Trichotillomania and skin picking: symptoms, causes and treatment

Key points

• Trichotillomania (hair pulling disorder) and skin picking disorder (dermatillomania) are body-focused repetitive behaviours, or BFRBs [1][3][10].
• They are not self-harm: the aim is not pain or injury, the damage is unintended, and much of it happens automatically [2][8][10].
• Both run on rising tension and relief rather than the intrusive thoughts that drive OCD, though ICD-11 groups them with obsessive-compulsive and related disorders [3][4][5].
• Habit reversal training, a form of CBT, has the most evidence behind it [1][3].
• No NICE guideline covers either condition, and neither is on the NHS Talking Therapies self-referral list [6][7].

What body-focused repetitive behaviours are

Trichotillomania, also known as hair pulling disorder, is when a person cannot resist the urge to pull out their own hair [1]. Skin picking disorder, also called dermatillomania or excoriation disorder, is the same pattern directed at the skin [3]. Both are body-focused repetitive behaviours: repeated self-grooming actions that end up damaging the body [10].

If you need help now. Samaritans: call 116 123, free, 24/7. Shout: text SHOUT to 85258. NHS 111, then choose the mental health option. Call 999 if anyone is in immediate danger.

Hair is most often pulled from the scalp, eyebrows and eyelashes, and picking most often affects the face and arms [1][3]. Having one of these alongside OCD or another related condition is common [5].

Neither is self-harm, which the NHS defines as intentionally damaging or injuring the body [8]. With pulling and picking the damage is not the point: the action is self-regulating and the injury unintended [10]. Some UK sources, including Mind, still list them alongside cutting and burning [9]. For a few people the two do overlap, and they deserve the same support as anyone else who self-harms. For most, it is a different thing, and being read as self-harming adds to the shame already attached to it [1][2].

There is no reliable UK prevalence figure. The NHS puts the usual start of trichotillomania between the ages of 10 and 13 [1]. OCD-UK reports it mainly in females, though males are affected too, with onset between adolescence and the early twenties [2].

Symptoms

Common to both conditions:

• An urge that builds until the behaviour happens, followed by relief [2][4].
• Repeated attempts to cut down or stop that have not worked [4].
• Pulling or picking that increases during stress and anxiety [1][3].

Trichotillomania:

• Hair pulled from the scalp, eyebrows, eyelashes or elsewhere on the body [1].
• Patchy hair loss in unusual shapes, sometimes worse on one side [1].
• In some people, chewing or swallowing hair, which can cause problems in the gut [1].

Skin picking disorder:

• Picking at spots, moles, scabs or uneven skin, often to make it smooth [3].
• Bruising, cuts, bleeding, scarring and a risk of infection [3].

Shame, low self-esteem and avoiding situations where the damage might be seen are common [1][2][3]. Both conditions are confused with self-harm [8][10], and with OCD, where compulsions follow intrusive thoughts and aim to prevent something bad rather than reduce tension [3].

Types

Neither condition has formal subtypes. Clinicians describe two modes instead, and most people do some of both [2].

• Focused pulling or picking is deliberate, often a response to stress or to a sense that a hair or patch of skin is not right [2][3].
• Automatic pulling or picking happens without conscious awareness, usually while reading, watching television or concentrating on something else [2][3].

The distinction changes what helps. Nobody can resist an urge they have not noticed, which is why habit reversal training starts by building awareness of when the behaviour happens [3].

Causes and risk factors

No single cause has been identified. The NHS lists possible contributors rather than one explanation [1]:

• Dealing with stress or anxiety.
• Changes in the balance of certain chemicals in the brain.
• Changes in hormone levels during puberty.
• A family history, which suggests genetics play some part.
• A behaviour that began as a habit and became hard to break.

Two popular explanations are not supported: that it is a bid for attention, which fits poorly with how carefully most people hide it [2][3], and that it is a bad habit willpower can stop. Repeated failed attempts to stop are part of the diagnostic definition [4].

How it is diagnosed

In the UK a GP is usually the first step and can refer to mental health services [1]. Assessment is a conversation about what happens, what leads up to it, what has been tried and the effect on daily life, and rules out a skin or hair condition that could explain the damage [4].

ICD-11, the World Health Organization’s current classification, places both in a group called body-focused repetitive behaviour disorders, code 6B25.0 for trichotillomania, within obsessive-compulsive or related disorders [4]. ICD-11 requires hair pulling that causes significant hair loss, with unsuccessful attempts to stop, and significant distress or difficulty in daily life [4].

Waiting times depend on the local service and no figure specific to these conditions is published. NHS Talking Therapies, the self-referral route in England, lists the conditions it accepts, and neither of these is among them [7].

A diagnosis does not mean a person has OCD [5], and it does not mean they have been self-harming [10].

Treatment

Habit reversal training, a form of CBT, is the treatment with the most support behind it for both conditions [1][3]. It usually involves:

• Keeping a diary of when pulling or picking happens [1].
• Working out the triggers that come before it [1][3].
• Replacing the behaviour with a different action, such as squeezing a stress ball [1].
• Practising tolerating the discomfort of not doing it [3].

It sits inside a wider course of CBT, which OCD-UK describes as the most effective treatment for both conditions [2][3]. That work also looks at the thoughts and feelings around the behaviour, and at changing the setting so the action is harder to start [2][3].

The NHS states that antidepressants are not usually prescribed for trichotillomania [1]. For skin picking disorder, some people are prescribed an SSRI antidepressant alongside therapy [3]. Any decision about medication is one for a GP or prescriber.

No NICE guideline covers either condition, and the closest, CG31, covers OCD and body dysmorphic disorder only [6]. NHS services are not commissioned around them and provision varies by area [7]. Many people are told simply to stop, which is not treatment: being unable to stop despite trying is part of what defines the condition [4].

Living with body-focused repetitive behaviours

• Keep a record of when it happens, where you were and how you felt: the starting point of habit reversal training [1].
• Give your hands something else to do, such as a stress ball or fidget toy [1][3].
• Change the setting rather than relying on willpower: short nails, gloves, and anything used for pulling or picking kept out of reach [3].
• Keep the affected skin clean and moisturised, which lowers the risk of infection [3].

At work or university you do not have to give a full account of the condition. Asking for something specific, such as time off for appointments, is often enough. OCD-UK publishes information on both conditions and the NHS points readers to it [1][2][3].

When to speak to a professional

Speak to a GP if:

• You are pulling out hair or picking your skin regularly and cannot stop [1][3].
• It is causing hair loss, sores, scarring or signs of infection [1][3].
• It is taking up hours of your day, or you are avoiding people because of it [3].
• You are eating hair, or think your child is. Swallowed hair can cause problems in the gut and needs medical attention [1].
• You think your child is pulling their hair out [1].

If distress about the behaviour is making it hard to keep yourself safe, call NHS 111 and choose the mental health option, or Samaritans on 116 123, free and 24/7. You can text SHOUT to 85258. Call 999 if you are in immediate danger.

Common questions

Is trichotillomania a form of self-harm?

No. The NHS defines self-harm as intentionally damaging or injuring the body, and here the damage is an unintended result of a grooming behaviour that is often automatic [2][8][10]. Mind’s description of self-harm does list hair pulling, which is one reason the two are confused [9].

Is trichotillomania a type of OCD?

No, although it is grouped close to it in ICD-11 [4]. OCD-UK reports that most specialists treat them as separate conditions: OCD compulsions follow intrusive thoughts, while pulling and picking are driven by tension and relief [3][5].

Can trichotillomania be cured?

There is no guaranteed cure, and without treatment the condition can carry on for many years [2]. Habit reversal training and CBT are the approaches with the most support behind them [1][3].

What is the difference between skin picking disorder and ordinary picking?

Most people pick at a spot or a scab occasionally. Skin picking disorder is repeated, hard to stop despite attempts to do so, and causes real damage or significant distress, sometimes taking hours a day [3][4].

Clinical review pending

References

1. NHS. Trichotillomania (hair pulling disorder). NHS. https://www.nhs.uk/mental-health/conditions/trichotillomania/
2. OCD-UK. Trichotillomania. OCD-UK. https://www.ocduk.org/related-disorders/trichotillomania/
3. OCD-UK. Skin Picking Disorder. OCD-UK. https://www.ocduk.org/related-disorders/skin-picking/
4. OCD-UK. Clinical Classification of Trichotillomania. OCD-UK. https://www.ocduk.org/related-disorders/trichotillomania/clinical-classification-of-trichotillomania/
5. OCD-UK. Related Disorders. OCD-UK. https://www.ocduk.org/related-disorders/
6. National Institute for Health and Care Excellence. Obsessive-compulsive disorder and body dysmorphic disorder: treatment (CG31). NICE, last reviewed 2024. https://www.nice.org.uk/guidance/cg31
7. NHS. NHS talking therapies for anxiety and depression. NHS. https://www.nhs.uk/mental-health/talking-therapies-medicine-treatments/talking-therapies-and-counselling/nhs-talking-therapies/
8. NHS. Self-harm. NHS. https://www.nhs.uk/mental-health/feelings-symptoms-behaviours/behaviours/self-harm/
9. Mind. About self-harm. Mind. https://www.mind.org.uk/information-support/types-of-mental-health-problems/self-harm/about-self-harm/
10. The TLC Foundation for Body-Focused Repetitive Behaviors. What are BFRBs? TLC Foundation for BFRBs. https://www.bfrb.org/what-are-bfrbs