Therapy | Trichotillomania from scratching the skin (2023)

Therapy | Trichotillomania from scratching the skin (1)

What therapy options are there?
What has been scientifically researched so far?
How do I find help?

The most important facts at a glance:

  • Dermatillomania and trichotillomania are recognized and treatable mental disorders.
  • In the ICD-10 still in use, there is no independent diagnosis for dermatilomania, unlike the ICD-11 which will be published soon. You can still receive treatment!
  • According to previous studies, cognitive behavioral therapy (CBT) is the first recommended treatment for the disorders.
  • At the current status of the study, no specific drug can be unreservedly recommended for the treatment of the conditions.

Therapy | Trichotillomania from scratching the skin (2)

Cognitive Behavioral Therapy (CBT)

CBT is one of four psychotherapy procedures approved by health insurers. This means that KBT is covered by health insurance companies if it is performed by licensed psychotherapists.

Until now, studies on dermatillomania and trichotillomania have been done almost exclusively with this form of therapy. As many of the studies point to the effectiveness of behavioral interventions in these disorders (see below), CBT is currently the method of choice.

In general, there is still a great need for research here!

Detailed general information about CBT can be found elsewhere (cf.connections).

For derma and trichotillomania, CBT includes the following elements, among others:

  • Psychoeducation (education about the disorder)
  • Introspection to identify and understand triggers
  • Stimulus control (reduce triggers)
  • Cognitive interventions (for example, to change certain thoughts like “I can't stop anyway”).
  • Clarifying motivation (What are the advantages and disadvantages of the behavior?)
  • relapse prevention

Habit Reversal Training (HRT) is used as a special behavior therapy technique. The main objective here is to change the motor skills that have been practised. The first step is to pay more attention to the behavior (see Insight above) to better understand the circumstances of the skin handling or hair pulling and create more awareness of the behavior. In the second stage, a muscular reaction incompatible with the behavior is practiced (for example, clenching the fist, opening the fingers). This should be done whenever there is a need to work on the skin or pluck the hair.

(Video) How To Stop Hair Pulling and Skin Picking! The ComB Model! (Part 1)

Therapy | Trichotillomania from scratching the skin (3)

Acceptance and Attachment Therapy (ACT)

ACT isNOan independent therapy method recognized by health insurance companies. However, some therapists have gained an additional qualification from the ACT.

ACT focuses on accepting, not avoiding, certain experiences and feelings. For example, skin working/hair pulling can be used to relieve or try to avoid tension.
This approach is primarily about dealing with distressing feelings and experiences with acceptance. At the same time, the alignment of one's own life with personal values ​​and goals is valued.
Initial studies show good results for ACT in dermatillomania and trichotillomania; however, combinations of behavioral therapy and ACT interventions have been studied in some cases.
In general, there are more or better studies on the effectiveness of ACT in trichotillomania than in dermatillomania.

Therapy | Trichotillomania from scratching the skin (4)

Dialectical Behavior Therapy (DBT)

The same applies to DBTNOan independent therapy method recognized by health insurance companies. However, many therapists have completed DBT training!
DBT is a therapeutic approach originally developed for self-injurious behavior. The main focus is on the topics of stress and emotion regulation, which also play a role in dermatillomania and trichotillomania.

So far, one study has reported promising results for a combination of CBT and DBT in trichotillomania (see below Keuthen et al., 2012). However, further studies are still pending.

(Video) How To Stop Skin Picking and Hair Pulling In 4 Steps

More information

Other therapeutic approaches (health insurance)

In addition to the therapeutic approaches described above, there are of course other psychotherapeutic treatment options.
In addition to behavioral therapy, health insurance companies allow the following additional therapy methods as so-called psychotherapeutic counseling methods:

1. Psychotherapy based on depth psychology
2. Psychoanalysis
3. Systemic therapy

To date, however, there are no studies on the effectiveness of these forms of therapy in BFRB.

General and detailed information about the various methods of therapy and their focal points, as well as the question "How do I find my way to psychotherapy?" can be found elsewhere (cf.connections).

(Video) The connection between skin picking, OCD, and stored trauma

Other therapeutic approaches (private payers)

In addition to the procedures in the psychotherapy guidelines, many other therapy or coaching approaches are offered (eg art therapy, body therapy, hypnosis) that you can use independently.

The security and quality of the respective offers must be verified on a case-by-case basis. The seriousness and quality of the offers are very different! Anyone wishing to take advantage of this offer should pay particular attention to transparency regarding the person's qualifications: What training did you complete? What professional associations are you a member of? To what extent does the person have professional experience in this area?
The less information about the rating, the more dubious!

Important to know:
Studies on the effectiveness of dermatillomania and trichotillomania are only available for the above mentioned therapy methods (CBT (+HRT), DBT, ACT).

appropriate therapists

Currently, there are very few psychotherapists who (eg on their homepage) explicitly mention BFRB as a treatment approach; this is particularly true for dermatillomania, as this diagnosis is even more recent than trichotillomania. Unfortunately, dermatillomania is still relatively unknown, often even among psychotherapists. But the disorder is getting more and more attention and more and more therapists are aware of it!

For both disorders, it makes sense to seek out therapists who specialize in “dermatillomania”, “trichotillomania” or “obsessive-compulsive and related disorders”. If you don't find anyone with these priorities nearby who might offer you a date, and it's quite likely, don't be discouraged.
Of course it is an advantage if you already have some prior knowledge on the subject of dermatillomania or trichotillomania, but in general psychotherapy is also about finding a solution together! Furthermore, many of the contents, strategies, and exercises in psychotherapy are similar for different disorders.
In the initial in-person consultation (and subsequent trial sessions) you will have a good feeling that you are on the same wavelength as the therapist and that you can envision the therapy there. This criterion is much more important for choosing a therapist than a specific procedure!

"Am I bad enough?"

It often happens that affected people are not sure whether they “deserve” help (eg psychotherapy) and ask themselves: “Is my problem really serious enough? Do I feel bad enough? I want to say that if you are suffering and need support, you can (and should) seek help.
No matter how small or unimportant problems may seem from the outside, when you feel the need for support and help, you can take them seriously. Nobody else is stuck in your head and feeling like you are. You know better than you need.
And when someone asks, "Am I bad enough to deserve help?" the answer is almost always "yes"; otherwise I wouldn't think about it.
It's always best to get help early. It is completely wrong to believe that you only have the right to help when “nothing else works”.
So yes, if you feel the need for support, don't hesitate to ask.
You can fight back!

(Video) Got Itchy, Crusty Ears? (Yuck!) - Dermatologist's Tips [2019]



Schumer, MC, Bartley, CA & Bloch, MH (2016). Systematic review of pharmacological and behavioral treatments for skin disorders. Journal of Clinical Psychopharmacology, 36(2), 147-152.

McGuire J, Ung D, Selles RR, Rahman O, Lewin AB, Murphy TK, & Storch EA. (2014). Treatment of trichotillomania: a meta-analysis of the treatment effects and moderators of behavioral therapy and selective serotonin reuptake inhibitors. Journal of Psychiatric Research, 58, 76-83.


Gallinat, C., Moessner, M., Haenssle, H.A., Winkler, J.K., Backenstrass, M. & Bauer, S. (2019b). An internet-based self-help skin-scratching intervention (SaveMySkin): randomized controlled pilot study. Internet Journal of Medical Research, 21(9), e15011.

Moritz, S., Fricke, S., Treszl, A. & Wittekind, C., E. (2012). Do it yourself! Evaluation of self-help versus uncoupling habit reversal training in pathologic skin picking: a pilot study. Journal of Obsessive-Compulsive and Related Disorders, 1(1), 41-47.

Schuck, K., Keijsers, GP & Rinck, M. (2011). The effects of brief cognitive-behavioral therapy on pathological skin scratching: a randomized comparison with waiting list control. Behavioral Research and Therapy, 49(1), 11-17.

Teng, E.J., Woods, D., W. & Twohig, MP (2006). Habit reversal as a treatment for chronic itchy skin. Behavior Change, 30(4), 411-422.


Keuthen, NJ, Rothbaum, BO, Fama, J, Altenburger, E, Falkenstein, MJ, Sprich, SE, et al., (2012). DBT-enhanced cognitive-behavioral treatment for trichotillomania: a randomized controlled trial.Behavioral Addiction Diary, 1(3):106-14. doi: 10.1556/JBA.1.2012.003.


Capriotti MR, Ely LJ, Snorrason I, Woods DW. (2015). Improved acceptance behavior therapy for excoriation disorder (skin picking) in adults: a clinical case series. Cognitive and Behavioral Practice, 22, 230-239.

Flessner CA, Busch AM, Heidemann PW, & Woods DW. (2008). Acceptance Enhanced Behavioral Therapy (AEBT) for trichotillomania and chronic skin picking. Investigating the impact of component sequencing. Behavior Modification, 32(5), 579-594.

Lee EB, Homan KJ, Morrison KL, Ong CW, Levin ME, & Twohig MP (2020). Acceptance and attachment therapy for trichotillomania: a randomized controlled trial in adults and adolescents. Behavior change, 44(1), 70-91.

Tellefsen Haaland, A., Eskeland, S.O., Moen, EM, Vogel, P.A., Haseth, S., Mellingen, K., et al. (2017). ACT-assisted behavioral therapy in a group format for trichotillomania: an efficacy study. Journal of Obsessive-Compulsive and Related Disorders, 12, 109-116.

(Video) How to STOP ITCH #Shorts

Twohig MP, Hayes SC & Masuda A (2006). A preliminary investigation of acceptance and attachment therapy as a treatment for chronic skin picking. Behavioral Research and Therapy, 44(10), 1513-1522.


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