Trichotillomania _0412 Derm Clinic
A teenage boy was referred to the dermatology clinic with a chief complaint of alopecia. His mother first noticed hair loss approximately six months ago.
The teenager had just entered high school and was nervous about doing well academically, according to his mother. No pain or pruritus was associated with the area of alopecia, and no OTC treatments had been tried. There was no family history of alopecia, and there are no pets in the household. Physical examination revealed an irregularly shaped area of alopecia with broken hairs throughout.
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Trichotillomania is derived from three Greek words: thrix (hair), tillein (pulling out) and mania (madness). The disorder is characterized by the irresistible urge to pull out hair from various regions of the body. The scalp, pubic regions, eyebrows and even eyelashes are primary targets for patients with trichotillomania.
The American Psychiatric Association (APA) classified trichotillomania as an impulse disorder; however, some in the psychiatry community have classified it as an obsessive-compulsive disorder.1 In the dermatologic world, trichotillomania is simply defined as self-induced plucking or breakage of the hair.
Trichotillomania may be caused by either a learned habit or psychiatric disorder. About 20% of people who have chronic hair-pulling issues do not fall into the APA classification, and these individuals have developed a learned behavior. Episodes of hair pulling occur throughout such activities as watching television, writing and reading.
Parents and teachers may be present during this time and distract the individual, which will cause cessation of the hair pulling activity. A successful episode of hair pulling will often occur just before the individual falls asleep. This is primarily attributable to the fact that a parent is not present to stop the episode and is often unaware that the child has developed the behavior.
From the psychiatric perspective, people with trichotillomania may be anxious and tense. Patients have reported feeling a great sense of tension just before the start of a hair-pulling episode. Afterward, they feel a pleasure sensation and a sense of calm. They may also be suffering from poor impulse control and unresolved subconscious anger. Patients with long-term trichotillomania may also have such behavioral disorders as thumb sucking, nail biting, cheek biting, acne picking, nose picking, poor social skills, poor family relations and a poor academic record.2
Some research shows the disorder to be very prevalent; as many as 1 in 200 persons have the disorder by age 18 years. Trichotillomania affects both sexes, although the female-to-male ratio is 5:1.3 Children are affected more commonly than adults, with the average age of onset for boys being 8 years and 12 years for girls.4
The most commonly affected area is the scalp, which results in a patchy alopecia. Within the scalp, the most commonly affected regions are the frontal, frontotemporal and frontoparietal areas. The occipital scalp tends to be spared, even in the most severe cases. Whether the alopecia is seen on the left or right side of the scalp depends on whether the individual is right or left handed, as the pattern is usually contralateral.5,6 Hence, if the patient is right-handed, he or she will likely pull hair from the left side.
A common technique an individual might use is to wrap multiple hairs around the finger in a twisting motion and pull them out simultaneously. The patient will usually start pulling hair in irregular patterns, centrifugally from a single starting point. The borders of the alopecia will be undefined and have unusual shapes. The plucking will most likely be incomplete, resulting in short and roughly fractured hair fibers.
Other areas of the body susceptible to hair plucking are the eyebrows, eyelashes, beard and pubic areas.7 When examining someone with trichotillomania, ask what he or she does with the plucked hair. Some patients have been known to consume the hair (trichophagy). This ingestion can cause intestinal obstruction, which may lead to severe illness and death.
Deformed and broken hair shafts are the histological hallmark of trichotillomania. Pigmented hair casts are another hallmark and are derived from the bulbar or hair-shaft melanin.7 The total number of hairs should remain normal, but the number of terminal catagen and/or telogen hairs will increase. A horizontal view of the biopsy will show distortion in the area where the rim of outer root sheath epithelium remains after the hair was forcefully pulled out. The follicle may be seen as partially avulsed rather than tightly anchored to the inner root sheath. On vertical sections, the hair canal will be seen as distorted in a spiral configuration. This distortion is likely caused by the twisting of the hair. No significant inflammation will be appreciated.
Diagnosing trichotillomania is fairly straightforward. If the disorder is suspected by visual observation of irregular alopecia, ask if the patient is pulling out the hair. If dealing with a child who does not admit to pulling out the hair, parents are recommended to observe the child during various time of the day. Some good times for observation are during reading time, while watching television, and when eating. Parents may also check their child’s bedroom, particularly under the pillow or mattress for clumps of hidden hair.
Other disorders that may be confused with trichotillomania are tinea capitis, alopecia areata and other nonscarring alopecias.2 Tinea capitis can be eliminated from the list by microscopic examination of the hair stubs and skin culture and biopsy.5 If the clinician is concerned about alopecia areata, history, physical examination and scalp biopsy may help confirm the diagnosis.
Treatment of trichotillomania is difficult due to the fact that 80% of patients may have an underlying psychiatric disorder, such as depression, anxiety or obsessive-compulsive disorder.2,5 Because of embarrassment of the disorder, the patient often does not seek treatment or delays treatment. Treatment should be a combination of tactics that individually target the different aspects of the disorder. Psychotherapy should target the obsessive-compulsive portion, while behavioral therapy should aim to break the habit and unlearn the behavior of pulling out the hair.6 Pharmacologic therapy has been tried and includes such medications as clomipramine (Anafranil) or a selective serotonin reuptake inhibitor.
Typically, the earlier the onset, the more likley the child will outgrow the behavior. Early detection is key, because it will stop the progression of the alopecia. If the onset of trichotillomania occurs in adulthood, the disorder is more likely to be chronic. Secondary infections caused by scratching, twisting and pulling the hair are very rare but may occur. Support groups are available for patients who suffer with trichotillomania.
This patient was referred for behavioral therapy and successfully broke the habit of pulling his hair.
Kerri Robbins, MD, is a resident in the Department of Dermatology at Baylor College of Medicine in Houston.
1. Stein DJ, Simeon D, Cohen LJ et al. “Trichotillomania and obsessive-compulsive disorder.” J Clin Psychiatry. 1995;56 Suppl 4:28-34.
2. Paller AS, Mancini AJ. Hurwitz Clinical Pediatric Dermatology. 3rd ed. Philadelphia, Pa.: Elsevier Saunders; 2006:159-163.
3. Greenberg H, Sarner C. “Trichotillomania – symptom and syndrome.” Arch Gen Psychiatry. 1965;12:482.
4. Messinger ML, Cheng TL. “Trichotillomania.” Pediatr Rev. 1999;20:249-50.
5. Bolognia JL, Jorizzo JL, Rapini RP eds. Dermatology. 2nd ed. St. Louis, Mo.: Elsevier-Mosby; 2008:111-112, 990-992.
6. Habif TP. Skin Disease: Diagnosis and Treatment. 2nd ed., Philadelphia, Pa.: Elsevier Mosby; 2005:524, 526-527.
7. RP Rapini. Practical Dermatopathology. Philadelphia, Pa.: Elsevier Mosby; 2005:145.
8. Christenson GA, Crow SJ. “The characterization and treatment of trichotillomania.” J Clin Psychiatry. 1996;57 Suppl 8:42-47.