Trichotillomania and skin-picking: GP guide to recognition and habit reversal

What trichotillomania and skin-picking are

Body-focused repetitive behaviours (BFRBs) are a spectrum of recurrent self-directed grooming behaviours that cause physical damage despite repeated attempts to stop. The two most clinically significant are:

• Trichotillomania (hair-pulling disorder, ICD-10 F63.3) — recurrent pulling of hair from the scalp, eyebrows, eyelashes, beard, or other body sites, resulting in noticeable hair loss and significant distress or functional impairment
• Excoriation disorder (skin-picking or dermatillomania, ICD-10 L98.1) — recurrent picking of skin from the face, shoulders, arms, or other sites, resulting in skin lesions, scarring, and distress

Both are classified under obsessive-compulsive and related disorders in DSM-5-TR. The BFRB spectrum also includes clinically significant nail biting, cheek/lip biting, and compulsive hair chewing.

Together, trichotillomania and excoriation disorder affect approximately 3–8% of the population over a lifetime. The female-to-male ratio is approximately 4:1 in adults. Onset typically occurs in childhood or early adolescence, peak onset 8–13 years, and the course is chronic without treatment. Most affected people never seek help, primarily because of shame and concealment — making GPs uniquely positioned to identify the condition.

A. Core clinical — the AU general practice framework

Recognising BFRBs in general practice

The clinical presentation depends on which behaviour is predominant:

Trichotillomania — what to look for:

• Patches of hair loss on the scalp, brows, or lashes — often asymmetric, with hairs of varying lengths and broken stubble (not the smooth, uniform patches of alopecia areata)
• Frequent hat or wig use to conceal scalp
• Absent or partial eyebrows or eyelashes
• The patient may not volunteer the behaviour — direct, non-judgemental enquiry is needed

Skin picking — what to look for:

• Multiple excoriation marks, scabs, or scars on the face, shoulders, chest, or hands at various stages of healing
• Sites that do not correspond to a recognised dermatological distribution
• Significant camouflaging with makeup or clothing

History to take:

• Which body sites, what frequency and duration per day
• Trigger states — boredom, anxiety, fatigue, mirrors, screens
• Automatic (outside awareness during sedentary tasks) vs focused (deliberate, with premonitory urge)
• Whether pulled hair is eaten — trichophagia is a surgical red flag
• Functional impact — avoidance of swimming, hairdressing, intimate relationships, work
• Comorbidities — depression, anxiety, OCD, ADHD, autism, eating disorder
• Prior diagnosis and treatment
• Suicidality — direct enquiry; shame load is consistently high in BFRBs

Examination:

• Systematic scalp examination under good light with hair parted
• Dermatoscopy — trichotillomania shows flame hairs, hook hairs, V-sign, hair powder, broken hairs of varying lengths; no exclamation-mark hairs (these favour alopecia areata)
• Skin-picking sites: excoriations, scabs, scars not in a dermatological pattern
• Abdominal palpation if trichophagia reported — trichobezoar produces an epigastric mass

Differentiating trichotillomania from other hair loss

Condition	Key discriminator
Trichotillomania	Hairs of varying lengths; behavioural history; no scalp inflammation
Alopecia areata	Smooth circular patches; exclamation-mark hairs on dermatoscopy; nail pitting
Telogen effluvium	Diffuse shedding 2–4 months post-trigger; positive pull test; no broken hairs
Tinea capitis	Scaling; broken hairs; positive KOH or fungal culture (paediatric especially)
Scarring alopecia	Perifollicular erythema; loss of follicular ostia on dermatoscopy; biopsy required

Investigations

Basic workup serves to exclude organic contributors and comorbidities:

• TFT — hypothyroidism / hyperthyroidism can worsen hair loss and contribute fatigue
• FBC and ferritin — iron deficiency worsens hair quality and can exacerbate telogen effluvium that overlaps with trichotillomania
• Vitamin D and B12 — baseline optimisation
• Bacterial swab of infected skin lesions if pustular or exudative
• Urgent abdominal ultrasound or CT if trichophagia with GI symptoms — trichobezoar (Rapunzel syndrome) is a surgical emergency

B. Evidence for habit reversal training and pharmacotherapy

Habit reversal training — first-line

Habit reversal training (HRT) delivered by a trained psychologist is the first-line treatment for trichotillomania and excoriation disorder. A 2011 meta-analysis by Bate et al. confirmed HRT as the most evidence-supported intervention across published trichotillomania trials.

HRT components:

1. Awareness training — systematic identification of the specific triggers, postures, emotional states, and environmental cues that precede the behaviour (many episodes are automatic and outside awareness)
2. Competing response training — substituting an incompatible physical action when the urge is detected; for example, pressing a closed fist against the skin, gripping a textured object, or making a fist for one minute — any response that blocks the pulling or picking
3. Social support — a trusted person is coached to prompt the competing response without judgment

Enhanced versions of HRT that improve outcomes:

• ACT-enhanced HRT (Twohig & Woods) — incorporates acceptance and defusion techniques alongside awareness and competing response training
• ComB (Comprehensive Behavioural) model — targets all functional dimensions of the BFRB: sensory, motor, cognitive, affective, and place/time triggers; tailors competing responses to the specific sensory need the behaviour is meeting

Access in Australia: MHCP (2715) unlocks up to 10 subsidised psychology sessions per year. Very few Australian psychologists have specialist HRT-BFRB training — the TLC Foundation for BFRBs maintains an international directory. Telehealth substantially expands access.

Pharmacotherapy — modest evidence

N-acetylcysteine (NAC) 1200–2400 mg/day — glutamate modulator available over the counter. Grant 2009 (Arch Gen Psychiatry) showed significant benefit over placebo in adults with trichotillomania; Bloch 2013 (JAACAP) found benefit in adolescents; Schumer 2015 found modest evidence in skin picking. Adverse effects are mild (GI, mild headache). NAC is a reasonable adjunct to HRT for moderate-to-severe cases; it is not a substitute for behavioural treatment.

SSRIs — evidence does not support SSRIs for trichotillomania specifically. Multiple RCTs have failed to show benefit over placebo for hair pulling. SSRIs remain appropriate when a comorbid anxiety disorder or major depression is present (treating the comorbidity is the goal, not the BFRB directly).

Clomipramine — modest RCT evidence in a small early trial; second-line consideration when NAC plus HRT has not been sufficient; requires baseline ECG given cardiac risk; psychiatric input recommended.

Olanzapine — small RCT evidence in refractory trichotillomania; associated with significant metabolic and sedation adverse effects; specialist-initiated.

C. GP-led stimulus control strategies

While waiting for specialist psychology referral, GPs and patients can begin stimulus control measures that reduce opportunities for automatic pulling or picking:

• Barrier methods — bandages, finger cots, fidget toys, textured hand grip for picking at hands and cuticles; wide-brim hat or headscarf while doing high-risk sedentary activities
• Environmental modification — reduce or cover mirrors for those who pick at skin during mirror examination
• Screen hygiene — identify high-risk screen-use situations (late evening, specific shows or platforms) and introduce breaks or substitutions
• Fidget alternatives — providing comparable sensory stimulation through legitimate channels (textured balls, fidget rings, clay)
• Awareness cues — simple physical reminders worn on the wrist or hand to shift automatic pulling into conscious awareness

These strategies do not replace HRT — they are bridges that reduce behaviour frequency and build awareness while formal therapy is accessed.

D. Australian operations

MBS items

• Standard consults — 23/36/44
• Mental Health Treatment Plan — 2715 preparation / 2717 review — unlocks 10 + 10 + 2 psychology sessions per year
• Psychology Better Access — 80000–80020 — focused psychological strategies
• Psychiatrist — 105/106 for refractory, severe, or comorbid presentations

PBS

• SSRIs (fluoxetine, sertraline, escitalopram) — PBS General Schedule where prescribed for comorbid depression or anxiety
• Clomipramine — PBS General Schedule
• Olanzapine — PBS Authority Required (off-label for BFRB)
• NAC is an OTC supplement; not PBS-listed

Referral pathway

Referral	Indication
Clinical psychologist (HRT or ACT-HRT trained)	First-line for all BFRBs — via MHCP 2715
Psychiatrist	Severe comorbidity, suicidality, paediatric PANS/PANDAS, refractory to HRT + NAC
Headspace (12–25 years)	Youth-friendly first contact
ED / surgical	Trichophagia + GI symptoms — possible trichobezoar
Dermatology	Diagnostic uncertainty with organic alopecia or scarring alopecia

Consumer resources

• TLC Foundation for BFRBs — international BFRB specialist directory, patient resources
• International OCD Foundation — BFRBs
• Beyond Blue — 1300 22 4636
• Lifeline — 13 11 14

E. Special populations

Children and adolescents. BFRBs that begin in early childhood (under 5 years) often resolve spontaneously. Onset in older childhood or adolescence is more likely to persist and warrants early behavioural intervention. Parental psychoeducation is central — many parents inadvertently increase shame through negative reactions. Headspace is the appropriate first referral for adolescents. Paediatric onset with abrupt onset alongside neuropsychiatric symptoms and tics following a streptococcal or viral illness should trigger consideration of PANS/PANDAS and paediatric neurology referral.

Comorbid ADHD. BFRBs and ADHD commonly coexist. The automatic phenotype (pulling during low-stimulation tasks) is particularly prevalent in ADHD, and the BFRB may serve a self-stimulatory function. Treating ADHD with stimulant medication may reduce automatic BFRB frequency; HRT remains necessary for the habitual component.

Comorbid autism spectrum disorder. BFRBs occur at higher rates in autism. Sensory components of the behaviour (tactile satisfaction from pulling or picking) are often more prominent and require a ComB-model approach targeting the sensory function specifically.

Trichophagia and Rapunzel syndrome. Any patient who reports eating pulled hair needs direct questioning about gastrointestinal symptoms. Trichobezoar — a compacted hair mass in the stomach — presents with epigastric pain, early satiety, nausea, vomiting, and weight loss. Rapunzel syndrome refers to extension of the tail of the bezoar into the small bowel, which can cause obstruction or perforation. Urgent surgical referral is required. Trichobezoar can accumulate over years with no obvious GI symptoms until the mass is large.

When to escalate

Refer urgently when:

• Suspected trichobezoar (trichophagia + GI symptoms) — urgent imaging and surgical review
• Active suicidal ideation — direct enquiry and risk assessment
• Secondary skin infection with signs of cellulitis, abscess, or systemic involvement
• Sudden-onset paediatric OCD-spectrum behaviour post-infection — PANS/PANDAS workup

Refer to psychiatry (not only psychology) when:

• Severe comorbid depression, OCD, eating disorder, or substance use disorder
• Inadequate response after adequate HRT course and NAC trial
• Paediatric presentation requiring combined assessment

What this article is and is not

This is general health information drawn from Therapeutic Guidelines (eTG), RANZCP OCD-related disorders CPG, TLC Foundation Expert Consensus Guidelines, and published trial evidence. It is not personal medical advice and does not create a doctor–patient relationship. Decisions about specific treatment — including medication and referral — are made with your own GP and treating clinician.

For urgent support: Lifeline 13 11 14, Beyond Blue 1300 22 4636. For consumer information: HealthDirect, TLC Foundation for BFRBs.

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Sources cited

1. Therapeutic Guidelines (eTG) — OCD-related disorders
2. RANZCP — OCD and related disorders CPG
3. RACGP — BFRBs in general practice (AFP)
4. TLC Foundation for BFRBs — Expert Consensus Treatment Guidelines
5. International OCD Foundation — BFRBs
6. Bate KS et al. — HRT meta-analysis (Behav Res Ther 2011)
7. Grant JE et al. — NAC for trichotillomania (Arch Gen Psychiatry 2009)
8. Twohig MP, Woods DW — ACT-enhanced HRT
9. Beyond Blue
10. HealthDirect — Trichotillomania