Treatment Choice and Sequencing of Treatment
Cognitive behavioral therapy (specifically components of HRT or ACT) should be started as first-line treatment for Trichotillomania where treatment is indicated. NAC should be considered as adjunctive therapy to CBT or prescribed as mono-therapy in cases where psychotherapy by a trained therapist is unavailable or unrealistic given geographical constraints of the patient or an inability of the patient to make regular appointments. For patients with co-occurring depressive or anxiety disorders, clomipramine combined with CBT may provide lessening of both Trichotillomania and depressive/anxiety symptoms, however, careful monitoring for safety and tolerability are of the utmost importance. Dronabinol is promising as a treatment for Trichotillomania but its availability is limited; it is a controlled substance in many geographical domains and is completely unavailable in others. Online therapy has been shown to be effective in reducing the symptoms of Trichotillomania but is not a replacement for in-person behavior therapy.
Consultation with Other Disciplines
Dermatologic consultation should occur where significant inflammation of the skin occurs at the site of pulling, or where there is diagnostic uncertainty as to the cause of hair loss. Consultation with colleagues can be helpful when an individual denies deliberate hair pulling and to help rule out medical causes for hair loss. For patients who repetitively bite their hair, run in between their teeth, or chew on their hair, dental consultation should also be encouraged.