INTRODUCTION
Trichotillomania (TTM) is a psychiatric condition characterized by recurrent, compulsive hair pulling resulting in noticeable hair loss, accompanied by repeated attempts to reduce or stop the behavior [1]. It may affect any hair-bearing body region. Onset most commonly occurs during late childhood or early adolescence, with a reported lifetime prevalence ranging from 0.5% to 2% in the general population and slightly higher rates in paediatric clinical samples [2, 3].
TTM can have a substantial impact on a child’s overall development and well-being.
ETIOLOGY AND RISK FACTORS
The etiology of TTM is considered multifactorial. Family studies suggest a hereditary component, with higher rates of hair pulling and related disorders reported in first-degree relatives [4]. Neurobiological models implicate dysregulation in cortico-striatal-thalamo-cortical (CSTC) circuits, similar to that observed in obsessive-compulsive disorder [5]. Some smaller studies have reported other structural brain changes, such as increased cortical volume in the lateral occipital lobe or decreased volume near the lingual gyrus of the inferior occipital-parietal region compared with controls, depending on the subtype of pulling [6]. Altered serotonin, dopamine, and glutamate signaling has also been proposed, although evidence in adults remains limited and pediatric data are largely extrapolated from adult studies [7].
Among risk factors, certain individual characteristics and temperamental traits, such as high emotional reactivity, distress intolerance, or sensory-seeking tendencies used to regulate negative emotions, appear to be more common [8]. Environmental stressors, including traumatic events or adverse childhood experiences, have been reported in some cases, although the evidence is mixed and likely nonspecific. Psychiatric comorbidities are frequent and may support clinical suspicion of TTM in patients presenting with unexplained hair loss [9].
CLINICAL PRESENTATION
TTM most commonly emerges during late childhood to early adolescence, with the typical age of onset reported between 10 and 13 years [1]; onset after the age of 20 is uncommon [10]. While cases have been documented in children as young as 18 months to 2 years, children this young are rarely suspected of having the disorder, and some studies suggest that hair pulling in this age group may be better conceptualized as an anxiety-related behaviour [11]. Early-onset hair pulling in very young children is often considered transient and may differ in etiology and clinical course from TTM that persists into later childhood and adolescence [12].
In pediatric populations, hair pulling often begins in response to stress, tension, boredom, or anxiety, and may serve as a self-soothing or tension-reducing behavior [13]. TTM typically presents with a pattern of either focused pulling, in response to emotional states such as anxiety and boredom, or automatic pulling, outside of conscious awareness. Hair-pulling behavior can manifest as brief, intermittent episodes throughout the day or as less frequent but prolonged sessions [14].
Affected areas primarily include the scalp, eyebrows, and eyelashes. However, any hair-covered region may be involved, sometimes with multiple areas affected simultaneously [15].
In children, TTM frequently co-occurs with other psychiatric conditions, including anxiety disorders, depression, body dysmorphic disorder, obsessive-compulsive disorder, and attention deficit hyperactivity disorder (ADHD) [9, 10, 16].
DIAGNOSIS AND ASSESSMENT
In the International Classification of Diseases, 11th Revision (ICD-11), TTM is listed under the broader category of “Obsessive-compulsive or related disorders” (6B20–6B2Z), with the specific diagnostic code 6B21. This classification closely aligns with the obsessive-compulsive andrelated disorders category in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5). The diagnostic criteria specify that the individual repeatedly pull out their own hair, resulting in noticeable hair loss. There must be repeated attempts to reduce or stop the behavior, and the hair pulling must cause clinically significant distress or functional impairment in personal, social, educational, occupational, or other important areas of life. The diagnosis requires the exclusion of other medical conditions, such as alopecia areata, or psychiatric disorders that could better explain the behavior, including psychotic disorders in which hair pulling may occur in response to hallucinations or delusions. Associated features may include rituals involving the pulled hair, such as inspecting, playing with, or ingesting it, as well as attempts to conceal the resulting hair loss. The classification of TTM within the obsessive-compulsive spectrum reflects its phenomenological and neurobiological similarities to other conditions in this category [1, 17].
The diagnosis of TTM in children requires a comprehensive, multifaceted approach combining clinical evaluation, behavioral observation, and input from caregivers. Differentiating TTM from somatic causes of hair loss can be challenging. The main differential diagnosis is alopecia areata [11]. It is also essential to distinguish TTM from other psychiatric disorders, particularly those frequently comorbid with it, such as generalized anxiety disorder, obsessive-compulsive disorder, and ADHD [10]. Assessment of common comorbidities may influence management, as accurate diagnosis is crucial for developing an appropriate treatment plan addressing both behavioral symptoms and underlying contributing factors. Early diagnosis is also important because of the high lifetime recurrence rates.
Standardized assessment tools may be valuable in clinical practice for evaluating symptom severity and guiding treatment in children. These include the Trichotillomania Scale for Children, a self-report questionnaire, and the Milwaukee Inventory for Styles of Trichotillomania–Child Version (MIST-C), which was developed to assess different pulling styles [18]. Other tools useful in the diagnostic process include the Children’s Yale-Brown Obsessive-Compulsive Scale (CY-BOCS) and the Yale-Brown Obsessive-Compulsive Scale–Trichotillomania (Y-BOCS-TM), which measure disorder severity [18, 19].
Trichoscopy plays an increasingly valuable role in the diagnosis of TTM, allowing visualization of characteristic hair and scalp findings that may not be easily detected with the naked eye. The most common and consistent findings include broken hairs of varying lengths and decreased hair density. Other common trichoscopic features include trichoptilosis, coiled hairs, and upright regrowing hairs. More specific markers, such as black dots, flame hairs, the V-sign (adjacent broken hairs emerging from a single follicular opening), follicular hemorrhages, tulip hairs, and hair powder, are less frequent but provide greater diagnostic specificity when combined with other features [20]. These patterns help differentiate TTM from other causes of hair loss, such as alopecia areata or tinea capitis [21]. Trichoscopy is particularly useful in pediatric cases, where obtaining a clear clinical history may be challenging, and can support early diagnosis and management planning [22].
Diagnostic criteria, together with additional features helpful in diagnosis, are summarized in Table 1.
IMPACT ON FUNCTIONING AND QUALITY OF LIFE
Quality of life
TTM can profoundly disrupt multiple domains of a child’s daily functioning, extending beyond the physical consequences of hair loss. The disorder may lead to significant psychosocial distress, affecting self-esteem, social relationships, academic engagement, and overall well-being. In a study conducted by Valle et al., participants with TTM had significantly lower quality of life compared with controls (t[421] = 7.858, p < 0.001), particularly in the domains of health, self-esteem, goals and values, play, learning, creativity, helping, love, friends, children, and home (all p < 0.003) [23]. Other studies have reported similar findings, indicating an overall reduction in quality of life [24].
Somatic health
Case reports have linked TTM to several medical complications, including repetitive strain injuries and gastrointestinal obstruction resulting from hair ingestion [7, 25, 26].
Psychological impact
Children with TTM frequently experience shame, embarrassment, guilt, and anxiety related to hair pulling and its visible consequences. These emotions may contribute to social withdrawal, avoidance of group activities, and reluctance to participate in situations where hair loss might be noticed, such as sports or school events [27, 28]. Lower distress tolerance has also been observed in children with TTM. Other studies have reported poor mental health outcomes, including self-esteem difficulties and depressive symptoms, particularly in older age groups [29, 30].
The chronic nature of the disorder and potential for co-occurring conditions, such as anxiety, depression, or obsessive-compulsive behaviors, may further compound these difficulties, underscoring the importance of early diagnosis and comprehensive, child-centered intervention.
Social functioning
Visible hair loss may provoke peer teasing, bullying, or stigmatization, further limiting the child’s social interactions. Many children develop strategies to conceal their hair loss, such as specific hairstyles, hats, wigs, or makeup, which may itself become a source of stress and vigilance [18]. Both parents and children have reported that hair pulling moderately interferes with social life and close friendships [27].
Academic and cognitive functioning
In academic settings, TTM may interfere with concentration, classroom participation, and school performance. Focused hair-pulling episodes, often occurring during periods of boredom, anxiety, or task avoidance, may reduce academic engagement and productivity. Associated anxiety and emotional distress can also affect cognitive functioning, memory, and learning [31]. Reports indicate that children and their parents perceive TTM as moderately affecting overall academic success by making studying and academic performance more difficult [27].
Family dynamics
TTM may create tension within the family, as parents and caregivers may experience frustration, helplessness, or guilt. Over time, this can lead to conflict over attempts to manage or control the behavior, potentially affecting the child’s emotional security and family cohesion [32]. In a study by Franklin et al., a substantial proportion of parents believed that TTM directly contributed to emotional difficulties in their child [27]. However, Ricketts et al. reported no significant family impairment compared with controls [24].
TREATMENT APPROACHES
Behavioral therapies used in TTM include habit reversal training (HRT), cognitive behavioral therapy (CBT), acceptance and commitment therapy (ACT), and group or support therapy [33, 34]. HRT is the best-supported behavioral intervention across age groups. In younger children, treatment usually requires active family involvement.
No medications are currently approved specifically for the treatment of TTM [3]. However, several pharmacological agents have been studied for their potential efficacy in reducing TTM symptoms. The most commonly investigated medications are selective serotonin reuptake inhibitors (SSRIs). Studies of fluoxetine, sertraline, and other SSRIs have yielded mixed results. Although some open-label studies and case reports have suggested partial symptom improvement, most randomized controlled trials (RCTs) have failed to demonstrate significant benefits compared with placebo [35, 36]. Sertraline and fluoxetine are approved for selected pediatric indications. However, studies evaluating their use in TTM have included adult populations only.
N-acetylcysteine (NAC), a glutamate modulator, has shown promising results in adults, with some RCTs reporting significant reductions in hair-pulling behavior [37]. However, pediatric studies have not confirmed its efficacy, although individual case reports suggest possible benefits in children and adolescents [38–41].
Clomipramine, a tricyclic antidepressant, has demonstrated moderate efficacy in reducing TTM symptoms in adults [42].
Antipsychotic medications have also been explored for TTM treatment. Among agents approved for pediatric use, aripiprazole has shown promise in open-label studies [43]. However, similar to SSRIs, studies of antipsychotics for TTM have been conducted exclusively in adult populations.
Overall, pharmacological treatments of TTM is supported mainly by case reports, open-label studies, and small clinical trials. Current evidence remains limited and inconsistent, particularly in pediatric populations, and is insufficient to guide routine pharmacological management.
Table 2 presents data from studies on pharmacological treatments for TTM in children, including medication types, dosages, and the age groups studied [35, 36, 38–47].
Table 2
New alternative and emerging therapies include mindfulness-based interventions, habit-monitoring electronic devices, and other complementary approaches. Evidence for these methods also remains limited [14, 31].
CONCLUSIONS
The impact of TTM on children’s daily lives extends far beyond the physical manifestation of hair loss. The disorder may lead to significant physical, psychological, and social impairment, substantially affecting quality of life and daily functioning over time. Affected children often experience marked emotional distress, and earlier onset without appropriate interventionmay be associated with a more chronic and treatment-resistant course, making early identification essential. Most existing research has focused on adult populations, with relatively few large-scale longitudinal studies addressing the natural course, risk factors, and psychosocial outcomes of TTM in children. Behavioral therapies, particularly habit reversal training, demonstrate the most consistent clinical benefit, whereas pharmacological and emerging interventions currently lack robust, high-quality evidence, especially in pediatric populations. Further research is needed to clarify the underlying neurobiological mechanisms, refine diagnostic criteria for younger children, and develop evidence-based, age-appropriate diagnostic tools and treatment protocols aimed at improving both symptom control and overall quality of life in this vulnerable population.
