Nail biting, skin picking and hair pulling: what BFRBs have in common

One family, three familiar habits

Body-focused repetitive behaviours, often shortened to BFRBs, are a group of recurrent behaviours directed at your own body. A 2013 review by Roberts and colleagues names the three most common: hair pulling, skin picking and nail biting. People who live with them report diminished control over the behaviour, along with physical and psychological consequences. Naming the family is not a diagnosis. It explains why the same urge can move from nails to skin or hair, and why the same methods tend to help.

Hair pulling: trichotillomania

The NHS describes trichotillomania, also called trich, as being unable to resist the urge to pull out your hair, from the scalp or from places such as the eyebrows, eyelashes or beard. It usually starts between the ages of 10 and 13. People feel an intense urge and growing tension until they pull, then a sense of relief. A 2016 review by Grant and Chamberlain describes repetitive pulling that leads to hair loss and functional impairment, with point prevalence estimates of 0.5% to 2.0% in community studies.

Skin picking: dermatillomania

Skin picking disorder is also called dermatillomania or excoriation disorder. The NHS notes that most people pick at their skin from time to time, and lists signs that it has become a disorder: not being able to stop, causing cuts, bleeding or bruising, picking moles, spots or scars to try to smooth them, not always realising you are doing it, and picking when anxious or stressed. A 2012 review by Grant and colleagues reported community prevalence estimates between 1.4% and 5.4%.

Where nail biting sits

Nail biting, or onychophagia, is the most familiar member of the family. A 2016 review by Halteh and colleagues describes habitual nail biting as affecting 20 to 30% of the population, across all age groups. It can lead to psychosocial problems, a lower quality of life and complications for the nails and the mouth.

What they have in common

In a 2012 review, Snorrason and colleagues examined how closely hair pulling and skin picking are related. The evidence suggests that the two co-occur more often than chance would predict, share substantial similarities in how symptoms present and how they evolve over time, and may have some risk factors in common, such as genetic vulnerabilities. In practice, it is common to have more than one of these behaviours.

Tension, relief and autopilot

The NHS notes that hair pulling may happen in response to a stressful situation, or without really thinking about it. Its list of triggers for skin picking includes boredom, stress or anxiety, negative emotions such as guilt or shame, and skin conditions such as acne or eczema. Many researchers describe these behaviours as a way of regulating emotions, which is the main model examined in the review by Roberts and colleagues. Both modes matter: a plan needs to cover the tense moments and the absent-minded ones.

Related to OCD, but not the same

Trichotillomania was grouped with obsessive-compulsive disorder (OCD) in the DSM-5, and the NHS describes skin picking disorder as related to OCD. Grant and Chamberlain caution that trichotillomania and OCD may have less in common than originally thought: the treatments that help are quite different, and some first-line treatments for OCD appear ineffective for trichotillomania. The NHS states that antidepressants are not usually prescribed to treat trich. This is one reason to ask for an assessment rather than assume that advice written for OCD applies.

The approach with the most support: habit reversal

For both conditions, the NHS points to cognitive behavioural therapy, including a technique called habit reversal training. For hair pulling, treatment usually involves keeping a diary, working out the triggers and how to avoid them, replacing pulling with another action such as squeezing a stress ball, and support from loved ones. For skin picking, it means becoming more aware of the behaviour and its triggers, then replacing it with something less harmful. The same method is used for nail biting.

Medication is a conversation for a doctor

Grant and Chamberlain list medication, such as N-acetylcysteine or olanzapine, among the approaches to trichotillomania alongside habit reversal. For skin picking disorder, Grant and colleagues mention serotonin reuptake inhibitors, N-acetylcysteine or naltrexone alongside cognitive behavioural therapy. The NHS adds that medicines for skin picking are more often prescribed by a specialist than by a GP. None of this is a reason to start a medicine or a supplement on your own. It is a list of questions to bring to a doctor.

Things you can try yourself

The NHS collects practical tips. For hair pulling: squeeze a stress ball, clench your fist and tighten the muscles of that arm, use a fidget toy, wear a bandana or a close-fitting hat, put plasters on your fingertips, or cut your hair short. For skin picking: keep your hands busy, wear gloves, keep your nails trimmed, keep tweezers and pins out of easy reach, apply moisturiser when the urge comes, and try to resist a little longer each time. For nail biting, the same logic applies: make the behaviour harder and give your hands another job.

Record the pattern, not just the count

The NHS advice for skin picking is to identify when and where you most commonly pick. A useful entry is short: the time, the place, what you were doing, how you felt, which behaviour it was, and what you did instead. After a week or two, look for the moments that keep coming back, such as screen time, reading or the evening in front of the bathroom mirror, and prepare a response for each.

When to see a doctor

The NHS advises seeing a GP if you are pulling your hair out, or notice that your child is, and especially if hair is being eaten, since swallowed hair can form hairballs in the stomach and lead to serious illness. For skin picking, see a GP if you cannot stop, if you are causing serious damage such as cuts that do not heal within a few days, or if it is causing you emotional distress or affecting your daily life. The same applies to nail biting that damages the skin or becomes infected.

Hiding it can make things harder

The NHS notes that trich may cause feelings of shame and low self-esteem, and that people often try to keep it to themselves. Opening up to people you trust can help, as hiding it can sometimes make anxiety worse, and many people who have learned to manage trich say that talking about it led to less pulling. The same advice appears for skin picking: tell other people, since they can help you notice when you are doing it. These are habits with a name, not a flaw in your character.

Where NailSafe fits

NailSafe is built for nail biting. Its quick log records which finger, the situation, such as screen time, a meeting, boredom or stress, and whether you resisted or bit, so your pattern becomes visible over time. Desk Mode, with your iPhone propped up and the front camera active, can signal when your hand stays near your mouth, and a short SOS routine gives you something to do once you notice an urge. The app does not track hair pulling or skin picking elsewhere on the body, and it is not a treatment for trichotillomania or skin picking disorder. Its Learn section describes nail biting as part of this family and links to the NHS pages on both conditions.

Further reading

• NHS · Trichotillomania (hair pulling disorder)
• NHS · Skin picking disorder
• Roberts, O’Connor & Bélanger (2013), Emotion regulation and other psychological models for body-focused repetitive behaviors, Clinical Psychology Review
• Grant & Chamberlain (2016), Trichotillomania, American Journal of Psychiatry
• Grant, Odlaug, Chamberlain, Keuthen, Lochner & Stein (2012), Skin picking disorder, American Journal of Psychiatry
• Snorrason, Belleau & Woods (2012), How related are hair pulling disorder (trichotillomania) and skin picking disorder? A review of evidence for comorbidity, similarities and shared etiology, Clinical Psychology Review
• Halteh, Scher & Lipner (2017), Onychophagia: a nail-biting conundrum for physicians, Journal of Dermatological Treatment