Trichotillomania & skin-picking

What body-focused repetitive behaviors are

Trichotillomania and excoriation (skin-picking) disorder are body-focused repetitive behaviors — or BFRBs. Both are recognized in the DSM-5 in the obsessive-compulsive and related disorders chapter.

• Trichotillomania — recurrent pulling of hair from the scalp, eyebrows, eyelashes, or other body areas, leading to hair loss. Often comes with repeated unsuccessful attempts to stop.
• Excoriation (skin-picking) disorder — recurrent picking at the skin causing skin lesions, with repeated attempts to stop.

Both typically begin in childhood or adolescence. Both are far more common than people realize — together affecting several percent of the population at some point.

What it feels like from the inside

Most patients describe some version of this:

• An urge or itch that builds, sometimes after a trigger and sometimes out of nowhere
• A sense of relief, satisfaction, or “rightness” when pulling or picking
• Sometimes near-trance-like episodes where you’re not fully aware
• Shame, secrecy, and avoidance afterwards — covering up affected areas, avoiding intimacy or hairdressers, dreading the gym or pool
• Multiple sincere attempts to stop, with relapses that don’t reflect lack of effort

If you’ve been hiding this for years, you’re not alone, and it’s not a moral failing.

How we treat trichotillomania and skin-picking

Habit Reversal Training (HRT) & the ComB model

The most evidence-based behavioral treatment is Habit Reversal Training, often delivered as part of the broader Comprehensive Behavioral (ComB) model. The core elements:

• Awareness training — learning to notice the early signs of an episode, often before it consciously starts
• Competing response — using a physically incompatible behavior (like clenching a fist or holding a stress object) when the urge hits
• Stimulus control — modifying the environments where pulling or picking is most likely (mirrors, certain rooms, certain times of day)
• Function-based work — understanding what the behavior is doing for you (regulating anxiety, soothing boredom, managing sensory needs) and finding healthier ways to meet that need

HRT works. It is not magic and it takes practice, but most patients meaningfully reduce their pulling or picking.

Acceptance and Commitment Therapy (ACT)

ACT-enhanced behavioral treatment has growing evidence in BFRBs — especially for the shame, urge tolerance, and self-criticism that keep the cycle going.

Medication

No medication is FDA-approved specifically for trichotillomania or skin-picking, but several have evidence:

• N-acetylcysteine (NAC) — an over-the-counter amino acid supplement with multiple positive trials in trichotillomania and skin-picking. Generally well tolerated.
• SSRIs — mixed evidence for the BFRB itself, but often helpful when there’s co-occurring depression, anxiety, or OCD.
• Memantine and other agents have emerging evidence for some patients.

We’ll talk through what makes sense based on what you’ve tried and what else is going on.

Co-occurring conditions

BFRBs commonly co-occur with anxiety disorders, depression, ADHD, and sometimes OCD. Treating those alongside the BFRB usually improves outcomes.