Trichotillomania (Hair-Pulling Disorder): How It Differs from Alopecia Areata and What Helps in Children and Adults
Short answer: Trichotillomania (hair-pulling disorder) means repeatedly pulling out one's own scalp hair, eyebrows or eyelashes and finding it hard to stop despite wanting to. It is not a "bad habit" or a bid for attention but a body-focused repetitive behaviour. A dermatologist distinguishes it from alopecia areata and ringworm with trichoscopy; the treatment with the strongest evidence is a behavioural therapy called habit reversal training. Because the follicle usually stays intact, hair grows back once pulling eases.
Some of the irregular bald patches referred to me as "alopecia areata" or "fungal infection" turn out, on trichoscopy, to be caused by hair pulling. In this article I explain what trichotillomania is, how it is told apart from other types of hair loss, and how to approach it in children and adults. For alopecia areata itself, see my alopecia areata article; for how the dermoscopic examination works, see trichoscopy and hair analysis.
What is trichotillomania?
Trichotillomania is recurrent pulling out of scalp or body hair that leads to noticeable hair loss and continues despite repeated attempts to cut down. In psychiatric classification it sits among obsessive-compulsive and related disorders, and together with skin picking and nail biting it belongs to the family of body-focused repetitive behaviours.
Pulling can take two forms: "automatic" pulling, done without awareness while studying, scrolling on a phone or watching television, and "focused" pulling, done deliberately in response to tension, unease or the feel of a particular hair. Most people have a mix of both. Many describe tension before pulling and brief relief afterwards.
Who gets it?
It is more common than people think; studies report it in roughly 0.5–2% of the population.
It usually begins around age 10–13, at the start of puberty.
In adults it is clearly more common in women; in childhood boys and girls are affected about equally.
The scalp is the most common site, followed by the eyebrows, eyelashes and other body areas.
In pre-school children, hair twirling and pulling while falling asleep or thumb sucking is often a passing habit that fades on its own.
Anxiety, depression, attention difficulties and other repetitive behaviours such as skin picking may coexist. This does not mean pulling is a lack of willpower; it simply means that these conditions need to be part of the treatment plan.
How is it told apart from alopecia areata and ringworm?
In trichotillomania the bald areas are usually irregular, contain broken hairs of different lengths and are not completely smooth. In right-handed people they may be concentrated on the right side or the crown. A reliable distinction is made by examining the scalp with a dermoscope (trichoscopy). In a trichoscopy study of patients with trichotillomania, the key findings were:
Irregularly broken hairs of different lengths: seen in every patient; the core finding.
The "V-sign": two hairs from the same follicular opening broken at the same length; seen in more than half of patients.
Coiled hairs and broken hairs with split ends: traces of hair snapping under tension.
Flame hairs, tulip hairs, hook hairs and "hair powder": different appearances of hair remnants; less frequent but distinctive.
Alopecia areata, by contrast, shows exclamation mark hairs, yellow dots and fine regrowing hairs of similar length, with a regular border. In children, scalp ringworm (tinea capitis) brings scaling, itching, sometimes swelling and comma- or corkscrew-shaped hairs; the diagnosis is confirmed by examining a scraping, and the treatment is entirely different (see scalp diseases). No single finding makes the diagnosis — the combination does; a biopsy is rarely needed. Alopecia areata and trichotillomania can also occur in the same person.
If you notice it in your child: an approach for parents
A parent's first reaction is often to say "stop that", hold the child's hand or punish. These responses are understandable but rarely work; they increase shame and secrecy and can shift pulling to the hours the child spends alone. More helpful steps:
Talk without blame and with curiosity: questions such as "When do you pull most, and how do you feel at that moment?" help identify the situations that make it worse.
Instead of constant reminders, agree on a quiet signal the child can ask for.
Offer alternatives that keep the hands busy: a stress ball, modelling clay, crafts.
Reduce trigger situations, such as long screen time or lying awake in bed for a long time.
Ask whether the child is being teased at school or among friends, and speak to the teacher if needed.
In pre-school children with brief, mild pulling, calm observation is often enough. In teenagers and when pulling has lasted for months, it helps to work with a child and adolescent psychiatrist or a psychologist experienced in this area.
Treatment options and the strength of evidence
Habit reversal training (behavioural therapy)
The treatment with the strongest evidence in trichotillomania is behavioural therapy based on habit reversal training. A systematic review pooling the studies found it more effective than medication. Its core components are:
Awareness training: noticing when, where and with which feelings pulling starts, and keeping a record for a while.
Competing response: when the urge comes, doing for a few minutes a movement that cannot be done at the same time as pulling, such as clenching the fist or keeping the hands busy with an object.
Stimulus control: avoiding long periods in front of the mirror, putting tweezers away, using barriers such as gloves or a hat.
Social support: non-judgemental encouragement from family or a close person.
Therapy usually runs over sessions spread across several weeks to a few months and can be combined with approaches such as acceptance and commitment therapy. This part is delivered by psychiatry or psychology; the dermatologist makes the diagnosis, monitors the hair and scalp and plans the referral.
Medication and N-acetylcysteine
No medicine is approved for trichotillomania. There is no consistent evidence that selective serotonin reuptake inhibitors reduce pulling, although a psychiatrist may use them to treat coexisting depression or anxiety. Clomipramine was superior to placebo in some studies but is used sparingly because of side effects.
N-acetylcysteine: in a small placebo-controlled trial in adults, just over half of those taking N-acetylcysteine improved markedly, compared with about one in six on placebo. A trial in children and adolescents, however, found no difference from placebo. The evidence is therefore limited: it is an option to discuss with a doctor, not a stand-alone solution, and starting it on your own as a supplement is not recommended.
Eating hair: trichophagia and trichobezoar
Some people bite, chew or swallow the hair they pull (trichophagia). This occurs in a notable minority of people with trichotillomania. Swallowed hair is not digested and can collect in the stomach as a hairball (trichobezoar); in advanced cases it can block the bowel and require surgery. Anyone with a history of swallowing hair who has abdominal pain, nausea or vomiting, early fullness, weight loss, bad breath or anaemia should see a doctor without delay. This is why I ask about it openly during the examination; it is nothing to be embarrassed about.
When does the hair grow back?
In trichotillomania the follicle is usually intact, so hair grows back once pulling eases. Because hair grows about 1 cm a month, a bald area takes a few months to fill in and longer to reach a noticeable length. Eyebrows and eyelashes usually regrow as well. However, heavy pulling from the same area over many years can damage follicles and leave permanent thinning in some people. Early diagnosis and treatment therefore also matter for the future of the hair. At follow-up visits I compare progress using trichoscopy photographs.
When to see a dermatologist
When you notice irregular bald areas on the scalp, eyebrows or eyelashes without a known cause
When a child's hair loss comes with scaling, itching or swelling (to rule out ringworm)
When pulling has lasted for months or affects school, work or social life
When a history of swallowing hair comes with abdominal pain, vomiting or weight loss (prompt assessment)
At my practice in Kırklareli (about an hour from Edirne), trichoscopy is done at the same visit; if needed, we plan the referral to psychiatry or psychology together.
Frequently asked questions
What is trichotillomania?
It is the medical name for hair-pulling disorder: repeatedly pulling out one's own scalp hair, eyebrows or eyelashes and finding it hard to stop despite wanting to. It is a body-focused repetitive behaviour disorder.
How can you tell trichotillomania from alopecia areata?
In trichotillomania the bald area has an irregular border and contains broken hairs of different lengths. In alopecia areata the border is regular, with exclamation mark hairs and yellow dots. Trichoscopy makes the distinction reliably.
Does pulled-out hair grow back?
Usually yes. The follicle is generally intact, so hair starts to return within a few months once pulling eases. Heavy pulling over many years can cause permanent thinning.
My child pulls their hair. What should I do?
Talk without blame or punishment, offer alternatives that keep the hands busy, and first have a dermatologist rule out ringworm and alopecia areata. If pulling has lasted for months, work with a child and adolescent psychiatrist or an experienced psychologist.
Does trichotillomania go away?
In young children it often fades on its own. In teenagers and adults it can come and go; behavioural therapy reduces pulling considerably. Flare-ups during stressful periods do not mean treatment has failed.
Which doctor treats trichotillomania?
A dermatologist for the diagnosis and to rule out other hair disorders, and a psychiatrist or an experienced psychologist for the behavioural part of treatment. Results improve when both work together.
References
Rakowska A, Slowinska M, Olszewska M, Rudnicka L. New trichoscopy findings in trichotillomania: flame hairs, V-sign, hook hairs, hair powder, tulip hairs. Acta Derm Venereol. 2014;94(3):303-306. DOI
Grant JE, Chamberlain SR. Trichotillomania. Am J Psychiatry. 2016;173(9):868-874. DOI
Bloch MH, Landeros-Weisenberger A, Dombrowski P, et al. Systematic review: pharmacological and behavioral treatment for trichotillomania. Biol Psychiatry. 2007;62(8):839-846. DOI
Grant JE, Odlaug BL, Kim SW. N-acetylcysteine, a glutamate modulator, in the treatment of trichotillomania: a double-blind, placebo-controlled study. Arch Gen Psychiatry. 2009;66(7):756-763. DOI
Bloch MH, Panza KE, Grant JE, et al. N-acetylcysteine in the treatment of pediatric trichotillomania: a randomized, double-blind, placebo-controlled add-on trial. J Am Acad Child Adolesc Psychiatry. 2013;52(3):231-240. DOI
This article is for general information; diagnosis and treatment are decided after examination.
Last updated: 24 October 2026 · Dr. Kağan Cingöz, MD, dermatologist
Contact
WhatsApp / Viber: +90 555 209 09 39 · info@drkagancingoz.com · İstasyon Mahallesi, Edirne Caddesi No:102, Kırklareli, Türkiye
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