This chapter extends the discussion of trichotillomania (TTM) beyond the fourth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) definition and describes the clinical approach to diagnosis and management of all hair pullers who may present in a dermatology or primary care outpatient setting. In most cases, patients with TTM present with a patchy alopecia of the scalp. The crown of the scalp is frequently involved, and significant loss in this distribution with maintenance of hair in the occiput is known as the Friar Tuck sign. In many cases, biopsy can aid in the diagnosis of TTM. Child hair pullers have a better prognosis and generally respond to more conservative measures. Adult hair pullers without insight create a unique challenge for the practitioner. Treatment for adult hair pullers includes both cognitive behavioral and pharmacologic therapy.