A family presented complaining of hair loss in their daughter, aged 11 years. The hair loss has been occurring for approximately a year and a half. The girl has had recurrent episodes of similar hair loss, and after each episode, the parents inspected her room and bathroom and never found any shed hairs. The parents reported that their daughter has never had a perfectly bald patch. Scalp pain was reported in the affected areas.
Initially, the girl was diagnosed with alopecia areata and underwent topical treatment. The girl’s parents disagree as to whether the treatment helped. A second clinician made a diagnosis of trichotillomania, which infuriated the family. The girl’s mother reported that the second clinician thought her daughter was “crazy.” The mother explained that she watches her daughter “like a hawk,” and she is “100% sure” that the hair loss is not self-induced. What’s your diagnosis?
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Trichotillomania is a relatively common impulse-control disorder that is characterized by the chronic compulsion to pull out one’s own hair. This compulsion, whether conscious or subconscious, may be a manifestation of obsessive-compulsive disorder or associated with anxiety or depression. However, trichotillomania frequently presents in the absence of another psychiatric comorbidity.
Trichotillomania most commonly presents between age 9 and 13 years but may be found in children as young as age 2 years as well as in adults. In younger children, boys and girls are equally affected. In older children and adults, females represent up to 93% of cases. The lifetime prevalence may be as high as 3.4% in females.
The scalp is the most commonly affected area, but the brows or eyelashes may be involved. Clinically, trichotillomania is characterized by the presence of a patch of alopecia in a bizarre configuration and with hairs of various lengths. The scalp may have a rough texture due to the broken off hairs. Unlike alopecia areata (and its variants), trichotillomania never results in a perfectly smooth and completely bald patch.
In trichotillomania, patients most commonly twirl several hairs around the finger and then pull. At times, patients utilize tweezers or shavers.
Individuals with trichotillomania often recount pain localized to a hair root that is relieved by plucking out the hair.
More than 50% of children will engage in such odd oral behaviors as rubbing or tickling their lips or nostrils with the hair. Additionally, up to 33% of patients will engage in trichophagy (hair eating), which may occasionally lead to intestinal obstruction.
The diagnosis of trichotillomania is based on the clinical appearance of a patch of alopecia associated with the following features:
- Bizarre configuration
- Irregular outline
- Hairs of varying lengths
- Rough-textured scalp
- Never completely bald
- “Pain” that is relieved by plucking the hair
The diagnosis is often not accepted by the patient or the family and is frequently met with denial, anger, and disbelief.
In difficult cases, a hair biopsy can be offered to help prove the diagnosis. Histologic features characteristic of trichotillomania are pigmented hair casts, empty hair follicles, and deformed hair follicles. Perifollicular inflammation is either absent or sparse.
Alopecia areata is an autoimmune condition in which lymphocytes attack the hair follicle leading to hair loss. Alopecia areata is characterized by the sudden appearance of one or more round well-circumscribed patches of nonscarring alopecia. The skin within the patch is smooth, soft, and almost entirely bald. The key histologic feature of alopecia areata is the “swarm of bees” appearance of lymphocytes around the hair bulb. Alopecia totalis and universalis are severe variants of alopecia areata. In alopecia totalis, the entire scalp is affected. In alopecia universalis, all hairy areas are affected (including eyebrows, eyelashes, pubic hair, etc.).
Treatment and prognosis
Treatment for trichotillomania includes behavior modification therapy, psychopharmacotherapy, hypnosis, and psychotherapy. Unfortunately, no specific treatment has been established as effective in any large controlled study.
In this case, a punch biopsy demonstrated features of trichotillomania. The family eventually accepted a referral to a child psychologist trained in impulse-control disorders.
Adam Rees, MD, is a graduate of the University of California Los Angeles School of Medicine and a resident in the Department of Dermatology at Baylor College of Medicine in Houston.
1. Bolognia J, Jorizzo JL and Rapini RP. Chapter 12: Alopecias. Dermatology. St. Louis, Mo.: Mosby/Elsevier, 2008.
2. James WD, Berger TG, Elston DM, Odom RB. Chapter 33: Diseases of the Skin Appendages. Andrews’ Diseases of the Skin: Clinical Dermatology. Philadelphia, Pa.: Saunders Elsevier, 2006.
3. Schachner LA, Hansen RC. Chapter 11: Hair disorders. Pediatric Dermatology. Edinburgh: Mosby/Elsevier, 2010.