Treatment

Pharmacotherapy

There are no labeled medications for the treatment of Trichotillomania; however, a multitude of studies have been conducted examining the safety and efficacy of different pharmacological interventions. Pharmacotherapies which have indicated efficacious outcomes in Trichotillomania include n-acetylcysteine (NAC), clomipramine, olanzapine, and dronabinol although each of these treatments has been shown to be efficacious in relatively small samples of clinical trial patients.

The most robust pharmacotherapy at this time is the glu- tamatergic agent n-acetylcysteine (NAC) for adults with Trichotillomania. Adult patients should start treatment at 600mg twice/day for one week, then 1200mg twice/day for up to four weeks, and then 1800mg upon awakening and 1200mg about 10 hours later per day.

An alternative medication for Trichotillomania is the serotonin tricyclic clomipramine, which should be started at 25-50mg/ day, with dose increasing by 50mg every five days. After reaching 150mg/day, the clinician can wait four weeks to judge effectiveness, and then further increase the dose in steps of 50mg every five days as-needed. The average target dose is 100-250mg/day, with usual maximum dose being 250mg/day.

Dronabinol, a cannabinoid antagonist and antiemetic, is a synthetic derivative of THC (the active ingredient in cannabis), and may reduce the excitotoxic damage caused by glutamate release in the striatum, offering promise in reducing pulling behaviors seen in Trichotillomania. Dronabinol is a Schedule III controlled substance in the United States and its availability and legal status are likely to differ as a function of world geographical location. Patients should be started on 2.5mg/day for 2 weeks, increasing to 5mg/day for 2 weeks, then 10mg/day for 2 weeks, and finally titrated to a maximum dose of 15mg/day thereafter depending on clinical efficacy and patient tolerability.

Olanzapine can be used, starting at 2.5mg/day for 2 weeks, then increased to 5mg/day for 2 weeks, then 10mg/day for two weeks, and finally a maximum dose of 20mg/day depending on clinical response and tolerability. Given the side effect profile of olanzapine and other antipsychotics, we recommend that these medications only be considered for patients who have failed to respond adequately to NAC or clomipramine treatment in the first instance.

Psychotherapy is considered the treatment of choice for children and adolescents.

 
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