“When I heard this, I tore my tunic and cloak, pulled hair from my head and beard and sat down appalled…then, at the evening sacrifice, I rose from my self-abasement,” wrote Ezra, a scribe and priest of biblical fame (Ezra 9.1-13). The Israelites, forsaking holy commands, were intermarrying their sons and daughters with people from a “land polluted by corruption,” and Ezra, distraught by their sins, felt “too ashamed and disgraced” to lift his face to God.

Early references to hair-pulling due to psychological distress include Aristotle, who wrote of the “morbid state” of those who pluck out their hair and gnaw at their nails (Nicomachean Ethics), and Hippocrates, who described a woman with periodic fevers who plucked and picked at her hair (Epidemics III.)

“Tearing our hair out,” with examples from Homer to Shakespeare (Kim, 2014; Waas and Yesudian, 2018), is a common expression of frustration, exasperation, grief, or even madness that has persisted throughout the centuries.

There are those, however, who suffer from a compulsive urge to pull out their hair. It was 19th-century French dermatologist François Henri Hallopeau who first coined the term trichotillomania (Altmeyer, 2023; Hallopeau, 1899.) Hallopeau described a young man who developed alopecia per grattage—alopecia from scratching. His patient pulled out clumps of hair from his entire body, including his head, beard, pubic hair, eyebrows, and eyelashes, creating “artificially-induced” alopecia.

Trichotillomania, characterized by recurrent, irresistible hair-pulling, is a “psychiatric disorder with dermatologic consequences” (Ghani et al, 2024). It is part of the relatively new multidisciplinary field of psychodermatology “that explores the intricate interplay between the mind and the skin” and aims to remove the stigma and shame often inherent in the symptoms.

The prevalence of psychiatric disorders with dermatological symptoms presenting to dermatologists is estimated to be up to 30% to 40% (Turk et al, 2022).

Trichotillomania is one of the disorders, including skin picking, cheek chewing, and nail-biting, described under the “umbrella term” of body-focused repetitive behaviors (Christensen and Jafferany, 2024; Grant et al., 2024; Okumus and Akdemir, 2023).

Though there is a continuum in severity, these disorders may lead to significant physical damage (e.g., baldness, infection, severe skin excoriations) and psychosocial impairment (Odlaug and Grant, 2008). The prevalence “of clinically meaningful” body-focused repetitive behaviors varies between 0.5% and 4.4% (Okumus and Akdemir), but it may be considerably higher due to underreporting and failure to seek treatment (Malayala et al., 2021; Parsa et al., 2023).

Most, but not all studies, (Grant et al, 2023), indicate these behaviors are far more common in women (Odlaug and Grant). Trichotillomania often begins in adolescence (Odlaug and Grant) but can appear during childhood (Torales et al, 2021). Hair plucking most commonly occurs on the scalp, but like Hallopeau’s patient, it can involve any body part........

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