Trichotillomania (hair pulling) and excoriation disorder (skin picking) are body-focused repetitive behaviors that cause visible damage and distress despite repeated attempts to stop. First-line treatment is habit reversal training within a comprehensive behavioral approach, typically 8 to 12 sessions. N-acetylcysteine and, in some cases, SSRIs or olanzapine add modest benefit. Most people reduce the behavior substantially within two to three months.
These conditions affect millions of people, most of whom hide them for years out of shame and have never been told that effective treatment exists. At Stedfast Psychiatry we treat trichotillomania and skin picking with habit reversal training and the comprehensive behavioral model that have the best evidence, with medication when it adds benefit, and we treat the depression, anxiety, OCD and ADHD that frequently accompany them.
Symptoms of body-focused repetitive behaviors
- Pulling out hair from the scalp, eyebrows, eyelashes, beard or body, with visible thinning or bald patches
- Picking at skin, pimples, scabs or bumps until there are sores, scars or infections
- Repeated attempts to stop or reduce the behavior that have not worked
- Pulling or picking that is often automatic, during screen time, reading, driving or in bed
- Rising tension or an itch-like urge before pulling or picking, and relief afterward
- Rituals such as examining, rolling or biting pulled hairs, or eating them in some cases
- Hiding the damage with hats, makeup, long sleeves, wigs or avoiding swimming and intimacy
- Shame, embarrassment and avoidance of medical or dental care
- Significant time lost to the behavior each day
Causes and risk factors
Body-focused repetitive behaviors have a strong genetic component. Trichotillomania and skin picking cluster in families with each other and with OCD, and twin studies estimate heritability around 40 to 80 percent. Mutations in the SLITRK1 gene have been identified in a small number of families with trichotillomania, and animal models show that disrupting certain striatal circuits produces compulsive grooming. The behaviors appear to involve dysregulated habit circuits in the basal ganglia and altered reward response, rather than the intrusive thoughts that characterize OCD.
The behaviors serve regulatory functions. Pulling and picking reduce tension, relieve boredom, occupy the hands during under-stimulation and provide a soothing sensory input; many people describe a trance-like state. Stress, anxiety, perfectionism and the sensory experience of a hair that feels different or a bump that feels wrong all trigger episodes. Onset is typically between 10 and 13, often around puberty, and both disorders are far more common in women among adults, though childhood trichotillomania affects boys and girls equally.
Trichotillomania affects about 1 to 2 percent of adults, and skin picking disorder affects about 1.4 to 2 percent; among adults, about 80 to 90 percent of those affected are women.
Source: American Psychiatric Association, DSM-5-TR; Grant and Chamberlain, American Journal of Psychiatry, 2016
In a randomized, placebo-controlled trial, N-acetylcysteine at 1,200 to 2,400 mg daily reduced hair-pulling symptoms significantly, with 56 percent of patients much or very much improved compared with 16 percent on placebo.
Source: Grant et al., Archives of General Psychiatry, 2009
Habit reversal training produces large reductions in hair pulling, with effect sizes well above those of medication, and benefits are maintained with relapse-prevention sessions.
Source: Woods et al., Behaviour Research and Therapy, 2006; Bloch et al., Biological Psychiatry, 2007 meta-analysis
Fewer than 20 percent of people with trichotillomania have received behavioral treatment, and many have never disclosed the behavior to any clinician.
Source: Woods et al., Journal of Clinical Psychiatry, 2006 (Trichotillomania Impact Project)
How we diagnose it at Stedfast Psychiatry
Many patients have never told a clinician about their pulling or picking, so we ask about it in every evaluation that involves anxiety, OCD or dermatologic complaints. The assessment at Stedfast Psychiatry covers where and when you pull or pick, how much is automatic versus focused, what the urge feels like, what you do with the hair or skin afterward, how much time it takes, and what it has cost you socially and medically. We use the Massachusetts General Hospital Hairpulling Scale and the Skin Picking Scale-Revised to measure severity and track progress.
We distinguish these disorders from OCD (where behavior is driven by obsessional thoughts rather than urge and sensation), body dysmorphic disorder (where picking aims to fix a perceived appearance flaw), stimulant-induced picking, picking caused by a real skin condition such as scabies or eczema, and hair loss from alopecia areata or other medical causes. We screen for depression, anxiety disorders, ADHD and OCD, which are common companions, and we refer to dermatology for infections, scarring or skin conditions that need medical care. If hair is being swallowed, we ask about abdominal symptoms, because a hairball in the stomach is a rare but serious complication.
Treatment options
Habit reversal training and the comprehensive behavioral model
Habit reversal training is the first-line treatment and has the strongest evidence. It has three parts: awareness training, in which you learn to notice the behavior and its earliest precursors, often with the help of a monitoring log; competing response training, in which you practice an incompatible action for one to three minutes when the urge arises, such as clenching fists, sitting on hands or squeezing a fidget; and social support, in which a family member helps you notice and prompts the competing response. The comprehensive behavioral model (ComB), developed by Charles Mansueto and colleagues, extends this by mapping the sensory, cognitive, affective, motor and place triggers for each person and choosing interventions for each, such as fidget tools for sensory needs, gloves or bandages for automatic pulling, and DBT or ACT skills for emotional triggers. Acceptance and commitment therapy adds strategies for sitting with the urge without acting on it. A typical course is 8 to 12 sessions, and in controlled trials most patients reduce the behavior by more than half, with many achieving near-complete control.
Medication management
No medication is FDA-approved for trichotillomania or skin picking disorder, and results from medication alone are modest, so we say so and use medication as an addition to behavioral treatment rather than a substitute. N-acetylcysteine (NAC), an over-the-counter amino acid supplement that modulates glutamate, reduced hair pulling significantly compared with placebo in a trial of adults at doses of 1,200 to 2,400 mg daily, with benefit emerging over about nine weeks; it is well tolerated and is often our first addition. Olanzapine at low doses reduced pulling in a small controlled trial but carries metabolic side effects. SSRIs have not consistently reduced pulling or picking in trials but are useful when depression, anxiety or OCD coexist, which is frequent. Clomipramine has some support. Naltrexone has mixed results. If ADHD is present, treating it can reduce automatic pulling and picking by improving the ability to stay aware; stimulants occasionally worsen picking, so we monitor. Memantine showed benefit in a 2023 trial and is an emerging option.
What to expect
Your first visit is a 60-minute psychiatric evaluation, in person or by video, in which we discuss the behavior without judgment, assess coexisting conditions and plan treatment. Most patients start habit reversal training within the ComB framework, weekly for 8 to 12 sessions, and may add NAC or another medication. Follow-ups for medication are every four to eight weeks. Telehealth works well for this treatment, since the behavior happens at home and sessions can address the actual settings where it occurs. We track pulling or picking frequency, damage and time lost, and we build a relapse-prevention plan for the high-risk periods that follow treatment.
When to seek help
Seek an evaluation if you are pulling hair or picking skin in a way that causes visible damage, infection or scarring, that takes significant time, that you hide from others or that you have tried and failed to stop. These are treatable conditions, and most people wait years before asking. If skin picking has caused a spreading infection, fever or wounds that will not heal, see a physician promptly. If you are having thoughts of suicide or self-harm, call or text 988, go to the nearest emergency room, or call 911 if you are in immediate danger.
Focused and automatic pulling and picking
Clinicians distinguish two styles, and most people have both. Focused pulling or picking is deliberate and driven by an urge, a sensation such as an itch or a hair that feels coarse, or a wish to remove an imperfection; the person is fully aware and often in a trance-like state of concentration. Automatic pulling or picking happens outside awareness, during reading, television, phone use, driving or lying in bed, and the person notices only afterward from the pile of hair or the bleeding. The two styles need different interventions: focused behavior responds to urge-management strategies, competing responses and emotional regulation skills, while automatic behavior responds to awareness training and stimulus control such as gloves, bandages, fidgets and changes to the settings where it happens.
Related and overlapping conditions
OCD, body dysmorphic disorder, anxiety disorders, depression and ADHD commonly coexist with body-focused repetitive behaviors, and each affects the plan. Picking driven by the belief that a skin feature is ugly or abnormal points toward body dysmorphic disorder and calls for treatment of that condition. Picking at real skin lesions from acne, eczema or scabies needs dermatologic treatment of the underlying condition alongside behavioral work. Stimulant medications, cocaine and methamphetamine can cause or worsen skin picking. Hair loss from alopecia areata, thyroid disease or iron deficiency is distinguished by its pattern and by the absence of pulling. Rarely, swallowing pulled hair produces a trichobezoar, a mass in the stomach that can cause pain, nausea and obstruction and requires surgical evaluation.
The comprehensive behavioral model
The ComB approach recognizes that pulling and picking are maintained by different factors in different people and designs treatment accordingly. Sensory triggers include the feel of a coarse hair, a bump, or the satisfying sensation of pulling, addressed with fidgets, textured objects and gloves. Cognitive triggers include perfectionistic thoughts about symmetry or imperfection, addressed with cognitive restructuring. Affective triggers include anxiety, boredom and frustration, addressed with emotion regulation skills. Motor factors include habitual hand-to-face postures, addressed with competing responses and posture changes. Place factors include the bathroom mirror, the car and the bed, addressed with changes such as dimmer lighting, covered mirrors and fidget tools kept in each location. Treatment selects interventions from each domain that matters for you.
Daily strategies
Keeping a simple log of episodes, settings and triggers is the foundation. Barriers such as gloves, bandaged fingertips, hats or a short haircut reduce automatic behavior while awareness is being built. Fidget tools, textured objects and stress balls kept wherever the behavior usually happens give the hands something else to do. Reducing time in front of magnifying mirrors and bright bathroom lighting cuts focused picking. Adequate sleep, exercise and limiting caffeine lower the tension that drives urges. Telling one trusted person reduces the isolation that makes the behavior worse.
Prognosis
With habit reversal training and the comprehensive behavioral model, most people reduce pulling or picking substantially within two to three months, and many reach a point where it is rare and minor. Relapses are common during stress and are expected; a relapse-prevention plan and booster sessions address them quickly. Hair regrows and skin heals once the behavior stops. The main obstacle to recovery is not the treatment, which is brief and effective, but the years of shame that keep people from describing the problem to anyone. We ask so that you do not have to raise it first.
Frequently asked questions
Is hair pulling or skin picking a form of OCD?
They are related but distinct. DSM-5 places both in the obsessive-compulsive and related disorders chapter, and they run in families with OCD. But the mechanism differs: OCD compulsions are driven by intrusive, anxiety-provoking thoughts, while pulling and picking are driven by urges, sensations and a soothing or trance-like reward, often without any thought at all. This matters because the treatments differ. Exposure and response prevention and high-dose SSRIs work for OCD; habit reversal training works for body-focused repetitive behaviors, and SSRIs help little unless OCD, anxiety or depression is also present.
Can I just stop if I try hard enough?
Most patients have tried very hard, often for years, and the behavior continues because it is largely automatic and serves a function, such as relieving tension or boredom or providing sensory stimulation. Willpower alone does not address any of that. Habit reversal training teaches you to notice the behavior before it starts, substitute a competing action and change the environments and emotional states that trigger it. It works where effort alone has not, and it is usually brief.
Does medication help?
Modestly, and we are honest about it. No medication is FDA-approved for these disorders. N-acetylcysteine, an over-the-counter supplement, reduced pulling in a controlled trial and is well tolerated, so we often add it. SSRIs do not reliably reduce pulling or picking but help if you also have depression, anxiety or OCD. Low-dose olanzapine and clomipramine have some support but more side effects. Behavioral treatment remains the core, and medication is an addition for people who need more.
Does insurance cover treatment?
Yes. Trichotillomania and excoriation disorder are recognized diagnoses, and psychiatric evaluation, medication management and psychotherapy are covered by most major commercial plans and Medicare, which Stedfast Psychiatry accepts. NAC is an inexpensive over-the-counter supplement. Dermatologic care for scarring or infection is billed separately by that provider. For patients without insurance, a self-pay new-patient visit is $185.
Can trichotillomania or skin picking be treated by telehealth?
Yes, and it is often ideal. The behavior usually happens at home, in the bathroom, bedroom or in front of a screen, and video sessions let your therapist see those settings and help you adjust them. Awareness training, competing responses and stimulus control all transfer well. We treat patients across Florida and South Carolina by video, with in-person care available at all 13 offices.
My child pulls their hair. Will they grow out of it?
Hair pulling in children under five is often transient and resolves on its own. Onset around puberty, between 10 and 13, is more likely to persist without treatment. Habit reversal training adapted for children, with parents trained as coaches, is highly effective, and treating it early prevents years of shame and social avoidance. Our child and adolescent psychiatry team evaluates children and teens with pulling or picking and screens for the anxiety and ADHD that often accompany it.
How long does treatment take?
Most people see a substantial drop in pulling or picking within four to eight weeks of starting habit reversal training, and a full course is 8 to 12 sessions. NAC takes about two months to show benefit. Because these behaviors tend to return during stress or transitions, we build a relapse-prevention plan and offer booster sessions. Hair regrowth takes months after pulling stops, and skin heals over weeks to months depending on the depth of damage.
Will my hair grow back? Will the scars fade?
In most cases hair regrows fully once pulling stops, though it can take three to six months to see meaningful regrowth and longer for eyebrows and eyelashes. After many years of pulling from the same spot, regrowth can be slower or finer. Skin scarring depends on depth: superficial picking heals without marks, while deep or infected lesions may scar. A dermatologist can help with scarring and with underlying conditions such as acne that drive picking. Treating the behavior is the first step to letting the body recover.
Where to get treatment for body-focused repetitive behaviors
Evaluation and treatment for body-focused repetitive behaviors is available at every Stedfast Psychiatry office and by video across Florida and South Carolina.
Related conditions
If you are thinking about harming yourself, call or text 988 now, or go to the nearest emergency room. This page is educational and does not replace an evaluation. Clinical content reviewed by Dr. David Husted, board-certified psychiatrist.