Trichotillomania (hair pulling disorder)

Trichotillomania (TTM) is a behavioural (impulse control) disorder that involves repetitive hair pulling, resulting in hair loss.(1) TTM most often begins in the preadolescent-adolescent years with the mean age of onset being 9-13 years.(2) In this age group, it is more common among females (70-93%).(2) However, TTM can also occur in preschool age children where it may appear similar to other habits such as nail biting or thumb sucking.

These young children are often unaware that they are pulling out their hair, which can be triggered by stressful situations such as a new sibling, lack of affection, or infections.(2) In preschool age children, TTM can usually be seen equally in males and females with most children growing out of it.(2) When TTM onset occurs in adulthood, it may be secondary to an underlying psychiatric condition and is generally a more chronic condition.(3) Interestingly, alopecia areata can also lead to TTM as a result of itchiness and pain that causes scratching of the scalp and hair pulling.(2) People with TTM may also pull out hair from their eyebrows, eyelashes, face, arms, legs, and pubic area (3) and demonstrate other habits such as nail biting, skin picking, and lip biting.(2)

Subconscious pulling vs. conscious pulling

About 75% of adults with TTM had times when they did not realize they were pulling out their hair.(2) Subconscious hair pulling may occur (especially in children) when reading, studying, or watching television. Conscious hair pulling usually occurs with a specific ritual (e.g. pulling out white hairs or hairs with different textures).(2) People with conscious TTM may pull the hair until it “feels right” or in response to a sensation in the area (e.g. feels like there is tension that is relieved once the hair is pulled).(2) There may also be rituals with the hair after it is pulled such as chewing, licking, rubbing along the lips, biting the hair bulb, and eating the hair.(2)

Clinical signs

Diagnosis of TTM is generally done using trichoscopy, a handheld microscope to examine the scalp.(3) Some signs of TTM include unusual patterns of patchy hair loss with broken hairs of different lengths and reduced hair density.(1,3) A typical pattern called the Friar Tuck sign often occurs when hair pulling involves the crown of the head with the periphery of the hair left unaffected. Diagnosis can also be made using a microscope if there are findings of increased catagen and telogen hairs without inflammation. The chronic hair pulling induces catagen phase and as the hair growth cycle continues, there are more telogen hairs.(2)

Treatment Of Trichotillomania

Most people with TTM have tried to stop at one point or another. Treatment may require addressing an underlying psychological issue, which may also include the use of pharmacological interventions such as anti-depressants.(2) However, the most successful form of treatment is cognitive behavioural therapy (CBT), or behaviour modification, including habit reversal therapy.(2) This includes awareness training to become alert to the triggers and then modifying the behaviour.

For more information and access to support groups, visit the Trichotillomania Wikipedia page for more information.

Article by: M.A. MacLeod, MSc., Mediprobe Research Inc.


  1. Yorulmaz A, Artuz F, Erden O. A case of trichotillomania with recently defined trichoscopic findings. Int J Trichology. 2014 Apr;6(2):77–9.
  2. Sah DE, Koo J, Price VH. Trichotillomania. Dermatol Ther. 2008 Feb;21(1):13–21.
  3. 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 May;94(3):303–6.