Trichotillomania and excoriation disorders involve recurrent picking that causes hair loss or skin lesions
Trichotillomania (hair pulling) and excoriation (skin picking), with repeated attempts to decrease or stop the behaviour, are categorized as obsessive–compulsive and related disorders.1 Hair is pulled commonly from the scalp, eyebrows or eyelashes, and skin is picked from the face, arms or hands.1 Onset of these behaviours often coincides with puberty.1 They may be automatic, focused (within conscious awareness) or both.1 Although not formally recognized by the Diagnostic and Statistical Manual of Mental Disorders (5th edition), other body-focused repetitive behaviours include nail and cheek biting.2
Hair-pulling and skin-picking disorders affect about 1% to 2% of the population1
Most affected people report distress and 25%–33% report functional impairment.2 They have a 2- to 4-fold increased risk of anxiety, depression and other obsessive–compulsive symptoms.3 Body-focused repeptitive disorders are distinguished from subclinical habits when they cause substantial distress or functional impairment.1
Body-focused repetitive disorders arise from a pathological urge to self-groom3 and differ from self-harm
Behaviours can be triggered by feelings of anxiety, boredom or tension,1 and people can experience temporary relief once the behaviour is performed.1
Randomized controlled trials have shown cognitive behavioural therapy with habit reversal therapy to be beneficial
Cognitive behavioural therapy with habit reversal therapy is first-line treatment.4,5 Habit reversal therapy involves awareness training, stimulus control and competing responses, and requires referral to a specialist. Access to therapy can be challenging. Health care providers can inquire within their local networks or through specialized not-for-profit organizations.
N-acetylcysteine may reduce body-focused repetitive behaviours
An amino acid derivative, N-acetylcysteine, is typically administered as 1200 mg twice daily.4,5 Evidence from lower-quality randomized trials and uncontrolled studies supports the use of olanzapine (20 mg/d) for treatment of hair pulling, and citalopram (20 mg/d), fluoxetine (55 mg/d), escitalopram (30 mg/d) or fluvoxamine (300 mg/d) for treatment of skin picking.4,5 Medications should be tried for 12 weeks, based on the average study duration. Referral to specialists should be considered in severe or treatment-resistant cases.
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Footnotes
Competing interests: None declared.
This article has been peer reviewed.
References
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