Habit Reversal Training for Trichotillomania: Investigator Q&A

trichotillomania girl pulling hair
trichotillomania girl pulling hair
Katlein França, MD, PhD, spoke with Dermatology Advisor about the use of the behavior therapy technique “habit reversal training” (HRT) for the treatment of trichotillomania, excoriation disorder, and itch.

San Diego, California — Of the various comorbidities associated with dermatologic conditions, psychological issues are common. Study data from 2017 published in the Asian Journal of Psychiatry found that 34.2% of patients receiving treatment at an outpatient dermatology facility met ICD-10 criteria for psychiatric disorders such as depression, anxiety disorder, and obsessive-compulsive disorder.1

The intersection of dermatology and psychiatry is evident in the body-focused repetitive behavior (BFRB) disorders. BFRBs are “psychiatric disorders that involve recurrent pulling and picking one’s own body resulting in skin lesions with varying degrees of severity,” wrote Daniela Sampaio, MD, of the department of psychiatry and behavioral neuroscience, University of Chicago, Pritzker School of Medicine, Illinois, and colleagues  in a 2018 paper published in Clinics in Dermatology.2 “For that reason, the interface with dermatology is important.”

Body-Focused Repetitive Behavior Disorders

Trichotillomania (hair-pulling) and excoriation disorder (skin-picking) are classified in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) in the category of Other Specified Obsessive Compulsive and Related Disorders.3 Other types of BFRBs include nail biting, cheek chewing, and lip biting.

The scalp is the main site of presentation of trichotillomania and various patterns of alopecia may be present.2 Eyebrows and eyelashes are other commonly involved sites, although many body areas may be involved including legs, armpits, and the pubic region.4

Excoriation disorder most commonly involves the face and “frequently starts with picking at an underlying dermatologic condition such as acne but can continue after dermatologic treatment,” according to Sampaio, et al.2 “The dermatologic findings and distribution are atypical and will help the clinician differentiate from other dermatologic conditions.”

Although estimates have shown varying rates of BFRBs, emerging findings suggest a higher prevalence than previously believed. In a 2018 study of 4335 college students, approximately 12% of patients met diagnostic criteria for these disorders and nearly 60% of the sample reported engaging in subclinical BFRBs.5

Despite the psychological nature of BFRB disorders, many “patients are unlikely to seek mental health treatment for their condition [and] will instead seek dermatologic help due to the cosmetic damage incurred,”2 the researchers wrote. In addition to dermatologic assessment of the affected areas, the optimal management strategy for BFRBs should include psychological treatment and, when indicated, pharmacotherapy.2

Habit Reversal Training (HRT)

In a presentation at the second annual Integrative Dermatology Symposium held October 3-5, 2019 in San Diego, California, Katlein França, MD, PhD, discussed the use of the behavior therapy technique “habit reversal training” (HRT) for the treatment of trichotillomania, excoriation disorder, and itch. Dr França is a clinical assistant professor in the department of dermatology and cutaneous surgery, and faculty in the department of psychiatry and behavioral sciences at the University of Miami Miller School of Medicine in Florida.

HRT was developed in the 1970s by Azrin, et al, as a treatment strategy for tics and other habitual behaviors.4 HRT typically includes the following core components:

Awareness training. To increase the patient’s awareness of their habitual behavior, a functional assessment interview is conducted that asks patients to describe what happens before, during, and after they engage in the behavior.4 This helps the patient identify “warning signs” of the impending behavior, which may include physical cues such as moving their hand toward their head and emotional cues such as boredom or stress.

Competing response training. The clinician collaborates with the patient to select a competing response to employ each time the “warning sign” or habitual behavior occurs. “The competing response should be selected in collaboration with the patient, and should be inconspicuous, easy to perform, and physically incompatible with the pulling behavior,” wrote the researchers in a 2015 paper on the topic.4 “Common competing responses include making hands into a fist, sitting on hands, and putting hands in pockets,” they stated.

Social support training/contingency management. This component involves the training of a “support person” close to the patient who can point out warning signs, reinforce the use of competing responses, and provide encouragement.4

Stimulus control is also often used in conjunction with HRT and involves minimizing environmental influence on the repetitive behaviors.4 Depending on the patient’s specific triggers, stimulus control may involve covering mirrors, reducing time spent in the bathroom, and avoiding situations likely to evoke boredom or other triggering emotional states.

Various enhancement strategies may increase the effectiveness of HRT by addressing the urges or negative emotions involved in BFRBs, including psychological approaches such as acceptance and commitment therapy and dialectical behavior therapy.4

Available data supports the efficacy of HRT in reducing BFRBs. For example, in a 12-week randomized trial of patients with trichotillomania, HRT was associated with substantial improvement in 64% of patients vs 9% of patients taking fluoxetine and 20% of patients with the waitlist condition.4 In  addition, an online HRT program for trichotillomania (stopPulling.com) demonstrated moderate efficacy, with 32% of patients showing a reduction in symptom severity of at least 25% on the Massachusetts General Hospital Hair-pulling Scale.4

Limited findings also suggest that HRT is effective for excoriation disorder, including a 2006 study demonstrating a 77% reduction in skin-picking in the HRT group compared with 16% in a waitlist group.6

Dermatology Advisor interviewed Dr França to learn more about the use of this technique for BFRBs.

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Dermatology Advisor: What is known about the effectiveness of HRT for patients with trichotillomania, excoriation disorder, and itch?

Katlein França, MD, PhD: HRT is the treatment for trichotillomania with the most empirical support. Several case studies, literature reviews, systematic reviews, and meta-analyses have shown the efficacy of this treatment in trichotillomania.

HRT has also been widely used to successfully treat patients with excoriation disorder. The treatment is often combination medication including selective serotonin reuptake inhibitors or n-acetylcysteine.7

Evidence suggests that HRT can also be used in patients with eczema. In a recent meta-analysis, HRT was found to reduce atopic dermatitis severity and scratching.8,9

Dermatology Advisor: How is HRT applied in a dermatology practice and what are some of the main challenges in providing this technique?

Dr França: HRT benefits patients with many different dermatologic and psycho-dermatologic disorders such as excoriation disorder, onychophagia, trichotillomania, and lip-biting. The challenges are the lack of trained professionals to perform this technique and the availability of treatment. Another challenge is that in some patients HRT alone may not be sufficient so mindfulness-based interventions combined with HRT have been used in these cases.4

Dermatology Advisor: How can clinicians learn more about providing HRT? 

Dr França: There are online courses, new papers, and book chapters describing HRT that can serve as tools to learn and implement this technique in clinical practice.

Dermatology Advisor: What are the remaining research needs in this area?

Dr França: BFRBs such as trichotillomania and excoriation disorder are quite common, with lifetime prevalence rates of up to 4%.10 These conditions affect patients’ quality of life and are associated with clinically significant levels of anxiety, depression, and stress.

Despite the relatively high prevalence, challenging treatment, and often chronic impairment of patients’ lives, these disorders have been neglected from a research point of view. New studies exploring different treatment options, neuroimaging, genetics, and epidemiology are necessary to better assist these patients.


  1. Raikhy S, Gautam S, Kanodia S. Pattern and prevalence of psychiatric disorders among patients attending dermatology OPD. Asian J Psychiatr. 2017;29:85-88.
  2. Sampaio DG, Grant JE. Body-focused repetitive behaviors and the dermatology patient. Clin Dermatol. 2018;36(6):723-727.
  3. Phillips KA, Stein DJ. Body-focused repetitive behavior disorder. Merck Manual Professional Version. 2018.  www.merckmanuals.com/professional/psychiatric-disorders/obsessive-compulsive-and-related-disorders/body-focused-repetitive-behavior-disorder. Accessed January 3, 2020.
  4. Snorrason I, Berlin GS, Lee HJ. Optimizing psychological interventions for trichotillomania (hair-pulling disorder): an update on current empirical status. Psychol Res Behav Manag. 2015;8:105-113.
  5. Houghton DC, Alexander JR, Bauer CC, Woods DW. Body-focused repetitive behaviors: More prevalent than once thought? Psychiatry Res. 2018;270:389-393.
  6. Teng EJ, Woods DW, Twohig MP. Habit reversal as a treatment for chronic skin picking: a pilot investigation. Behav Modif. 2006;30(4):411-422.
  7. Jones G, Keuthen N, Greenberg E. Assessment and treatment of trichotillomania (hair pulling disorder) and excoriation (skin picking) disorder. Clin Dermatol. 2018;36(6):728-736.
  8. Medical Xpress. Review suggests habit reversal beneficial in atopic dermatitis. https://medicalxpress.com/news/2015-10-habit-reversal-beneficial-atopic-dermatitis.html . October 3, 2015. Accessed January 3, 2020.
  9. Daunton A, Bridgett C, Goulding JM. Habit reversal for refractory atopic dermatitis: a review. Br J Dermatol. 2016;174(3):657-659.
  10.  Huynh M, Gavino AC, Magid M. Trichotillomania. Semin Cutan Med Surg. 2013;32(2):88-94.

This article originally appeared on Dermatology Advisor