Written using peer-reviewed research including Farhat et al. (2023, Journal of Psychiatric Research), Thomson et al. (2022, Journal of Psychiatric Research), Snorrason et al. (2012, Clinical Psychology Review), Grant et al. (2021, Journal of Psychiatric Research), Grant et al. (2016, JAMA Psychiatry), and Grant et al. (2023, American Journal of Psychiatry), alongside guidance from the TLC Foundation for BFRBs.
If you pull your hair out, that's trichotillomania. If you pick at your skin, that's dermatillomania. The words themselves carry the whole distinction, and most pages that rank for this comparison spend two thousand words getting to a point you already knew before you searched.
The question worth answering is the one underneath: now that you know which word applies, what changes?
Less than you'd expect, and more than nothing. The two conditions share a diagnostic chapter, a mechanism, and a first-line treatment. Five specific things do differ, and each one changes what you should actually do next. There's also a third group that comparison tables tend to skip, which is people who do both, and it's larger than either pillar page suggests.
Side by Side
| Dermatillomania | Trichotillomania | |
|---|---|---|
| Also called | Excoriation disorder, skin picking disorder, SPD | Hair pulling disorder, trich, HPD |
| The behavior | Picking at skin until it's damaged | Pulling out hair until it's lost |
| DSM-5 chapter | Obsessive-Compulsive and Related Disorders | The same chapter, two entries apart |
| Population prevalence | 3.45% | 1.14% |
| Female-to-male odds ratio | 1.45 (statistically significant) | 1.29 (not statistically significant) |
| Typical onset | Adolescence, often on the back of acne | Ages 10 to 13 |
| Most common site | The face | Scalp first, then eyebrows and eyelashes |
| What sets an episode off | Something you can see or feel: a bump, a scab, a rough patch | A hair that feels wrong: coarse, gray, wrong at the root |
| Role of the mirror | Central. Examining skin is one of the top triggers | Minor. The hand usually finds it before the eyes do |
| Main physical risk | Infection and permanent scarring | Follicle damage, and trichobezoar if the hair is swallowed |
| Ruled out first | Primary skin disease | Other causes of hair loss: alopecia areata, tinea, telogen effluvium |
| First-line treatment | Habit reversal training | Habit reversal training |
| Best medication evidence | NAC, 47% improved vs 19% on placebo | NAC, 56% vs 16% in adults, no benefit in children |
| Hardest part to conceal | Facial damage, visible daily | Eyelashes and eyebrows |
Read the shared rows first. There are more of them than the differing ones, and they're the reason the two conditions are usually studied, funded, and treated as a pair.
What's Identical, and It's Most of It
Both conditions sit in the same DSM-5 chapter, alongside OCD and body dysmorphic disorder. Both belong to the family called body-focused repetitive behaviors, which also includes nail biting and cheek chewing. Both are grooming behaviors that stopped being grooming.
The mechanism is the same in the part that matters. The behavior gives short-term relief from something uncomfortable, that relief teaches the brain to repeat it, and the repetition outlasts anyone's ability to decide their way out of it. Both diagnoses require that you've tried to stop and haven't been able to. That criterion is doing the heavy lifting in both definitions.
The treatment core is the same too. Habit reversal training is first-line for both, with the largest effect sizes in both literatures, and the same four components: catching the behavior, doing something incompatible with it, changing the environment that cues it, and having someone know you're working on it.
If what you actually want is the full picture of one condition rather than the comparison, the two foundational guides cover them properly: what dermatillomania is and what trichotillomania is. Neither is summarized here, on purpose.
Where the Difference Actually Changes Something
1. What starts an episode
Skin picking usually needs a physical starting point. A spot, a scab, a rough patch, a bump you can feel through your fingertip. The skin supplies a target, and the picking has a stated goal, which is to fix or remove the thing. Examining your own skin is one of the highest-frequency triggers recorded in the research.
Hair pulling more often starts with a hair that feels wrong rather than one that looks wrong. Coarse, gray, kinked, sitting at an odd angle. People find it by touch, often while doing something else entirely, and the goal is to remove that particular hair rather than to fix a visible flaw.
That difference has a practical consequence. Skin picking often has an outside supply problem: acne, eczema, dry skin, or a healing wound keeps generating new targets, which is why treating the underlying skin condition is part of the behavioral work rather than separate from it. Hair pulling doesn't have an equivalent supply to switch off.
2. What a doctor has to rule out first
Both diagnoses require ruling out a medical explanation, but they send you to different appointments.
Missing hair has a substantial differential. Alopecia areata, tinea capitis, and telogen effluvium all cause hair loss and none of them involve pulling. That's why so many people with trichotillomania see a dermatologist before they ever see a therapist, and why telling hair pulling apart from alopecia areata is its own subject with its own diagnostic signs.
Damaged skin has a shorter differential but a more urgent one. Open wounds get infected. The signs to act on are increasing redness, swelling, warmth, pus, red streaks spreading from the wound, or fever.
3. Which environment changes work
Stimulus control is a named component of habit reversal training, and it's the component where the two conditions diverge most.
For picking, the highest-impact changes are visual and tool-based. Covering or removing magnifying mirrors. Dimming bathroom lighting so pores stop announcing themselves. Moving tweezers and pins somewhere inconvenient. Keeping nails short. Hydrocolloid patches over the spots you keep returning to.
For pulling, the changes are tactile and hand-based. Something on the fingertips. A bandana or a close-fitting hat. Shorter hair. A stress ball or fidget object within reach of the chair where it usually happens.
Applying the wrong list is a common and quietly demoralizing failure. Removing every mirror in the house does very little for someone who pulls with their eyes closed, and it can look like proof that nothing works. The step-by-step versions are separated for this reason: HRT for skin picking and HRT for hair pulling.
4. What the damage does over time
Skin picking scars. That's the durable cost, and it accumulates from the wound stage onward, which is why interrupting healing is treated as part of the behavior rather than a side effect of it. Infection risk is ongoing rather than one-off.
Hair usually grows back, but not always, and the uncertainty is its own weight. Repeated pulling can permanently damage hair growth and quality in some people, and nobody can tell you in advance which group you're in. The other cost is concealment: hats, partings, powders, scarves, false lashes, and the plans quietly declined to avoid needing any of it.
Neither is heavier than the other. They're different shapes, and the shape determines what recovery feels like. For picking, progress shows up as fewer new wounds and old ones finally closing. For pulling, it shows up weeks later as regrowth, which means the first stretch of real progress is invisible.
5. Who it shows up in
Skin picking is roughly three times more common. Two meta-analyses from the same research group, using comparable methods, put it at 3.45% of the general population against 1.14% for trichotillomania.
The gender picture is where popular pages get it most wrong. You'll read that these conditions are overwhelmingly female, usually citing ratios like 9 to 1. Those figures come from clinic attendees and self-report, not from population samples.
So skin picking does lean female, by a real but modest margin. Trichotillomania's tilt didn't reach significance in population samples at all. Neither comes close to the ratios repeated on most pages. If you're a man who has quietly concluded from those numbers that this isn't your condition, the population data doesn't support that conclusion.
When It's Both
This is the group the comparison tables leave out, and it isn't a rounding error.
In a four-site study of 279 adults using structured diagnostic interviews, 100 met criteria for trichotillomania, 81 for skin picking disorder, and 40 met full DSM-5 criteria for both. In a separate survey of 455 people with body-focused repetitive behaviors, 28.9% reported picking, 39.3% reported pulling, and 30.7% reported both.
If you do both, that's the most-populated column on the board, not evidence that something unusual is going on.
Doing both changes three practical things.
It changes what you tell a clinician. Assessment for one BFRB doesn't automatically include the others, and treating one while ignoring the other tends to leave both in place. Say both out loud in the first appointment.
It changes what you track. The behaviors usually share triggers even when they don't share body parts, so splitting them into two separate records hides the pattern that would have been visible in one. Snorrason and colleagues found that when multiple body-focused behaviors co-occur in the same person, they tend to cluster around the same body area.
It changes which techniques you lean on. Habit reversal training holds up across both behaviors, which makes it the sensible spine when you're treating two at once. The environment changes still have to be built separately, because a mirror does nothing to a hand in your hair.
SkinAware, which publishes this site, lets you select more than one behavior rather than committing to a lane, so picking and pulling land in the same timeline and the app's language adapts to both. If you'd rather compare options first, the roundup of BFRB apps covers the alternatives, including the free ones.
One timeline for both behaviors
SkinAware logs episodes and resisted urges for skin picking, hair pulling and nail biting, and teaches habit reversal training module by module. Pick more than one, and it adapts.
Where to Go Next
If you pick your skin, start with the guide to dermatillomania, then the practical guide to stopping.
If you pull your hair, start with the guide to trichotillomania, then the practical guide to stopping.
If you do both, read the one that's costing you more right now, and mention both when you talk to anyone clinical.
Frequently Asked Questions
Yes, and it's common. In a four-site study of 279 adults, 40 met full DSM-5 criteria for both conditions. In one survey of people with body-focused repetitive behaviors, 30.7% reported doing both. They're diagnosed separately, and both should be assessed rather than assuming the more obvious one is the whole picture.
Neither is inherently more severe. They carry different risks. Skin picking carries infection and permanent scarring. Hair pulling carries possible permanent follicle damage, and a rare but serious risk of intestinal blockage in people who swallow the hair. Severity within each condition varies far more than severity between them.
No. They sit in the same DSM-5 chapter as OCD, which is not the same as being OCD. OCD compulsions are performed to neutralize an intrusive thought or prevent a feared outcome. Picking and pulling aren't structured that way, and many people describe them as relieving or pleasurable in the moment, which is unusual for an OCD compulsion.
The core does. Habit reversal training is first-line for both and has the strongest evidence in both literatures. The stimulus control component has to be built separately, because the environmental cues are different. Medication evidence also overlaps: N-acetylcysteine has positive randomized trials in both adult populations, and a 2023 memantine trial enrolled people with either condition or both.
Skin picking, by roughly three to one. A 2023 meta-analysis put skin picking disorder at 3.45% of the general population; a 2022 meta-analysis from the same group put trichotillomania at 1.14%.
Because the two behaviors share more than they differ, including triggers and the relief they provide. Research on people with several body-focused behaviors found they tend to cluster around the same body area. Switching between them, or trading one for the other during a stretch when you're actively resisting, is a documented pattern rather than a sign of anything unusual.
No. A therapist trained in body-focused repetitive behaviors treats both. The International OCD Foundation (iocdf.org), which now hosts the TLC Foundation's BFRB resources, maintains a directory, which is a shorter path than searching general therapy listings and hoping.
Continue Reading
References
- Farhat LC, Reid M, Bloch MH, Olfson E. Prevalence and gender distribution of excoriation (skin-picking) disorder: A systematic review and meta-analysis. Journal of Psychiatric Research. 2023;161:412-418.
- Thomson H, Farhat LC, Olfson E, et al. Prevalence and gender distribution of trichotillomania: A systematic review and meta-analysis. Journal of Psychiatric Research. 2022;153:73-81.
- Snorrason I, Belleau EL, Woods DW. How related are hair pulling disorder (trichotillomania) and skin picking disorder? A review of evidence for comorbidity, similarities and shared etiology. Clinical Psychology Review. 2012;32(7):618-629.
- Snorrason I, Ricketts EJ, Flessner CA, et al. Skin picking disorder is associated with other body-focused repetitive behaviors: findings from an internet study. Annals of Clinical Psychiatry. 2012;24(4):292-299.
- Grant JE, Chamberlain SR, Redden SA, et al. Identifying subtypes of trichotillomania and excoriation disorder using mixture modeling in a multicenter sample. Journal of Psychiatric Research. 2021;137:603-612.
- Grant JE, Chamberlain SR, Redden SA, Leppink EW, Odlaug BL, Kim SW. N-Acetylcysteine in the Treatment of Excoriation Disorder: A Randomized Clinical Trial. JAMA Psychiatry. 2016;73(5):490-496.
- Grant JE, Odlaug BL, Kim SW. N-acetylcysteine, a glutamate modulator, in the treatment of trichotillomania. Archives of General Psychiatry. 2009;66(7):756-763.
- Grant JE, Chamberlain SR. Prevalence of skin picking (excoriation) disorder. Journal of Psychiatric Research. 2020;130:57-60.
- Pathoulas JT, Olson SJ, Idnani A, Farah RS, Hordinsky MK, Widge AS. Cross-sectional survey examining skin picking and hair pulling disorders during the COVID-19 pandemic. Journal of the American Academy of Dermatology. 2021;84(3):771-773.
Last updated: July 2026