Treatments for hair pulling (trichotillomania) and other body focused repetitive behaviors

I see several kids each year who pull hair from their scalp, eyelids, or eyelashes. This is called trichotillomania (sometimes shortened to trich). Because I see families struggle with this and other similar issues, I am breaking my general rule of blogging within the realm of standard guidelines and am going outside of conventional medical advice to talk about an interesting new treatment that is showing positive benefit with studies (many of which are linked into the post). I say this only to caution the reader that you should discuss this with your (or your child's) doctor about it and to remind you not to take this (or anything else I write) as medical advice.

Trichotillomania is more common in children who have anxiety, and it can also lead to more anxiety from the social isolation and bullying that result from hair loss. It is a vicious circle where the self-inflicted hair loss is in itself distressing, but that distress leads to more pulling. You can see from the following picture that cutting hair short is not an effective treatment. Skin picking and nail biting are similar body focused repetitive behaviors (BFRB).

Do dietary changes help?

There have been conflicting studies that suggest avoiding certain foods can help prevent the urges to pull hair. Some people report that avoiding sugar and caffeine helps. Since added sugar and caffeine are not parts of a healthy diet, I think whether or not it helps, avoiding added sugar and caffeine is a good idea for all kids.

What help is available?

The first treatment recommended for trich (as well as other body focused repetitive behaviors- BFRB) is therapy. Treating BFRB should involve cognitive behavioral therapy or habit reversal therapy from a trained therapist with experience in this issue. During therapy they will learn to identify emotions, label them, and appropriately address them. In habit reversal therapy they learn to do another action instead of the hair pulling (or nail biting/skin picking). This might mean clenching fists, playing with play doh, or another activity. Family support can help ease the anxieties that are caused by the behavior itself and it is important that family members praise the positive steps along the journey. There are support groups available in many areas. 

Are there supplements that help?

A relatively new development in the treatment of trichotillomania and other BFRBs is a supplement called N-acetylcysteine (NAC), a glutamate modulator. NAC is available over the counter in stores that sell supplements and online for a relatively low cost. How NAC might work is not completely understood and well beyond the scope of this blog, but is reviewed in the Journal of Psychiatry and Neuroscience.

I've been recommending NAC for awhile now for trichotillomania (as well as nail biting and OCD) and have had mixed response, but overall positive. For those who did not find it helpful, I suspect they did not use it long enough since it can take over a month to see benefit. I think parents like the fact that it is a supplement, which is easier to provide than behavioral therapy, but therapy is still an important part of the treatment. Those who have the best results do therapy along with the supplement.

How long does it take to see results with NAC?

It takes about a month or two (studies show 4-9 weeks) of NAC to show benefit. Taking a supplement for that length of time without benefit can be difficult and might cause some to quit prematurely, but I'd recommend at least two months before deciding it doesn't work. Talk with your child's doctor before starting any supplement and before stopping it.

How much NAC do you give?

Most studies have been done in adults, so the best pediatric dose is not known. For adults and children over about 45 pounds, 600 - 2400 mg has been studied, but no ideal dose is known. It has been suggested about 60mg/kg/day for younger children, but there is no standard dose.

It may also be difficult to give to a child who cannot swallow the capsules. While in theory the capsule could be opened (and the powder is available in bulk), the taste and smell is of rotten eggs, so I cannot imagine a child taking it mixed in food or drink. Tips on teaching kids to swallow pills is covered here.

Talk with your child's pediatrician before beginning any supplement, even though they are sold over the counter. This helps your child's doctor know more about what is going on, what works and what doesn't for your child, and to help monitor for possible reactions if they are known (especially if your child is on prescription medicines).

One dosing strategy for children over 45 pounds is to give a 600 mg capsule twice per day (1200 mg) for a week and increasing to 2 capsules twice per day (2400 mg) after 4 weeks if needed. I have also seen titration methods, beginning with one capsule daily for the first week (600mg), then one capsule twice a day for the 2nd week (1200mg), then 3 capsules divided in 2 unequal doses (1800 mg) for the 3rd week and 4 capsules divided in 2 doses (2 capsules twice per day = 2400 mg) thereafter.

Is NAC safe with other medicines?

NAC might interact with other medicines, so it is recommended to discuss interactions with your doctor and pharmacist. Since antidepressants are often used in anxiety disorders such as trichotillomania, I have tried to see what interactions might be known. Research has shown that rats need lower doses of imipramine (a tricyclic antidepressant I don't use in kids) and escitalopram (Lexapro, an SSRI antidepressant) when taking NAC, but NAC doesn't affect the dose of desipramine (another tricyclic antidepressant) and bupropion (Wellbutrin). In contrast, NAC in the rats actually made fluoxetine (prozac) less effective, so higher doses were needed. Obviously people are not rats, and this is an area that needs to be further studied, but if your child is on any prescription medicines, be sure your doctor and pharmacist know that he is starting NAC.

If anyone knows of human studies or more information, please post in the comments below!

How long will NAC be needed?

It is thought that NAC is safe long term and might be needed long term since the underlying anxiety does not go away, only the symptoms are controlled with the NAC. This is an important reason to do the therapy too, since learning techniques to identify and appropriately deal with stressors can help life long without side effects. When NAC is stopped, symptoms might return. I will often suggest a trial off NAC once all habits being treated have been gone for at least a month. Weaning to a lesser dose for a few weeks is one way to test without going completely off, and I find many families feel more comfortable with a wean versus sudden stopping. If symptoms resume, restart the NAC. (Note: This is my own version of what to do -- I have not found guidance in the studies I've read. If anyone knows anything more specific, please comment below so we can all learn!) I did see one case report of a person treated for 6 months with NAC and the symptoms did not return for a full month after stopping NAC.

Is NAC safe?

Side effects are rare, but may include gastrointestinal upset, diarrhea, nausea, rash, vomiting and fatigue. One study of AIDS patients used 8000 mg of NAC per day, showing overall safety at high doses. This is NOT the dose recommended for hair pulling, skin picking, and most psychiatric and neurologic disorders. Some studies suggest kidney stones are more common at higher doses, but taking high doses of Vitamin C at the same time as each NAC dose can help prevent kidney stones from forming. A supplement of Vitamin B6 has also been recommended by some because NAC increases the body's use of Vitamin B6, but most children can get plenty of this vitamin from a healthy diet. Many foods are rich in B6, including fish, beef, poultry, fruits (not citrus fruits), vegetables, and grains. Vitamin B6 is also in most multivitamins, so if you choose to supplement, a standard multivitamin would be considered safe. Talk with your child's doctor if you plan on doing mega doses of vitamins, as that can sometimes be harmful.

What else is NAC used for?

When I was a pediatric resident, we used NAC for acetaminophen (Tylenol) overdoses. I hadn't thought of it for many years, then a few years ago I started to hear of it being used for other things. Research for using NAC for a variety of psychiatric and neurologic disorders in addition to trichotillomania is promising. There is evidence that NAC works for some symptoms involved with autism, Alzheimer's disease, cocaine and cannabis (marijuana) addiction, bipolar disorder, depression, nail biting, skin picking, obsessive-compulsive disorder, schizophrenia, drug-induced neuropathy and progressive myoclonic epilepsy. Disorders such as anxiety, attention deficit hyperactivity disorder and mild traumatic brain injury also have preliminary studies supporting NAC use but require larger confirmatory studies.

Suggested NAC 

I do not typically recommend any brand over another, but supplements present a problem due to the lack of regulation. Investigations have shown that there is variability of what is actually in the product from bottle to bottle. I recommend Swanson Vitamins. During the study on BFRB’s done by Jon Grant, MD, JD, MPH, Swanson products were used because they were the only company in the US that would provide a certificate of purity and batch to batch sameness. For this reason I recommend Swanson’s for NAC as well as their other products if you will be taking a supplement.

Update 11-3-17: I just heard of an effervescent tablet that gets good reviews from specialists. PharmaNac has 900 mg per tablet, and their website recommends 2-4 tablets per day. Note: Their website mentions a potential issue with some antibiotics and NAC, but those claims have been disputed. It would not be wrong to separate dosing of antibiotic and NAC, but it might not be an issue.

For More Information:

For more information, see Experts Consensus Treatment Guidelines for Trichotillomania and Skin Picking and the many other resources found on The TLC Foundation for Body-Focused Repetitive Behaviors.

KidsHealth has a Trichotillomania page for teens.

"It's just my allergies." Is it?

I've seen many parents over the years who complain that their allergies are really giving them (or their children) problems. They insist it's just allergies though when I suggest that maybe they're sick. Why do they think it's allergies and I think they might have a virus-- and why does it matter?

Allergies can cause runny nose, watery eyes, sneezing, headache, ear pain or popping, cough and sore throat from postnasal drip.

Viruses can cause the same symptoms, so it's very confusing which is the culprit sometimes. If there's a fever or body aches, it is more likely from illness, not allergy, but not everyone with an infection gets a fever, especially older kids and adults. Not everyone with fever needs an antibiotic. Many people think clear mucus is certainly allergies and discolored mucus is bacteria, but that isn't always the case. The color of mucus depends on how long the mucus is in the nose and sinuses and how much your immune system is fighting back. It is common after a few days for the mucus to be yellow, even if it's not a bacterial sinus infection.

I've seen people treated by allergists for years for allergies only to find out with allergy testing that there aren't any allergies. It's hard for even the experts to know sometimes!

Why do I suspect these parents (or kids) have a virus and not allergies?

• Time of year. Allergies can occur year round, but there are typical times that various pollen counts go up. If it's not a high pollen count time (or other possible exposure to allergen such as a new cat), I wouldn't expect a sudden increase in allergy symptoms. 
• Their child is sick. If a child is sick with fever, runny nose, cough, ear infection, or other similar symptoms, it is common for them to share with the parent (and siblings). Parents and older kids often get colds without fever, so no fever doesn't rule out an infection.
• The community is sick. When we're seeing a lot of upper respiratory tract infections in the community, it is at least something to consider.

Why does this all matter anyway?

• Not all treatments for allergies work well for viruses. Treating the symptoms with the proper treatment is important (although there really isn't a wonder treatment for most upper respiratory viruses). When people think they become tolerant to their allergy medicine because it doesn't work for their symptoms, they are likely to not use it when appropriate for allergies. They might switch to a more expensive medicine for the wrong reasons. Bottom line: If the allergy medicine works for allergies, it can be used for allergies, but don't expect it to work for your cold.
• If people presume it's allergies they aren't as careful to wash hands to prevent the spread of infections. This is especially important to infants, young children, immunocompromised, and the elderly. What is a minor cold for you can be a significant illness to others.

So the short of it is, if you think your allergies are flaring, still be careful to not spread germs. It is fine to use allergy medicines, but if they aren't working, consider that you might have a cold. Even if they do help, it doesn't mean that you aren't contagious, so still wash your hands often, especially after blowing your nose!

Flu shots: Who needs them and which type is best?

Flu vaccines are recommended every season for just about everyone over the age of 6 months. There are specifics to age group and risk factors that help determine if they need an injectable vaccine or if they can get the nasal vaccine.

For as common as the flu vaccine is, there is often confusion about who needs what for many reasons:

• it changes yearly 
• recommendations vary by age and history of flu vaccine or not
• there are options for nose sprays and shots. The nose spray (FluMist) and the injectable vaccine (many brands available for different age groups and our office uses Fluzone quadrivalent) both have the same strains as the other each year but they differ in that the spray is a live virus that has been changed so it doesn't cause all the symptoms as the natural virus but still gives the body memory fighter cells (antibodies). The injectable vaccine is an inactivated virus (not live virus) vaccine. It is safer for people with decreased immune function, such as infants and young children or those with compromised immune systems from disease or chemotherapy.
• there is concern that it might be of little value (this is a whole blog in itself and won't be discussed here) 

If you really want to get to the details, this year's trivalent (3 strain) influenza vaccines will contain: 

• hemagglutinin (HA) derived from an A/California/7/2009 (H1N1)-like virus

• A/Switzerland/9715293/2013 (H3N2)-like virus

• B/Phuket/3073/2013-like (Yamagata lineage) virus

Quadrivalent (4 strain) influenza vaccines will contain these vaccine viruses, and a B/Brisbane/60/2008-like (Victoria lineage) virus, which is the same Victoria lineage virus recommended for quadrivalent formulations in 2013–14 and 2014–15

All FluMist last year and this year are quadrivalent. Injectable vaccines vary by manufacturer and the one we will offer is a quadrivalent type.

Last year there was concern that the FluMist didn't work as well as the injectable. In previous years the mist was considered to work better than the shot. We do not have data on the efficacy of the vaccines this year, so I encourage you to pick the one that best suits the needs of your child because any vaccine is better than no vaccine at all, even if the effectiveness isn't 100% (which it will never be).

Here's a breakdown of what is needed by age group to help decide what your child will need. For people with egg allergies, see the bottom of this page. (Quick note: this year there is a delay of shipment of the FluMist again. The flu shot will be available sooner than the mist, and any child over 6 months can do the shot. It is never wrong to give the shot to ensure protection especially if you're in an area that the flu season is starting. The flu season is generally October to May, with peak activity December to February.)

Six months - 2 years

This age group should get the injectable flu vaccine and cannot get the nasal FluMist.

For children under 9 years of age who have not had two flu vaccines, they will need two doses of the same strain. Think of it as the first dose is a primer dose, getting the body primed to make continued antibodies. The second dose boosts that primer. Each season we need a booster to get the antibodies for the strain of virus that is anticipated that year. Talk to your doctor to see if your child will need one or two doses. Each dose must be at least 28 days apart, but can be separated by many months and count as long as they are the same strains of virus. In recent years the same virus strains were in two different seasons, so it even counted if one was given one season and the other the following year. That doesn't often happen and usually two vaccines in the same season must be given. The strains are different this year from last, so if your baby got only one dose last season, he will need two this season.

2 - 4 years

This group can get the FluMist if they have not had wheezing. The reason for this is the nasal vaccine is a live virus and could trigger wheezing in a susceptible child. The injectable vaccine does not carry this risk. If they have had wheezing or if they just have an aversion to things in their nose they can do the injectable vaccine.

These children are still in the age group that might require two doses, see the 6 months - 2 years section for more information on that.

5 - 9 years

This age group is eligible for either the injectable or nasal vaccine. If they have wheezing in the past 12 months you will need to discuss with your doctor or nurse if they should get the nasal FluMist. Since the FluMist is a live virus, it is possible that it can trigger wheezing. My personal recommendation is if the child prefers the nasal spray over the shot and the parent is able to handle any wheezing that might happen, the nasal vaccine is okay. If the child tends to have severe wheezing that is difficult to control or needs oral steroids often, it is not recommended to risk the mist. Most children do not report wheezing after the FluMist, but it is always a possibility.  

Children under 9 years of age who have not had two flu vaccines of the same strain (generally in the same season) will need two doses for full protection. See the 6 months - 2 years section for more information.

10+ years

This age group is also eligible for either the injectable or nasal vaccine. If they have asthma or recent wheezing, you will need to discuss with your doctor or nurse if they should get the nasal FluMist. Since the FluMist is a live virus, it is possible that it can trigger wheezing. My recommendation is usually if the child or teen prefers the nasal spray over the shot and the parent (or older child) is able to handle any wheezing that might happen, the nasal vaccine is okay. If there is a history of severe wheezing I do not recommend the mist. Most people do not report wheezing after the FluMist, but it is always a possibility.  

Only one dose of vaccine is required at this age, regardless of immunization history.

If you're more of a visual person, the following is from the CDC:

For those with egg allergies,  this is helpful guidance from the CDC. People with egg allergy may tolerate egg in baked products but that does not eliminate the risk of vaccine reaction. If children have never eaten egg but previously performed allergy testing shows probable egg allergy talk to your doctor before vaccination.