Trichotillomania: A Review of Treatment Options

There is a need for effective pharmacologic treatment options for patients with trichotillomanis, according to published in Dermatologic Therapy. Researchers assessed the nonpharmacologic and pharmacologic therapies that are currently available as well as new pharmacotherapy options being investigated.

Nonpharmacologic Treatments

Nonpharmacologic treatments for patients with trichotillomania include cognitive behavioral therapy (CBT), which has been used with success. Habit reversal training (HRT)is often used as a first-line nonpharmacologic treatment and involves helping a patient gain a greater awareness of his or her hair-pulling and then replacing that behavior with a different type of behavior. HRT can be combined with stimulus control training, which involves modifying a patient’s environment to make it less receptive to hair-pulling behavior.

Acceptance and commitment therapy, which can be used in combination with HRT and stimulus control techniques, aims to help patients with trichotillomania view hair-pulling behavior from the perspective of interfering with achieving personal or life goals rather than viewing it as a means to avoid negative emotions or feelings. Other nonpharmacologic options include metacognitive therapy, dialectical behavioral therapy, and exposure and ritual prevention therapy.

Pharmacologic Therapy

There are currently no FDA-approved medications for treating patients with trichotillomania. However, the first-line pharmacotherapy typically involves selective serotonin reuptake inhibitors (SSRIs) or the tricyclic antidepressant clomipramine, “but this likely has more to do with psychiatric comorbidity than efficacy for trichotillomania,” commented the researchers. SSRIs are widely used for the treatment in adult and pediatric patients, but evidence of benefit is weak, they noted.

Antipsychotics have also been investigated as potential treatment options for patients with trichotillomania, owing to their efficacy in treating patients with tic disorders. Olanzapine has been the most frequently studied antipsychotic for trichotillomania, but “olanzapine and other antipsychotic medications have many side effects including metabolic dysfunction and extrapyramidal symptoms,” noted the study authors.

Naltrexone, an opioid antagonist, has also been targeted as a potential treatment in patients with trichotillomania, but a double-blind, randomized controlled trial found no significant difference in reducing hair pulling compared with placebo for the disorder.

Newer Pharmacotherapies

Some of the newer potential pharmacotherapies that have been studied include N-acetylcysteine (NAC), a derivative of the naturally occurring amino acid l-cysteine, which has direct and indirect antioxidant activity and alters glutamate metabolism. Although evidence of its efficacy for trichotillomania has varied, according to the researchers, “In nonplacebo-controlled studies, the evidence has been promising,” they commented. “In the two main placebo-controlled studies done, one has shown significant benefit over placebo while a second trial has not.” They continued, “Due to its relative safety and tolerability compared to other treatments for trichotillomania such as antidepressants or antipsychotics and its low cost, NAC has the potential to be an important treatment option for those struggling with this disorder.”

Recent research has also targeted milk thistle, probiotics, and inositol, but any evidence of significant benefit in trichotillomania is “very weak,” according to the researchers. Dronabinol, a cannabinoid agonist, showed significant benefit in reducing hair-pulling behavior in 1 small study, they noted.

“Trichotillomania is a complex psychodermatologic disorder with much yet to be researched regarding its pathogenesis and pharmacological treatment,” wrote the researchers. “Studies on its comorbidity and genetics have shown the potential for future investigation and novel strategies for patient-specific treatment.”

References

Everett GJ, Jafferany M, Skurya J. Recent advances in the treatment of trichotillomania (hairpulling disorder) [published online June 12, 2020]. Dermatol Ther. doi.org/10.1111/dth.13818