GPAtlas🧭 When to suspect
Suspect trichotillomania (hair-pulling disorder) in anyone presenting with patches of non-scarring hair loss and a history – often reluctantly disclosed – of pulling out their own hair. It is a body-focused repetitive behaviour (BFRB): the urge is typically preceded by rising tension and followed by relief, gratification or pleasure. Although it is classified within the obsessive-compulsive and related disorders, it is not OCD – there are no driving obsessional thoughts – and it is not deliberate self-harm.
Two patterns aid recognition. Focused pulling is deliberate, in response to an urge or emotional state; automatic pulling happens during sedentary activities such as reading or screen time, often outside the person's awareness. Onset is usually around 10–13 years. In children it is frequently a benign, self-limiting habit; in adolescents and adults it tends to be chronic and relapsing, more often affects females, and should prompt assessment of psychological distress and of self-harm and suicide risk.
The hair loss has a characteristic look – irregular or geometric patches with hairs of varying length on an otherwise normal scalp. The two practical priorities in primary care are to recognise the pattern (and distinguish it from other causes of patchy hair loss), and to screen for what changes management: trichophagia, comorbidity and risk.
| Differential | Distinguishing feature |
|---|---|
| Alopecia areata | Smooth, round patches; exclamation-mark hairs and uniform yellow dots on trichoscopy; no broken hairs of varying length. |
| Tinea capitis | Scaling, itch and broken hairs, sometimes a kerion; positive mycology – important in children. |
| Traction alopecia | Loss at the hair margins from tight styling; symmetrical, with no urge to pull. |
| Telogen effluvium | Diffuse shedding rather than a localised patch; follows stress, illness, childbirth or a new drug. |
Source: DermNet · NICE CG31
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