When do you consider the use of N-acetylcysteine (NAC) in patients with trichotillomania?

Great question! NAC comes up frequently in clinical discussions of trichotillomania, and it's worth being clear-eyed about what we actually know.

NAC restores extrasynaptic glutamate homeostasis via the cystine-glutamate antiporter (system Xc⁻), which increases tonic activation of presynaptic mGluR2...

Generally speaking, there is no FDA-approved medication available to date for the treatment of trichotillomania. Various case reports have shown variable benefits with SSRIs, SNRIs, TCAs, and antipsychotics. However, Habit reversal therapy (HRT) is the gold standard for the treatment. N-Acetylcystei...

Consider using memantine, which is well-tolerated and has evidence. I've used it successfully (Grant et al., PMID 36856701).

NAC is usually the go-to, but it doesn't always work, and apparently, it doesn't taste good. I've had memantine work as monotherapy for skin excoriation disorder or trichotillo...

I completely agree with Dr. @Dr. First Last above. If patients have not benefited from targeted psychotherapy or have logistical hurdles to engaging in the therapy (cost, time, availability, motivation), then a trial of an SSRI or SNRI is worthwhile. I frequently will add N-acetylcysteine to the med...

I’ve also had some meaningful success with cariprazine. Obviously, informed consent needs to be obtained, including that this is off-label and the risks with all SGA’s and akathisia, in particular here. I’ll also note I didn’t use this exclusively for the trichotillomania, so that the risk/benefit r...