Hair-Pulling Disorder Hits Minorities Harder, and Science Is Only Now Catching Up

Trichotillomania, a disorder marked by compulsive hair-pulling, has long been treated in clinics as if it looks the same in everyone. A new narrative review published in the Archives of Dermatological Research argues that this assumption has quietly shaped decades of misdiagnosis and undertreatment, particularly for Black, Asian, and Hispanic and Latino patients whose hair, culture, and experiences of psychiatric care differ in ways that standard diagnostic tools and therapies were never designed to capture.

The condition belongs to a family of body-focused repetitive behaviors and sits within the obsessive-compulsive spectrum of the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition. Pulling typically begins in adolescence and can consume minutes to hours each day, most often targeting the scalp, eyebrows, and eyelashes, though pubic and perirectal regions may also be involved. The visible consequences feed shame and erode self-esteem, and most people who live with the disorder never seek treatment at all, which helps drive its chronic course. Even when patients do present, clinician unfamiliarity frequently delays diagnosis, and the absence of established treatment guidelines leaves providers improvising.

How common the disorder actually is remains surprisingly contested. A 2023 online panel study of 1,481 people led by Stefan Moritz and colleagues estimated a prevalence of 2.5 percent, while a 2025 analysis of 844,490 participants in the United States All of Us database reported a dramatically lower figure of 0.04 percent. Sex distribution is similarly unsettled, with some studies suggesting comparable rates in males and females and others showing a clear female predominance. Racial and ethnic patterns are just as inconsistent: Moritz’s team found higher rates of body-focused repetitive behaviors among White participants, whereas an earlier study of 635 college students reported roughly equal prevalence, about 2 percent, between African American and non-African American respondents.

What is far more consistent is the psychiatric burden. Large cohorts confirm that trichotillomania travels with depressive, anxiety, and personality disorders, and Swedish national register data show most adults diagnosed with the condition carry at least one additional psychiatric diagnosis. These patterns hold across minority groups: researchers have documented significant correlations between anxiety and hair-pulling in African American samples, including a positive relationship between pulling severity and anxiety symptoms among African American women. Yet a study of 539 adults with body-focused repetitive behaviors found that although symptom severity and comorbidities were comparable across racial and ethnic groups, Black, Asian, and other minority ethnic participants spent more time pulling than White participants, a disparity that hints at unmeasured cultural and contextual drivers.

Culture is precisely where the review’s authors, a team from Baylor College of Medicine led by Nisa Ilsin and Oyetewa Asempa, concentrate their argument. Hair carries profound meaning in many communities, and in Black communities especially it is intertwined with identity, self-worth, and belonging. The authors trace this weight through a painful history: because Black hair differs physically from straight hair, it was long altered with heat and chemicals to fit a White standard of attractiveness and to blunt discrimination, while in the twentieth century the rejection of straightening became an act of empowerment and resistance. That legacy built a thriving hair-care industry and rituals, from salon visits to braiding appointments, that remain central to community life. When hair-pulling destroys the very hair around which identity is organized, the emotional fallout is amplified, and African American women with strong positive racial identification report feeling less relief after pulling because the behavior feels incongruent with who they understand themselves to be.

Those cultural dynamics also reshape the clinical picture. Minority patients are more likely to report heightened anxiety before pulling episodes, and although the scalp is the most common pulling site across all groups, minority patients are less likely than White counterparts to pull from the eyelashes or eyebrows. Such differences matter enormously for diagnosis, because clinicians trained on majority-population presentations may simply fail to recognize the disorder when it looks different.

Diagnostic technology carries its own blind spots. Trichoscopy, the dermatoscopic examination of hair and scalp, reliably identifies trichotillomania through characteristic findings such as trichoptilosis, hook hairs, V-signs, flame hairs, coiled hairs, tulip hairs, and hair powder. But the studies that defined these markers were conducted almost exclusively in White populations with light skin types. In Asian patients, exclamation mark hairs, typically considered a signature of alopecia areata rather than trichotillomania, appeared in 26 percent of cases versus 14 percent in White populations, plausibly because Asian hair’s greater tensile strength allows more stretching under mechanical pulling. Black dots, another recognized marker, were also more frequent in Asian patients, likely due to greater hair-to-skin contrast. Similar nuances appear elsewhere: North Indian patients with alopecia areata show lower rates of yellow dots than the classic literature describes. Without recalibrated criteria for diverse populations, the review warns, diagnostic delays will persist.

Treatment access is where the inequities become starkest. Despite spending more time on their behaviors, minority patients in the 539-person study were significantly less likely to receive treatment or be prescribed medication. White individuals were more likely to seek care than African American and Hispanic or Latino individuals, reflecting a well-documented pattern of reduced psychiatric service use compounded by cultural stigma, limited access to specialized care, and systemic barriers. Among Hispanic and Latino adults, an international survey of 166 people with trichotillomania found treatment-seeking rates higher than typically reported for minority populations, yet participants still cited shortages of knowledgeable mental health professionals, low community awareness, financial constraints, and shame or fear of judgment. A case report of a Hispanic woman who delayed disclosing her diagnosis for fear of community judgment illustrates how those barriers operate in a single life. In Asian populations, data are scarce, but a Singaporean case series suggested the condition goes under-reported because of embarrassment among children and parents, worsened by cultural expectations of perfectionism in which scolding for symptoms increased stress and intensified pulling.

The therapies themselves carry a majority-group imprint. Behavioral treatment, particularly habit-reversal training, remains the mainstay, with no first-line medication established, though N-acetylcysteine, olanzapine, clomipramine, and naltrexone have shown promise in trials. The newer Comprehensive Behavioral model individualizes treatment around pulling triggers, and an online survey found that when treatment was accessible, minority and majority patients reported similar perceived improvement. But a randomized trial analysis by Falkenstein and colleagues found web-based self-help benefited minority participants less than majority participants, while in-person behavioral therapy produced comparable response rates, a signal that culturally loaded delivery formats matter. The most promising culturally responsive model is Acceptance-Enhanced Behavior Therapy, which fuses habit-reversal training with emotional regulation, dialectical behavior therapy, acceptance and commitment therapy, and psychoeducation; it succeeded in the Hispanic case report precisely because it integrated the patient’s cultural and community values, though its long-term trial struggled to recruit minority participants, limiting generalizability.

The review’s conclusion is a call to rebuild the evidence base from the ground up. The authors urge multidisciplinary care spanning dermatology, psychiatry, and psychology, education for hairdressers, who occupy a uniquely trusted position to recognize pulling damage and encourage treatment, and a decisive move away from one-size-fits-all frameworks toward therapies that incorporate each patient’s heritage. Until studies recruit representative samples and trichoscopic criteria are validated across skin tones and hair types, they argue, a disorder that disfigures and distresses millions will continue to be underdiagnosed and undertreated in exactly the communities where its cultural toll runs deepest.

Subject of Research: Disparities in the presentation, diagnosis, and treatment of trichotillomania among ethnic and racial minority groups

Article Title: Trichotillomania in ethnic and racial minority groups: a narrative review

Article References: Ilsin, N., Catinis, A., Montejano, D., Okwara, C., Smith, M., & Asempa, O. (2026). Trichotillomania in ethnic and racial minority groups: a narrative review. Archives of Dermatological Research, 318(1), Article 528. https://doi.org/10.1007/s00403-026-04835-w

Image Credits: AI Generated

DOI: 10.1007/s00403-026-04835-w

Keywords: trichotillomania, body-focused repetitive behaviors, health disparities, minority health, trichoscopy, hair-pulling disorder, cultural psychiatry, habit-reversal training, dermatology, mental health stigma, behavioral therapy, health equity