) were published within the past 10 years, and (4) appeared in peer‐reviewed journals published in English. Ultimately, 10 studies met our inclusion criteria, from which data were extracted and synthesized following formal quality assessment. Our results indicate that behavioral interventions, particularly habit reversal training, consistently demonstrated the greatest therapeutic benefit. Pharmacological treatments, including selective serotonin reuptake inhibitors, have been explored in various case series. Although some individuals have shown improvement, overall evidence remains insufficient to support pharmacotherapy as first‐line. Alternative therapies, such as N‐acetylcysteine, have also been studied, though findings are variable and require further investigation in pediatric cohorts. Our review underscores the importance of early behavioral intervention and the need for larger, controlled studies to inform standardized treatment protocols. Given the functional and psychosocial burden of TTM in youth, comprehensive management strategies are essential.

1. Introduction

Trichotillomania (TTM), also known as hair‐pulling disorder, is a psychocutaneous condition characterized by the recurrent and compulsive pulling of one's hair, leading to alopecia and significant impairment in daily functioning [1]. Classified within the obsessive‐compulsive and related disorders category in the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM‐V), TTM remains an underreported yet prevalent condition, particularly among the pediatric population (i.e., individuals aged 18 years and under) [2]. The term trichotillosis has been introduced in clinical practice as an alternative nomenclature for TTM, with the aim of reducing stigma associated with the condition. However, TTM remains the more widely used and recognized term in the literature and will therefore be referenced throughout the remainder of the manuscript. According to the DSM‐5 diagnostic criteria, TTM is defined by: (1) recurrent hair pulling resulting in hair loss; (2) persistent efforts to decrease or stop the behavior; (3) clinically significant distress or impairment in social, occupational, or other important areas of functioning due to the behavior; (4) the hair pulling or hair loss cannot be attributed to another medical condition; and (5) the hair pulling is not better explained by the symptoms of another mental disorder [3].

Although large epidemiological studies are still lacking, TTM is estimated to affect 1.1%–1.7% of the general adult population, with prevalence rates rising to as high as 4% when considering the pediatric population [2, 4, 5]. Importantly, children and adolescents with TTM face significantly elevated risks of various comorbid mental health disorders. Research indicates that these young patients are more likely to be subsequently diagnosed with attention‐deficit/hyperactivity disorder, conduct disorders, and tic disorders, while also experiencing higher occurrences of obsessive‐compulsive, anxiety, and mood disorders [6]. Furthermore, there is a concerning association between pediatric TTM and an increased risk of suicide attempts [6]. These findings highlight the importance of early identification and comprehensive treatment strategies for individuals with TTM, particularly in the pediatric demographic.

Clinically, TTM is characterized by irregular, nonscarring patchy alopecia with angulated borders and variable hair shaft lengths due to breakage [7, 8, 9]. In children, hair pulling often affects multiple body sites, with a preference for the parieto‐temporal regions of the scalp, typically presenting symmetrically [10]. The differential diagnosis of TTM includes alopecia areata, tinea capitis, traction alopecia, and telogen effluvium [8]. Trichoscopic evaluation is particularly useful in revealing distinctive features such as broken hair shafts of different lengths, black and yellow dots, and various patterns of broken hairs, including coiled and sprinkled hairs [7, 8, 9].

Diagnosing and treating TTM in pediatric patients presents unique challenges, primarily due to its varied presentation and the lack of gold‐standard treatment [10]. In younger children, TTM is often perceived as a habit that may spontaneously resolve, with parental education and support playing an essential role [10]. However, a timely and accurate diagnosis is essential to mitigate potential academic, social, and mental health impairments. Various treatment approaches, including cognitive behavioral therapy, pharmacological management, and combined therapies, are currently employed [8]. Nonetheless, controlled studies, particularly those focused on pediatric outcomes, remain limited. This systematic review aims to synthesize and evaluate the existing treatment strategies for pediatric trichotillomania, focusing on the most current adaptations and highlighting the need for effective interventions.

2. Methods

A comprehensive search was conducted on April 4, 2024, using the Ovid MEDLINE, Embase, PsycINFO, CINAHL, and Web of Science databases. Search concepts included trichotillomania, pediatric populations, and treatments/interventions. Terms were combined using Boolean operators (AND, OR), with keywords and controlled vocabulary (e.g., MeSH, Emtree) including: “trichotillomania,” “hair pulling,” “child,” “adolescent,” “therapy,” “intervention,” “pharmacologic,” and “psychotherapy.” Searches were limited to English‐language articles, excluding editorials, commentaries, conference abstracts, preprints, and non‐human studies. After removing duplicate articles, 1054 remained and were independently screened for eligibility by two reviewers (SS and ME). When abstracts lacked sufficient information for inclusion or exclusion, full‐text articles were reviewed. Discrepancies between reviewers were resolved through discussion to reach consensus.

Studies were included if they (1) directly addressed the treatment of pediatric trichotillomania, (2) were of an appropriate study type (e.g., clinical trials, case–control studies, cohort studies, cross‐sectional studies, case series, or interview studies), (3) were published within the past 10 years to ensure that the findings were reflective of the most recent developments in the field, and (4) appeared in peer‐reviewed journals in English given that a significant proportion of research is published in English and thus would capture most publications. Eligible studies had to employ systematic data collection methods, including structured surveys, standardized clinical interviews, and validated symptom rating scales. Studies were excluded if they were irrelevant to the topic, used an incorrect study type (e.g., letters to the editor, commentaries, reviews, conference abstracts, preprints, or protocols), were published outside the designated time frame, or did not meet language criteria.

Ultimately, 10 studies met the inclusion criteria for this review. The included articles underwent formal quality assessment procedures, including validating diagnostic tools and outcome measures and assessing the risk of biases. Validated instruments to assess TTM severity, such as the National Institute of Mental Health Trichotillomania Severity Scale (NIMH‐TSS) or Massachusetts General Hospital Hair Pulling Scale (MGH‐HPS), were noted when applicable. We did not conduct statistical tests for reporting bias due to the narrative nature of synthesis but acknowledge the potential for publication bias. Data extraction involved two independent reviewers (SS and ME/LT) extracting pertinent information from eligible studies and organizing and summarizing the findings using the online platform, Covidence. A narrative synthesis was conducted to summarize findings, which were grouped by intervention type. We assessed certainty in the body of evidence using principles adapted from the Grading of Recommendations Assessment, Development and Evaluation (GRADE) framework; given the heterogeneity and small sample sizes, we applied narrative judgments of confidence.

A summary of the included studies can be found in Table 1, and the screening process is outlined in our Preferred Reporting Items for Systematic Reviews (PRISMA) diagram (Figure 1). This review was registered via the International Prospective Register of Systematic Reviews (PROSPERO) (ID: 1044452). Our included studies encompassed six clinical trials, one cohort study, and three case series.

TABLE 1.

Characteristics of studies included, ordered by author.

Author/year	Type of study (sample size)	Treatment	Tool used for TTM severity	Key findings
Fodstad et al. 2021 [11]	Case series (n = 2)	Combined behavioral techniques including positive reinforcement for hair pulling and sleep hygiene	Parental observation	Patient 1: percentage of intervals with hair pulling decreased from 31.3%–54.2% to 20.6%, reflecting an 85.7% overall decrease (p < 0.001). Patient 2: Percentage of intervals with hair pulling decreased from 29.2%–50% to 15.6%, reflecting a 98.1% overall decrease (p < 0.001) In both patients, results were maintained at 1‐ and 3‐month follow‐up
Grant et al. 2019 [12]	Double‐blind, placebo‐controlled, crossover negative study (n = 20, four children and 16 adults)	Milk thistle (150–300 mg twice a day) for 6 weeks, followed by placebo for 6 weeks with a 1‐week wash‐out period	NIMH‐TSS, MGH‐HPS, CGI	No statistically significant treatment type‐by‐time outcomes for NIMH‐TSS total scores Statistically significant decrease in MGH‐HPS scores (p = 0.02) Statistically significant decrease in CGI severity (p = 0.004)
Lee et al. 2018 [13]	Unblinded randomized control trial (n = 22)	Computerized response inhibition therapy	CGI, NIMH‐TSS	The response rate for CGI improvement was significantly higher in the treatment versus control group (p = 0.048) Treatment group showed a lower total score on the NIMH‐TSS, but results were not statistically significant (p = 0.373) Treatment group showed a significantly lower level of impairment on the NIMH‐TSS (p = 0.041)
Patkar et al. 2021 [14]	Case series (n = 5)	Patient 1: fluoxetine 80 mg and buspirone 20 mg plus augmentation with pimozide 2 mg and behavioral therapy Patient 5: 40 mg fluoxetine and psychotherapy, of unspecified type	Clinical observation	Patient 1: over 3 months, 50% improvement in symptoms via clinical observation Patients 2–4: lost to follow‐upPatient 5: significant improvement in mood and hair‐pulling tendencies via clinical observation
Petersen et al. 2022 [15]	Unblinded randomized control trial (n = 28)	10, 50‐min sessions of online acceptance‐enhanced behavioral therapy, which combines traditional habit reversal training and ACT	Patient and parent observation	Significant decrease in parent‐ and youth‐reported severity at 3‐, 6‐, and 12‐month follow‐ups compared to waitlist control
Petersen et al. 2022 [16]	Unblinded randomized control trial (n = 28)	10 sessions of online acceptance‐enhanced behavioral therapy	Patient and parent observation, TSC‐C/P	More comorbid conditions predicted greater decreases in severity over time (p < 0.05) Baseline psychological inflexibility (both general and trichotillomania‐specific) and age did not moderate treatment outcomes (p > 0.05)
Rahman et al. 2017 [17]	Unblinded randomized control trial (n = 40)	8 weekly habit reversal training sessions (including awareness training, competing response training, and social support)	NIMH‐TSS, MGH‐HPS	Treatment group had a significant decrease in NIMH‐TSS total score and MGH‐HPS total score (p < 0.001), compared to a moderate decrease in the control group for both parameters 76% of the treatment group were rated as treatment responders, compared to only 21% in the control (p < 0.001)
Rautio et al. 2024 [18]	Cohort study (n = 63)	8 sessions of habit reversal training (including psychoeducation, functional intervention, stimulus control, awareness training, competing response training, avoidance training, and relapse prevention), combined with pharmacotherapy when deemed appropriate	NIMH‐TSS, NE‐YBCOS	Treatment group showed a significant reduction in symptom severity (NIMH‐TSS) (p < 0.001) and skin‐picking severity (NE‐YBCOS) (p < 0.001) post‐treatment Treatment gains were maintained at 12‐month follow‐up on NIMH‐TSS and NE‐YBCOS
Schumer et al. 2015 [19]	Double‐blinded randomized control trial (n = 30)	12‐weeks of 600 mg N‐acetylcysteine once per day, titrated up to 2400 mg per day	MGH‐HPS, TSC‐C/P, MIST‐C	Hair‐pulling severity did not differ significantly between posttreatment and 1.5 years following the original trial according to MGH‐HPS (p = 0.77), TSC‐C (p = 0.52), TSC‐P (p = 0.89) At follow‐up, children had significantly decreased automatic (p < 0.05), but not focused (p = 0.84) pulling on the MIST‐C
Srivastava et al. 2023 [20]	Case series (n = 2)	Patient 1: valproate 100 mg/d Patient 2: nonpharmacologic interventions of distractions, rewarding of desirable behaviors, diet changes and general habit reversal measures	Clinical observation	Patient 1: frequency of hair pulling was decreased Patient 2: results not reported

Abbreviations: CGI, clinical global impression; MGH‐HPS, Massachusetts general Hospital hair pulling scale; MIST‐C, Milwaukee inventory for styles of trichotillomania‐child; NE‐YBCOS, yale‐brown obsessive compulsive scale modified for neurotic excoriation; NIMH‐TSS, National Institute of mental health trichotillomania severity scale; TSC‐C/P, trichotillomania scale for children and parents.

FIGURE 1.

PRISMA diagram [21].

3. Results

3.1. Behavioral Interventions

Habit reversal training (HRT) has emerged as the standard for the treatment of TTM [22]. To provide an overview of psychotherapeutic options evaluated for TTM, including HRT, we summarize key treatment components in Table 2. Findings in recent literature support the efficacy of HRT, as demonstrated by Rahman et al. [17] randomized controlled trial of 40 pediatric patients, which reported significant reductions in total scores on the NIMH‐TSS and MGH‐HPS (p < 0.001). Their treatment cohort underwent eight weekly HRT sessions, including awareness training, competing response training, and social support. Similarly, Rautio et al. corroborated these results in their cohort study of 64 pediatric patients. Following eight sessions of HRT with psychoeducation, functional intervention, stimulus control, awareness training, competing response training, avoidance training, and relapse prevention, patients showed a significant reduction in symptom severity (NIMH‐TSS) (p < 0.001) and skin‐picking severity (Yale‐Brown Obsessive Compulsive Scale Modified for Neurotic Excoriation [NE‐YBCOS]) (p < 0.001) with sustained improvements at 12‐month follow‐up [18]. Importantly, HRT was combined with pharmacotherapy, when deemed medically appropriate, in the latter study.

TABLE 2.

Overview of psychotherapeutic interventions for TTM.

Therapy	General characteristics
Habit reversal training (HRT)	A traditional behavioral therapy designed to reduced repetitive behaviors such as tics or hair pulling Involves identifying triggers, increasing awareness, and teaching competing responses Delivered in individual sessions with optional family involvement
Acceptance and commitment therapy (ACT)	A form of cognitive‐behavioral therapy focused on accepting distressing thoughts and urges while committing to actions aligned with personal values Helps develop psychological flexibility and can complement HRT Delivered individually or in group settings
Dialectical behavioral therapy (DBT)	A skills‐based therapy designed to manage emotional dysregulation Incorporates mindfulness, distress tolerance, and interpersonal effectiveness Delivered through structured group or individual models
Acceptance‐enhanced behavioral therapy (AEBT)	A hybrid approach that combines HRT with ACT principles Aims to increased psychological flexibility while directly targeting behaviors Often structured as online individual sessions
Response inhibition training	A computerized intervention targeting deficits in impulse control Typically self‐guided or therapist‐assisted with repetitive cognitive tasks to strengthen inhibitory control Usually an adjunctive modality

Recent studies have explored new adaptations of HRT to improve long‐term outcomes, including dialectical behavioral therapy or acceptance and commitment therapy (ACT) [23]. Petersen et al. investigated ACT paired with HRT—referred to as acceptance‐enhanced behavioral therapy (AEBT)―in a randomized control trial of 28 pediatric patients. Following 10 sessions of online AEBT, patients showed significantly decreased parent‐ and youth‐reported severity at 3‐, 6‐, and 12‐month follow‐ups, compared to waitlist control [15]. Effect sizes ranged from g = 1.04–1.34 for youth and 0.71–1.08 for parents. Within this cohort, comorbid psychiatric conditions at the time of treatment predicted greater decreases in TTM severity over time (p < 0.05). On the other hand, baseline psychological inflexibility (both general and trichotillomania‐specific) and age did not moderate treatment outcomes (p > 0.05) [16].

Given that deficient response inhibition is thought to underlie TTM, some researchers have explored targeting this mechanism through response inhibition training. In a pilot clinical trial by Lee et al. 22 pediatric patients were randomized to receive computerized response inhibition therapy or waitlist control. The treatment group showed significantly higher response rates on the Clinical Global Impression (CGI) scale compared to controls (p = 0.048) [13]. Although the total scores on the NIMH‐TSS did not differ significantly (p = 0.373), the treatment group experienced a significant reduction in functional impairment (p = 0.041).

3.2. Pharmacotherapy

Other strategies for combating TTM include pharmacotherapy options, such as selective serotonin reuptake inhibitors (SSRIs), tricyclic antidepressants, lithium, and antipsychotics; however, their scientific evidence remains limited. According to a case series of five pediatric patients, one patient treated with fluoxetine 80 mg, buspirone 20 mg plus augmentation with pimozide 2 mg, and behavioral therapy showed 50% clinical improvement over 3 months [14]. A second patient in this cohort treated with 40 mg fluoxetine and psychotherapy demonstrated significant improvement in mood and hair‐pulling tendencies. Another case series from Srivastava et al. [20] evidenced one patient with improvement in the frequency of hair pulling following treatment with valproate 100 mg/d.

3.3. Alternative Therapies

N‐acetylcysteine (NAC) has more recently emerged as a potential treatment option, due to its role in modulating glutamate concentrations, thought to play a key role in the pathogenesis of compulsive behaviors. However, its clinical effectiveness remains uncertain [24]. In a randomized controlled trial by Schumer et al. [19] involving 30 pediatric patients, NAC treatment led to a significant reduction in automatic hair pulling (p < 0.05), but not focused pulling (p = 0.84), as measured by the Milwaukee Inventory for Styles of Trichotillomania‐Child (MIST‐C) at follow‐up. Hair‐pulling severity immediately posttreatment was maintained at 1.5 years follow‐up, according to MGH‐HPS (p = 0.77), TSC‐C (p = 0.52), and TSC‐P (p = 0.89).

Milk thistle has surfaced among case reports with promising outcomes from its antioxidant and immune‐modulating silymarin compound [25]. By combating oxidative stress at the root of various neurological processes, silymarin may alleviate body‐focused repetitive behaviors seen in psychiatric disorders such as TTM. Grant et al. piloted a double‐blind, placebo‐controlled, crossover negative study of 20 patients, four of whom were children. Following the administration of 150–300 mg milk thistle twice a day for 6 weeks, no statistically significant treatment type‐by‐time outcomes were seen for NIMH‐TSS total scores. However, statistically significant decreases in MGH‐HPS scores (p = 0.02) and CGI severity (p = 0.004) were observed [12].

4. Discussion

Treatment for trichotillomania has been primarily studied in adults, despite evidence suggesting this condition typically presents in late childhood to early adolescence [26]. Additionally, research indicates that earlier intervention is linked to better long‐term outcomes [10, 26, 27]. This systematic review provides an up‐to‐date evaluation of the psychotherapeutic and pharmacological treatments for pediatric TTM and contributes to the limited literature specific to the pediatric population.

Our review found multiple studies showing sustained improvements with cognitive‐behavioral therapy and adjunctive models such as habit‐reversal training, suggesting this should be considered first‐line treatment. Given that children often exhibit automatic rather than focused pulling behaviors, early behavioral intervention targeting these patterns may be particularly effective [28]. Moreover, these techniques offer modifiable structures with notable success with children of all ages [28]. However, social and family support are crucial to patient success, highlighting the importance of ongoing family engagement and appropriate counseling by providers. Timely referral to behavioral health specialists, including child psychiatry, psychology, and appropriately trained therapists like social workers, is essential for early access to evidence‐based therapies. Such referrals also help ensure that patients are matched with the appropriate cognitive‐behavioral treatments. Practically, clinicians may find it beneficial to initiate contact with the nearest academic department of child psychiatry to explore referral options. Additionally, professional directories like Psychology Today and Zencare can serve as useful starting points for identifying qualified providers.

For pharmacological approaches, treatments for obsessive‐compulsive disorders, such as SSRIs or anxiolytics, have demonstrated marginal benefits for pediatric TTM, given their evidence is restricted to case reports and case studies. Such pharmacotherapy options may alleviate cases of comorbid anxiety and depression, offering relief from TTM behaviors. Additional agents, including antipsychotics and mood stabilizers, have been explored in various case reports and case series; though outcomes remain limited. Finally, alternative medications like NAC and milk thistle have been evaluated in clinical trials, although a clear benefit has not been demonstrated in pediatric cohorts. At present, no pharmacological treatment is considered first‐line for management, necessitating an individualized approach to pharmacologic treatment choice.

Although habit‐reversal training is effective for treating TTM, from a methodological perspective, it is important to note that most psychotherapy methods were studied in small trials involving single‐site institutions. Additionally, many of these studies were unblinded, which could lead to bias if self‐reported measures are used as the primary outcome. Similarly, for pharmacological treatment, there are several methodological limitations to consider. The available studies and case series generally include small sample sizes, resulting in limited statistical power. Moreover, given that milk thistle and NAC are sold as over‐the‐counter substances not subject to FDA regulations, variability in their composition may lead to differences in treatment efficacy. While generally well tolerated, NAC and milk thistle have been associated with gastrointestinal upset and rare hypersensitivity reactions. Although these formularies are considered hepatoprotective, there have been isolated cases of transiently elevated liver enzymes and hepatotoxicity, warranting consideration in pediatric patients [29, 30].

A further limitation in both pharmacologic and therapy intervention studies is the heterogeneity of instruments used to assess the severity of TTM and the lack of standardized definitions for treatment response. Outcomes may also be affected by the high prevalence of comorbid psychiatric symptoms experienced by patients. Finally, certainty in the evidence was assessed narratively using adapted GRADE principles; though formal scoring and assessment of reporting bias were not feasible due to study heterogeneity and limited sample sizes. Given the lack of robust, large‐scale studies in pediatric populations, studies with small cohorts, such as case series, were included to capture the full scope of available data. However, the generalizability of these studies is limited and should be considered. Further research involving prospective designs, larger cohorts, and standardized measuring and reporting systems will be required to evaluate the efficacy of various treatment options. Hence, despite advancements in pediatric TTM management, ultimately, the lack of robust study methodologies persistently hinders the development of evidence‐based guidelines.

5. Conclusion

This systematic review highlights the critical need for effective interventions in managing pediatric TTM, a condition that poses significant challenges due to its varied presentation and the absence of a gold‐standard treatment. Cognitive behavioral therapy, specifically habit‐reversal training, remains the first‐line treatment, with emerging evidence supporting response inhibition training as a promising adjunct. Moreover, the review underscores the importance of early intervention for improved clinical outcomes, especially in consideration of the high rates of comorbid mental health disorders associated with TTM in children and adolescents. Future research efforts should prioritize larger controlled trials to establish standardized treatment protocols and explore novel therapeutic options.

Ethics Statement

The authors have nothing to report.

Consent

The authors have nothing to report.

Conflicts of Interest

The authors declare no conflicts of interest.

Sharifi S., Estill M., Tordjman L., Millan S. H., and Ouyang J. X., “Treatment Strategies for Pediatric Trichotillomania: State‐of‐the‐Art Review on Progress and Persistent Challenges,” Pediatric Dermatology 43, no. 1 (2026): 3–10, 10.1111/pde.70014.

Data Availability Statement

All data generated or analyzed in this study is included in the article. Further inquiries can be directed to the corresponding author.