Understanding Hair Loss in People with Trichotillomania

Key Takeaways:

• What is trichotillomania? Trichotillomania is a mental health disorder where people feel the irresistible compulsion to pull out their own hair.
  
• Who does it affect? It affects both men and women, usually beginning in adolescence.
  
• What is the main symptom? The most common symptom is recurrent hair pulling, more commonly on the scalp but can occur on eyebrows and other areas of the body as well.
  
• Does the hair grow back? Hair loss is usually temporary; however, if the pulling is recurrent for a long period, it may become permanent.
  
• Where can you get help? Speak to your GP if you recognise the symptoms and would like support to help you stop pulling your hair. 

What Is Trichotillomania?

Trichotillomania, also known as trich, is a condition where people cannot control urges they have to pull out their own hair.¹ The pulling may be done either consciously or while you are unaware. More commonly, it is a mixture of both.²

What Causes Trichotillomania?

Trich is a mental health condition where people suffering from it experience an extreme urge to pull out their hair, after which they feel a sense of relief after doing so.

As such, environmental factors such as stress and changes in the brain structure and activity are believed to be central to its development. It is also linked to other mental health conditions such as anxiety and OCD.³

How Does Trichotillomania Cause Hair Loss?

Trichotillomania causes hair loss as it involves manually and forcefully pulling out hair. This can be in any hair-bearing part of the body, though most commonly involves the scalp. This repeated pattern of pulling can result in patches without hair on your scalp. It can also lead to complete balding, with the back and base of the head usually not involved. 

The process of plucking frequently fractures the hair shaft above or within the follicle. Pulling out hair in this way may lead to an infection. Over time, trichotillomania causes a scarring form of hair loss, which means the affected hair follicles never grow hair back as a result of the damage they have received.⁴

What Are the Signs and Symptoms of Trichotillomania?

The main symptoms are:

• The overwhelming urge to remove hairs from your head.

• Irregular patches of hair loss at the sites of pulling.

• Hairs in the affected area will reveal a blunt end rather than a normally tapering hair. This is the point at which the hair has been torn in two, with a remnant usually still left in the scalp. 

• Hairs present will be of varying lengths.

• A stubbly sensation may be felt when you pass your hand over the affected areas. 

“With some of my patients who suffer from trichotillomania or hair pulling, the condition is often part of a wider psychopathy such as anxiety or OCD. It is important to treat the underlying mental health condition before restoring hair with surgery, as there is a risk that further hair pulling will pull out transplanted grafts.” 

Dr Roshan Vara, Co-Founder and Surgeon at The Treatment Rooms London

Could It Be Trichotillomania?

According to the DSM-5, a manual for disorders of the mind, Trichotillomania is related to Obsessive-Compulsive disorder(OCD). It can be spotted by the following features:⁵

• Recurrent pulling out of your own hair, resulting in hair loss

• Repeated attempts to decrease or stop hair pulling

• The distress caused by the hair pulling behavior is leading to difficulties in your relationships, work or school performance, and overall quality of life, having implications for your wellbeing and daily functioning

• The hair pulling or hair loss is not attributable to another medical condition or mental disorder

How to Treat Trichotillomania

Trich can be treated in several different ways; however, addressing the underlying mental health condition is the important factor in achieving hair growth.

As it is a disorder of the mind, treatments that show the most benefit are therapies that change the way you think about hair pulling. 

Behavioural Therapy

Habit reversal therapy: This is a type of behavioural therapy that focuses on increasing your awareness of your hair pulling habit and focuses on developing ways of coping with the urges in a less harmful way.³

Acceptance and commitment therapy (ACT): This therapy focuses on helping you to accept your difficult emotions without trying to change or avoid them. It involves taking a step back from unhelpful thoughts so you can view them more objectively and still take concrete steps towards your chosen values despite any obstacles.

Practical Changes and Self-Help

Try to understand what triggers you to pull out your hair. It may be possible to develop a competing habit that you can do instead when the urge to pull comes. This could be squeezing a stress ball or a technique where you focus on contracting specific muscle groups deliberately, one at a time, called progressive muscle relaxation.¹

Medication

Medication has a limited role in trich. It is best considered as a secondary treatment to the main work of creating new mental patterns to change your thought process surrounding hair pulling.¹

Medications such as N-acetylcysteine (NAC) have shown promising results based on their ability to help with impulse control.

It’s important to note that medication on its own is not an effective treatment option for trichotillomania.

Supporting Hair and Scalp Recovery

In order to support hair and scalp recovery, the most important thing is to get the habit of hair pulling under control. This determines how much damage can be prevented from occurring to the hair follicles. Unless you can cease hair-pulling activity, there is a limited ability for your scalp to recover. 

Hair Transplant and Trichotillomania

Hair transplantation in trichotillomania will be deferred until you receive successful behavioural therapy and you are no longer actively pulling out your hair. This is because if you still suffer from hair pulling, you can pull on the transplanted grafts, causing them damage over time and eventually causing them to fail. 

Conclusion

Trichotillomania, or Trich, is a psychological condition that involves an irresistible urge to repeatedly pull out your own hair. This can lead to broken hairs, irregular patches of hair loss, and possibly permanent hair follicle damage, which means the lost hair never regrows. 

Behavioural therapy is the most effective treatment. Medications may be considered but only in a secondary role. If you recognise these symptoms present in yourself, speak to your GP for further assessment and support.

References:

1. DuBois MC, Feler BM, Flessner CA, Franklin ME. Trichotillomania and its treatment: an updated review and recommendations. Expert Rev Neurother. 2025;25(11):1335–1345. doi:10.1080/14737175.2025.2557395. 
   
2. Grant JE, Chamberlain SR. Trichotillomania and skin-picking disorder: an update. Focus (Am Psychiatr Publ). 2021;19(4):405–412. doi:10.1176/appi.focus.20210013. 
   
3. Christensen RE, Tan I, Jafferany M. Recent advances in trichotillomania: a narrative review. Acta Dermatovenerol Alp Pannonica Adriat. 32:151-157, 2023. 
   
4. Doolan BJ, Ali R, Baron SE. Optimizing treatment of compulsive hair pulling in children and young people: a case series from a pediatric psychodermatology service. J Dermatol. 2024;51(4):612–613. doi:10.1111/1346-8138.17136. 
   
5. American Psychiatric Association. Trichotillomania (hair-pulling disorder). In: Diagnostic and statistical manual of mental disorders. 5th ed. Arlington (VA): American Psychiatric Publishing; 2013. p. 251–254. doi:10.1176/appi.books.9780890425596.