Trichotillomania is deliberate, impulsive, and recurrent hair pulling that can cause significant and noticeable hair loss. Any region of the body with hair can be involved, most commonly it is the eyebrows, eyelashes, and scalp. The Diagnostic and Statistical Manual of Mental Disorders, 5th edition (DSM-V) classifies it as a separate diagnosis in the group “Obsessive-Compulsive and Related Disorders.”1 However, obsessive thoughts are not usually a characteristic of trichotillomania. Treatment is important to restore a patient’s quality of life that can be impacted by social isolation and psychological disability. Currently, there are no FDA-approved medications to treat trichotillomania. A referral to psychiatry is appropriate as effective treatment involves treating any underlying psychiatric disease. A combination of pharmacotherapy and behavioral therapy has been shown to be effective. Habit reversal training can also be helpful especially in children, possibly preventing disease progression into adulthood. Antipsychotics and antidepressants have demonstrated mixed efficacy. Notably, no selective serotonin reuptake inhibitor (SSRI) studies show strong evidence of a treatment effect.2 Overlap of trichotillomania and obsessive-compulsive spectrum disorders, such as tic disorders has been suggested based on response to similar pharmacotherapy. Overall, there is a paucity of controlled studies with large sample sizes, thus therapy decisions should be made on a case-by-case basis. See Table 96-1.
Table Graphic Jump Location Table 96-1Trichotillomania Treatment Table ||Download (.pdf) Table 96-1 Trichotillomania Treatment Table
|MEDICATION NAME ||INDICATION ||MECHANISM OF ACTION ||DOSING ||ADVERSE EFFECTSa ||SUGGESTED MONITORING ||LEVEL OF EVIDENCE (REFERENCE) |
|Behavior therapy with habit-reversal training component ||Trichotillomania ||— ||— ||— ||— ||IA3,4 |
|N-Acetylcysteineb ||Trichotillomania ||Glutamate modulator ||1200-2400 mg BID for 12 wk ||Headache, pruritus, flatulence, increased blood pressure, fatigue, worsening asthma ||— ||IB5 |
|Olanzapine ||Trichotillomania ||Antagonism of serotonin 5-HT2A and 5-HT2C, dopamine D1-4, histamine H1, and alpha1-adrenergic receptors ||2.5-10 mg QD ||Weight gain, glucose abnormalities, dyslipidemia, sedation ||Vital signs, labs (lipid panel, fasting plasma glucose/HbA1c, CBC, CMP, TSH), BMI, extrapyramidal symptoms and tardive dyskinesiac ||IB6,7 |
|Clomipramine ||Trichotillomania ||Affects serotonin and norepinephrine uptake ||25-250 mg QD ||Anticholinergic, drowsiness, QTc prolongation, weight gain, sexual dysfunction ||CBC, CMP, Vital signs, EKGd ||IB8,9 |
|Sertraline ||Trichotillomania ||Selective inhibition of presynaptic serotonin (5-HT) reuptake ||50-200 mg QD ||Insomnia, sexual dysfunction, nausea, diarrhea ||BMI, suicidality,10 sodium, bone mineral densitye ||IB11 |