DOI: 10.1111/pde.

13954

Pediatric
REVIEW ARTICLE Dermatology

Pediatric trichotillomania: Review of management

Emily D. Henkel BA1 | Sasha D. Jaquez PhD2,3,4 | Lucia Z. Diaz MD4,5,6

1
Long School of Medicine, University of
Texas Health Science Center at San Antonio, Abstract
San Antonio, Texas Trichotillomania can present in childhood, with many families seeking initial evalu‐
2
Department of Psychiatry, Dell Medical
ation by a dermatologist for hair loss. Prompt and accurate diagnosis by dermatolo‐
School, University of Texas at Austin, Austin,
Texas gists is crucial, as children can suffer from academic or social impairments as well as
3
Texas Child Study Center, Austin, Texas mental health sequelae. Children are especially vulnerable to lasting psychological
4
Dell Children’s Medical Center, Austin, distress from appearance‐related bullying. This article reviews the psychosocial im‐
Texas
5 pacts of pediatric trichotillomania and the current interventions studied in this popu‐
Division of Dermatology, Dell Medical
School, University of Texas at Austin, Austin, lation. Included are studies evaluating behavioral therapies as well as pharmacologic
Texas
6
options. This review highlights the importance of early and appropriate identification,
Department of Pediatrics, Dell Medical
School, University of Texas at Austin, Austin, intervention, and the need for more treatment studies in the pediatric population.
Texas
KEYWORDS
Correspondence
body‐focused repetitive behavior, habit reversal therapy, trichotillomania
Lucia Z. Diaz, MD, Dell Children’s Medical
Group, 1301 Barbara Jordan Blvd Suite
200A, Austin, TX 78723.
Email: LzDiaz@ascension.org

1 | BAC KG RO U N D
Trichotillomania (TTM) is classified by the Diagnostic and Statistical
Manual of Mental Disorders (DSM‐5) as an obsessive‐compulsive or
related disorder in which a person recurrently pulls out hair from
1
any region of their body resulting in hair loss. Additionally, the hair
pulling causes significant distress or functional impairment of the
patient. Age of onset is usually between ages 10 and 13 years, and
female predominance has been observed in late adolescence. The 1 cases can lead to significant functional impairment and/or psychi‐
most common sites of hair removal are the scalp, eyebrows, eye‐
1
lashes, and pubic region. Epidemiologic data on the affected pe‐
diatric population are relatively scarce, but lifetime prevalence is
estimated to be around 1%‐3%. 2
Although TTM is considered a psychiatric diagnosis, many fam‐
ilies will initially present to a dermatologist for evaluation. Pulling
is not always focused and may occur in private, leading parents to
believe the hair is falling out. The differential diagnosis for childhood
hair loss includes alopecia areata, tinea capitis, traction alopecia,
telogen effluvium, and trichotillomania. In more ambiguous cases,
advanced techniques such as trichoscopy will show flame hairs and
coiled hairs that aid in diagnosis.3 The National Institute of Mental
Health Trichotillomania Symptom Severity Scale (NIMH‐TSS) is a de‐
tailed questionnaire that may aid diagnosis in children ages 10‐17.4 If
the diagnosis remains unclear or the family has difficulty accepting
the self‐inflicted nature of a TTM diagnosis, biopsy of the region may
be offered for confirmation. However, it is not encouraged in a pedi‐
atric population when diagnosis is clinically apparent.
The noticeable hair loss and unrelenting urge to pull in many
atric comorbidity.1 Common comorbidities include mood disorders,
anxiety disorders, eating disorders, substance use disorders, and dis‐
ruptive behavior disorders. Rarely, patients may concomitantly suf‐
fer from trichophagia, a subset of pica, in which patients consume
the pulled hair creating trichobezoars, or hairballs, that can lead to
significant gastrointestinal complications and the need for further
intervention.
This article reviews the limited literature on pediatric psycho‐
social impact and management options of TTM to better equip the
dermatologist for educating families and recommending treatment
options.

Pediatric Dermatology. 2019;00:1–5. wileyonlinelibrary.com/journal/pde

© 2019 Wiley Periodicals, Inc. | 1
2 | Pediatric
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2 | P S YC H OS O C I A L I M PAC T O F T TM
While some TTM patients engage in automatic (unconscious) hair
pulling, others may experience the conscious urge to pull.5 The per‐
sistent urges coupled with noticeable bald spots can be function‐
ally disabling, especially in younger individuals. Appearance‐related
bullying or teasing is unfortunately common among the school‐aged
population, and children with dermatologic disorders are shown to
have increased risk of being targeted.6 Families and children of mid‐
dle schoolers affected by TTM have reported significant impairment
in social and academic functioning, including less social acceptance
among peers, which increases vulnerability to bullying and social iso‐
lation.7,8 The sequelae of childhood bullying or teasing is long‐last‐
ing and associated with mental health morbidity including anxiety,
depression, and low self‐esteem.9
Resulting impairments from TTM give rise to additional stress,
which can subsequently exacerbate pulling.5 The development of
negative affective states and low self‐esteem are notable triggers
to pulling, thus creating a cyclic worsening of the condition.10 While
psychiatric comorbidity in adult patients has been well‐documented,
the pediatric population lacks comparable data to inform whether
these comorbidities are TTM consequential or independent of the
condition.7
As children age, there is an increase in the reported number of
pulling sites, frequency of urges, and amount of focused pulling,
suggesting TTM may have a developmental progression and could
worsen if left untreated. 2 Focused pulling can be associated with
negative emotional states, which would theoretically increase as
a child emotionally matures, begins to manifest feelings of shame,
and undergoes increased exposure to bullying and/or social impair‐
ments. The possible developmental progression of this disorder may
also explain the increase of comorbid psychiatric conditions among
adult patients. This information emphasizes the need for early inter‐
vention to prevent clinical progression and mental health sequelae.
Unfortunately, the median time from symptom onset to first psychi‐
atric appointment in the pediatric TTM population is nine months.11
Repeated visits to physicians to appropriately diagnose TTM may
also increase the financial burden on families. The majority of pe‐
diatric TTM patients are referred to a child psychiatrist or psychol‐
ogist by a pediatric dermatologist demonstrating the important
role pediatric dermatologists play in early disease recognition and
intervention.11
3 | T TM M A N AG E M E NT
A wide variety of treatment options for TTM has been explored
including cognitive behavioral therapy, pharmacological manage‐
ment, and combination therapies. Controlled studies on outcomes
are significantly limited, especially in the pediatric population. In
2008, the Trichotillomania Learning Center Scientific Advisory
Board conducted the Child and Adolescent Trichotillomania
HENKEL et al
Project (CA‐TIP) to help capture the state of TTM treatment in
the pediatric population.7 This project reported less than half of
the children treated for TTM had improvement; however, this was
confounded by surveying a disproportionate number of severely
affected patients.7 The unsatisfactory TTM treatment response
from this study has prompted subsequent treatment studies to
help inform physician management of TTM. As there is currently
no gold standard treatment for TTM, disease management is
challenging.
3.1 | Cognitive behavioral therapy
Cognitive behavioral therapy (CBT) is a skill‐based, present‐focused,
and time‐limited approach to therapy. It is often considered the gold
standard for many psychological disorders and focuses on identify‐
ing and restructuring negative thought patterns and behaviors that
can be modified by the individual. Habit reversal training (HRT) is
a type of CBT that has shown efficacy in the treatment of TTM, as
well as other body‐focused repetitive behaviors, including nail biting
or skin picking.12 HRT should be conducted by a CBT‐trained pro‐
vider (eg, psychologist, psychiatrist, etc) and consists of weekly ses‐
sions lasting approximately 45‐60 minutes each. Resources on the
structure of HRT sessions are available specifically for dermatolo‐
gists to familiarize themselves with the process and provide patients
and families with accurate, detailed information.13 Social and family
support is imperative to treatment success and can be promoted by
having a dermatologist who is knowledgeable on HRT. Each ses‐
sion is designed to address one of the five key components: aware‐
ness, competing responses, stimulus control, relaxation, and social
support.13
First, awareness of the undesirable behavior must occur for
the individual in order to recognize the habit and triggers. Older
children may be able to attain awareness of thoughts or moods
that precede pulling, but younger children will likely need some
parental observation and assistance in increasing awareness.
Baseline data will be obtained first, as it is important for outcome
comparison. Baseline data will likely involve collateral informa‐
tion from social supports, particularly in younger patients. Next,
competing responses to the undesirable behavior should be deter‐
mined. Typically, this could be identifying an activity a child can
perform with their hands during urges that inhibits pulling, such
as using a fidget spinner or putty. Another option could be the use
of physical barriers to inhibit pulling, such as wearing hats, gloves,
or placing non‐medicated ointment, such as petroleum jelly, on
the area from which hair is typically pulled. These competing re‐
sponses should specifically be focused when the behavior is more
likely to occur as specified by the triggers identified in the first
step of treatment. Relaxation techniques such as diaphragmatic
breathing, progressive muscle relaxation (PMR), or guided imagery
are another component to HRT and involve teaching the patient
how to actively enter a relaxed state. Finally, social support is crit‐
ical, especially in a pediatric patient. Younger children with more
HENKEL et al
automatic pulling may rely on familial involvement, such as the use
of code words from family members when pulling is observed. The
HRT protocol involves the patient performing “homework” assign‐
ments between each session in order to master the key compo‐
nents. Components of HRT may be modified or eliminated based
on the age and developmental level of the child.
Recent data have demonstrated very successful outcomes for
pediatric TTM patients who practice HRT, making it a strongly rec‐
ommended treatment option. In 2017, a randomized controlled trial
of HRT in TTM youth demonstrated a 76% response rate with en‐
couraging maintenance data at 1 and 3 months, providing strong evi‐
dence for the superiority of HRT to placebo.14 The long‐term success
of HRT among this population was also demonstrated by a study
with a 64% maintenance rate at 6‐month follow‐up.15
An advantage of HRT is its utility across the pediatric age spec‐
trum. Data demonstrate the success of HRT is not affected by age
and is a promising treatment option for children aged 7‐17 years.16
In general, children with TTM engage in more automatic pulling than
adults, which portends success with HRT in the younger age group.8
The ability to modify sessions to the developmental level of the child
is key to a successful outcome. Physicians should counsel families
that their involvement is crucial for success.
3.2 | Electronic devices
Recently, the invention of electronic devices that monitor habits
may positively augment the effectiveness of HRT. One example
device unit consists of an electronic necklace that casts inaudible
sound waves around the head and communicates to a bracelet that
vibrates when crossing into the head region for longer than three
seconds.17 A feasibility trial involving this device demonstrated sig‐
nificant improvements measured by the Trichotillomania Severity
Scale when monitors were operational, but concluded that future
design modifications were indicated for reliability.17 Companies cre‐
ated around this innovative idea have similar awareness‐enhance‐
ment devices that are already commercially available, with one
currently undergoing a National Institutes of Health (NIH)‐funded
study.18 These monitors may be particularly helpful during the
awareness and stimulus‐control components of HRT. A pilot clinical
trial of computerized response inhibition training (RIT) in pediatric
TTM patients demonstrated a 55% response rate using the Clinical
Global Impression‐Improvement scale, though limited by a small
sample size.19 The possibility of including technology in HRT may
present an opportunity to target therapy at the unconscious pulling
predominantly seen in the pediatric population. Additional longitu‐
dinal studies would be helpful in demonstrating if lasting effects are
maintained throughout adulthood.
3.3 | Hypnotherapy
Alternative behavioral intervention approaches, such as hyp‐
notherapy, have been utilized to sensitize and alert patients to
Pediatric | 3
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impending pulling behaviors. Case series of solo hypnotherapy
have demonstrated complete or near‐complete resolutions of TTM
in children with low relapse rates that should encourage further
investigation of this treatment modality. 20,21 Cases of solo hyp‐
notherapy in adolescents and adults are limited and show mixed
results, likely due to the increased prevalence of comorbid psychi‐
atric conditions in this age group. 20,22 The lack of controlled trails
of hypnotherapy makes it difficult to ascertain the true efficacy of
this therapy.
3.4 | Group and support therapy
Support groups are widely utilized in many medical conditions to
bring together individuals to share the challenges and successes of
their illness management. The TLC Foundation for Body‐Focused
Repetitive Behaviors provides an online means for patients and fam‐
ilies to locate the closest support group for TTM. In addition, they
also provide free educational materials for patients and families.
Since TTM is a relatively rare disease, providing patients and fami‐
lies with these resources can greatly aid in the management process.
Support groups may not be developmentally appropriate in younger
children; however, guardians of the child may find them helpful as
TTM often contributes to familial distress.8 Group therapy has not
been studied in children with TTM, but a study comparing group
behavioral therapy to supportive therapy in adults demonstrated
short‐term improvement in those in group behavioral therapy. 23
This suggests group therapy could play an adjunctive role in TTM
management.
3.5 | Pharmacologic options
Although there are currently no FDA‐approved medications for
TTM, there has been investigation into the use of several different
pharmacologic options. However, most trials have focused solely on
the adult population leaving effectiveness in the pediatric popula‐
tion relatively unexplored.
The sole pharmacologic randomized controlled trial in children
to date was performed in 2013 and investigated the use of N‐ace‐
tylcysteine (NAC) in TTM management. Glutamatergic dysfunction
is implicated in obsessive‐compulsive disorder and related disorders
such as TTM. NAC may benefit TTM patients by way of two mech‐
anisms of action: (a) restoration of extracellular glutamate in the
nucleus accumbens resulting in the inhibition of synaptic release of
glutamate and (b) neuroprotective effects of glutathione regenera‐
tion. 24 While NAC demonstrated significant improvement in adults
with TTM, data from the pediatric trial did not demonstrate any
benefit. 24 However, an individual case of pediatric TTM treated with
6 months of NAC resulted in complete recovery with no recurrence
at 8‐month follow‐up. 25 Given reported success among adults with
TTM and patients with other body‐focused repetitive behaviors (ex‐
coriation disorder, nail biting), the use of NAC should be explored by
additional randomized controlled trials in the pediatric population to
4 | Pediatric
Dermatology
better inform its role in treatment. 25,26 NAC’s low‐risk side‐effect
profile and demonstrated case success make it a consideration for
childhood TTM refractory to behavioral therapy. 27
Other investigated pharmacologic options in the adult popula‐
tion include serotonin reuptake inhibitors (SSRIs), antipsychotics,
dronabinol, and tricyclic antidepressants. However, most data on
these options are from case reports or limited trials; thus, there is
inconsistent evidence to inform pharmacologic treatment, especially
in children. 28 Children who meet diagnostic criteria for anxiety or
depression may see improvement of TTM by treating these comor‐
bid conditions with traditional pharmacotherapy such as SSRIs.
Overall, the extremely limited data on pharmacologic manage‐
ment of TTM in children suggest behavioral therapy serves as the
first‐line treatment until further evidence arises.
3.6 | Considerations in management
Occasionally, when delivering a diagnosis of trichotillomania to a pa‐
tient and/or family, a dermatologist may be met with unexpected
hostility, disbelief, or justification/proof of the diagnosis. The physi‐
cal manifestations of TTM may make it difficult for families to un‐
derstand the psychiatric etiology of the disease and accept that it
is not a skin condition, but rather the result of an involuntary be‐
havior. Therefore, when delivering a diagnosis of TTM, it is impera‐
tive that dermatologists adequately explain that the child is likely
unaware of their engagement in this behavior. This information
should be presented in a positive light, sharing the good news that
there is an evidence‐based treatment available. Mental/behavioral
health referrals should then be shared. Unfortunately, public and
self‐stigma surround mental health diagnoses can create significant
barriers to receiving treatment or willingness to accept the diagno‐
sis. Family members should be thoroughly educated that negative
feedback and punishment for hair pulling are not conducive to posi‐
tive results. Parental optimism and support are shown to be protec‐
tive against self‐stigmatization, which results in a child feeling less
shame and rejection during mental health treatment. 29 Since social
support is a crucial pillar to successful HRT, physicians must convey
the importance of familial support to achieving remission. Given that
HRT requires several sessions with a trained professional, families
may express frustration toward the financial burden of treatment.
Dermatologists can assist families by staying up to date on upcoming
treatment options, such as electronic devices and online apps, and
relaying these options as appropriate.
4 | CO N C LU S I O N
Trichotillomania can be an extremely disabling chronic condi‐
tion that impacts the psychosocial development of children.
Recognizing this disorder and being informed of treatment options
allows dermatologists to diagnose and intervene early in the dis‐
ease course.
HENKEL et al
When patient presentation suggests TTM, dermatologists
should conduct a thorough history with the patient and caretaker
and a physical exam which may include trichoscopy. Biopsy may
offer diagnostic confirmation but should be utilized only if nec‐
essary. Upon diagnosis, the provider should educate both the pa‐
tient and family on TTM and its potential psychosocial effects and
triggers, as well as discuss behavioral therapy. Behavioral therapy
should be delivered by professionals with knowledge and training in
HRT. Dermatologists are encouraged to develop relationships with
community psychologists and psychiatrists experienced in behav‐
ioral intervention and HRT. Dermatologists appropriately trained in
CBT may consider initiating HRT for patients unable or unwilling to
access care from a mental health provider.
Habit reversal therapy is first‐line treatment in all age groups and
may require family involvement in younger children. Pharmacological
options are not well understood, especially in the pediatric pop‐
ulation. This presents opportunities for additional research. It is
important to recognize the significant level of psychiatric comor‐
bidities among these patients and ensure that they are addressed by
the appropriate provider in order to improve quality of life.
ORCID
Emily D. Henkel https://orcid.org/0000-0001-8096-2514
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How to cite this article: Henkel ED, Jaquez SD, Diaz LZ.
Pediatric trichotillomania: Review of management. Pediatr
Dermatol. 2019;00:1–5. https​://doi.org/10.1111/pde.13954​