Drug treatments for chronic hair-pulling (trichotillomania)

Trichotillomania (TTM) (hair-pulling disorder) is a common and disabling condition characterised by repeated hair-pulling leading to hair loss. TTM can be associated with much distress and impairment for people with the condition. This systematic review of randomised controlled trials (RCTs) set out to review the evidence for medication in treating TTM. The findings are based on eight studies (which included a total of 204 people). Not enough evidence was found to conclude definitively that any particular medication is effective in the treatment of TTM. Furthermore, side effects related to medications were not well-documented in the majority of the studies. Because of differences in the way the included studies were carried out, we were unable to combine their results to draw more conclusive evidence. However, an early trial found some evidence for the efficacy of clomipramine, and two recent trials reported statistically significant treatment outcomes with olanzapine and N-acetylcysteine. More research is needed to find an optimal treatment for TTM.

Authors' conclusions: 

No particular medication class definitively demonstrates efficacy in the treatment of trichotillomania. Preliminary evidence suggests treatment effects of clomipramine, NAC and olanzapine based on three individual trials, albeit with very small sample sizes.

Read the full abstract...

Trichotillomania (TTM) (hair-pulling disorder) is a prevalent and disabling disorder characterised by recurrent hair-pulling. The effect of medication on trichotillomania has not been systematically evaluated.


To assess the effects of medication for trichotillomania in adults compared with placebo or other active agents.

Search strategy: 

We searched the Cochrane Central Register of Controlled Trials and the Cochrane Depression, Anxiety and Neurosis Group Register (to 31 July 2013), which includes relevant randomised controlled trials from the following bibliographic databases: The Cochrane Library (all years); EMBASE (1974 to date); MEDLINE (1950 to date) and PsycINFO (1967 to date). Two review authors identified relevant trials by assessing the abstracts of all possible studies.

Selection criteria: 

We selected randomised controlled trials (RCTs) of a medication versus placebo or active agent for TTM in adults.

Data collection and analysis: 

Two review authors independently performed the data extraction and 'Risk of bias' assessments, and disagreements were resolved through discussion with a third review author. Primary outcomes included the mean difference (MD) in reduction of trichotillomania symptoms on a continuous measure of trichotillomania symptom severity, and the risk ratio (RR) of the clinical response based on a dichotomous measure, with 95% confidence intervals (CIs).

Main results: 

We identified eight studies with a total of 204 participants and a mean sample size of 25. All trials were single-centre trials, and participants seen on an outpatient basis. Seven studies compared medication and placebo (n = 184); one study compared medication and another active agent (n = 13). Duration of the studies was six to twelve weeks. Meta-analysis was not undertaken because of the methodological heterogeneity of the trials. The studies did not employ intention-to-treat analyses and were at a high risk of attrition bias. Adverse events were not well-documented in the studies.

None of the three studies of selective serotonin reuptake inhibitors (SSRIs) demonstrated strong evidence of a treatment effect on any of the outcomes of interest. The unpublished naltrexone study did not provide strong evidence of a treatment effect. Two studies, an olanzapine study and a N-acetylcysteine (NAC) study, reported statistically significant treatment effects. One study of clomipramine demonstrated a treatment effect on two out of three measures of response to treatment.