Trichotillomania and Skin Picking: Care Staff Guide to Body-Focused Repetitive Behaviours

Hair pulling and skin picking are often hidden. People with these conditions may cover bald patches or damaged skin, avoid swimming or intimate care, and feel deep shame about something they find extremely hard to stop. Care staff may notice hair loss, scabs, sore patches or signs of infection, and how they respond can make the difference between a person seeking help and keeping it secret. This guide, based on NHS information, explains trichotillomania and skin picking disorder and how to support people with kindness and practical help.

What are trichotillomania and skin picking disorder?

The NHS describes trichotillomania, also called trich or hair pulling disorder, as a condition in which someone cannot resist the urge to pull out their hair. The NHS says it usually starts between the ages of 10 and 13. People may pull hair from the scalp or from other places such as the eyebrows, eyelashes, genital area, beard or moustache.

The NHS describes skin picking disorder, also called dermatillomania or excoriation disorder, as a condition in which a person repeatedly picks at their skin and finds it hard to stop. It is linked to obsessive compulsive disorder (OCD), is similar to trichotillomania and is related to body dysmorphic disorder. People with one of these conditions often have other OCD-related conditions that may need their own assessment, as explained in our guide to OCD and body dysmorphic disorder.

Signs to notice

For hair pulling, the NHS lists an intense urge to pull, tension that builds until the person pulls, and a sense of relief afterwards. Pulling can happen during stress or without much thought. Bald patches may have an unusual shape and are often more noticeable on one side of the head. Many people hide the behaviour because of shame and low self-esteem.

For skin picking, the NHS lists being unable to stop picking, causing cuts, bleeding or bruising, picking moles, freckles, spots or scars to smooth or perfect them, often not realising they are picking, and picking when anxious or stressed. People may use fingers, nails, teeth or tools such as tweezers, pins or scissors.

What triggers it?

The NHS says the cause of trichotillomania is not fully known. It may be a way of coping with stress or anxiety, may involve a brain chemical imbalance or hormone changes in puberty, and may run in families. Over time hair pulling can become a habit that is hard to break. For skin picking, the NHS identifies triggers including boredom, stress or anxiety, negative emotions such as guilt or shame, skin conditions such as acne or eczema, and blemishes the person wants to remove, which may not be visible to others. Anxiety is a common thread, so staff may find our guide to generalised anxiety and panic disorder helpful.

Health risks

Skin picking can lead to cuts that do not heal, serious skin damage, infection, emotional distress and effects on daily life. The NHS advises seeing a GP if cuts do not heal within a few days or if picking causes serious damage. For trichotillomania, the NHS points out that some people eat the hair they pull out, which can form hairballs in the stomach and cause serious illness. Tell the GP promptly if you know or suspect this is happening, and seek urgent advice if the person has abdominal pain, vomiting or loss of appetite. Skin wounds need clean, careful handling to reduce infection, and our guide to infection prevention and control covers good practice for wound care and hand hygiene.

Getting help

The NHS recommends seeing a GP if you or your child is pulling out hair, or if you cannot stop picking your skin, are causing serious damage or experience distress or interference with daily life. The GP may check for other causes, such as a skin infection. Where trichotillomania is suspected, the person may be referred for cognitive behavioural therapy (CBT), which for under-18s may be offered through children and young people's mental health services. For skin picking, a GP may refer to a dermatologist if the skin is badly damaged or an underlying condition such as acne or eczema is contributing.

Treatment

For both conditions, the NHS describes CBT as the main approach, particularly habit reversal training. This involves keeping a diary of the behaviour, identifying triggers, replacing pulling or picking with another action, and getting support from loved ones. For trichotillomania, the NHS states that antidepressants are not usually prescribed. For skin picking, the NHS says medicines are sometimes recommended, more often by a psychiatrist than a GP. Staff should never suggest stopping or starting medicines.

Practical support

The NHS offers self-help ideas for each condition that staff can reinforce:

• keep hands busy, for example by squeezing a stress ball or using a fidget toy
• spot the times and places when picking or pulling is most likely and plan around them
• try to resist the urge for a little longer each time
• use gloves, plasters on fingertips, a bandana or beanie, or short hair to make pulling harder
• keep nails trimmed and keep tweezers and pins out of easy reach
• look after the skin: keep it clean and moisturise when the urge arises
• try soothing activities such as a bath, deep breathing or exercise
• tell trusted people, who can help the person notice when they are pulling or picking

How staff can help

• Be matter-of-fact and kind. Avoid comments such as "stop that" or "you're making it worse". Shame fuels the cycle.
• Do not use restraint or punishment. These behaviours are not deliberate misbehaviour.
• Offer privacy. Support discreet ways of managing hair loss or skin damage, such as hats, scarves or wigs if the person wishes.
• Notice patterns. Record times and situations, such as boredom or distress, which help therapists tailor treatment.
• Increase meaningful activity. Boredom is a common trigger, so offering stimulation helps.
• Watch for low mood. Raise any hopelessness or self-harm concerns using your service's procedures.

Frequently asked questions

Is hair pulling or skin picking the same as self-harm?

Not necessarily. The NHS describes these as conditions linked to urges, tension and habit, often connected to OCD-related conditions. However, any injury, distress or thoughts of self-harm should be taken seriously and reported.

Can people just stop if they try hard enough?

No. The NHS explains that people often cannot resist the urge, and many do not realise they are picking. Effective help includes CBT and habit reversal training.

Where can people get more information?

The NHS directs people to OCD UK for further information on trichotillomania. A GP can arrange referral for talking therapy.

Keep building your knowledge

Compassionate responses to hidden conditions protect dignity and encourage people to seek help. Explore the health and social care learning available through Learnsignal CPD to keep your knowledge current.

This article is general information for care staff, based on published NHS guidance, and does not replace the advice of a person's own clinicians.