Treatment for Body-Focused Repetitive Behaviors (BFRB)
Habit reversal training (HRT) is the first-line treatment for all body-focused repetitive behaviors, including trichotillomania (hair pulling), excoriation disorder (skin picking), nail biting, and other repetitive behaviors. 1, 2
Primary Treatment: Habit Reversal Training
Deliver 10-20 sessions of HRT as the foundational intervention for BFRB. 1, 2 This behavioral therapy consists of two essential components:
Core Components of HRT
- Awareness training: Teach patients to identify specific triggers, situations, and early warning signs that precede the repetitive behavior episodes 1, 2
- Competing response training: Train patients to practice alternative behaviors when the urge to engage in the BFRB emerges 1, 2
- HRT can be delivered in-person or via internet-based protocols with equivalent effectiveness 2
- Patient adherence to between-session homework exercises is the single most robust predictor of both short-term and long-term treatment success 2
Treatment Structure
- Individual or group formats are both effective 2
- HRT has demonstrated substantial efficacy across all BFRB subtypes including hair pulling, skin picking, nail biting, and chronic cheek biting 3
- One study showed 74% of patients achieving clinically significant improvement with large effect sizes (g = 2.04 for completers) 4
Pharmacotherapy Options
First-Line Medication
N-acetylcysteine (NAC) is the preferred first-line pharmacological treatment due to significant benefits and low side effect risk. 1, 2
- Dose: 1200-2400 mg daily 1
- Three out of five randomized controlled trials demonstrated superiority to placebo 1, 2
- NAC can be combined with HRT for moderate-to-severe symptoms or when patients prefer a combined approach 1
Second-Line Medications
SSRIs (fluoxetine, escitalopram) have demonstrated improvement in BFRBs, but require higher doses than typically used for depression. 1
- Allow at least 8-12 weeks at maximum tolerated dose before declaring treatment failure 1, 2
- Clomipramine requires the same 8-12 week trial at maximum tolerated dose 2
- Monitor for serious adverse effects with clomipramine including seizures, cardiac arrhythmias, and serotonin syndrome, especially when combined with other serotonergic agents 2
Treatment Algorithm
Start with HRT alone (10-20 sessions) if the patient is motivated for behavioral therapy and has no severe comorbidities requiring immediate medication. 1
Start with N-acetylcysteine plus HRT if:
- Moderate-to-severe symptoms are present 1
- Patient prefers combined approach 1
- Initial HRT alone shows insufficient response 1
Add or switch to SSRIs if:
- NAC plus HRT combination fails after adequate trial 1
- Significant comorbid depression or anxiety requires treatment 1
Maintenance and Relapse Prevention
Continue successful interventions for at least 12-24 months after achieving remission, given the chronic, fluctuating nature of BFRBs. 1, 2
- Develop a relapse prevention plan identifying triggers, warning signs, and specific action steps 1, 2
- Consider monthly booster CBT sessions for 3-6 months after acute response to prevent relapse 1
- Monitor for medical complications including infection, scarring, and tissue damage 1
- Screen for emergence or worsening of depression, anxiety, and suicidal ideation 1
Important Clinical Considerations
Do not prematurely discontinue medication trials before completing 8-12 weeks at maximum tolerated dose. 2 This is a common pitfall that leads to unnecessary medication switching.
If using antipsychotics (off-label), monitor metabolic parameters including weight, glucose, and lipids, and assess for serotonin syndrome if combining serotonergic medications. 1
Most patients with BFRBs are unlikely to seek mental health treatment and instead present to dermatology clinics due to cosmetic damage. 5 Dermatologists should be prepared to offer basic HRT or refer appropriately.
BFRBs can be reliably assessed as part of the tic spectrum rather than exclusively as obsessive-compulsive spectrum disorders. 4 This conceptualization informs the focus on tension and emotional buildup preceding the behaviors rather than treating them as purely compulsive acts.