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Proc (Bayl Univ Med Cent). 2005 July; 18(3): 269–272. | PMCID: PMC1200734 |
Copyright © 2005, Baylor University Medical Center A child with nonscarring alopecia J. Christian Cather, MD 1 and Jennifer Clay Cather, MD  11From the Department of Psychiatry, The University of Texas Southwestern Medical School (Christian Cather) and the Division of Dermatology, Department of Internal Medicine, Baylor University Medical Center (Jennifer Cather), Dallas, Texas. A 4-year-old girl presented in her usual state of good health except for two areas of alopecia (hair loss) involving the left parietal scalp (Figure ). The child was taking no medications and had no significant past medical history. Her hairstyling did not include repetitive, tight braids (Figure ). On physical examination, her scalp had no scaling or pustules. She had no palpable occipital lymphadenopathy. The result of a Wood's light examination was negative. What are the diagnosis and prognosis, and what are the treatment options? DIAGNOSIS: Trichotillomania. At least three times during the office visit, the patient reached up with her left hand and twirled and pulled at her hair at the site of involvement, confirming our clinical suspicion of trichotillomania. Patients with trichotillomania may present in the dermatology office but often require psychiatric intervention and co-management. This dermatologic disorder is one of several that have psychosocial aspects that must be addressed for full disease resolution. Trichotillomania was first described in 1889 by the French dermatologist François Henri Hallopeau ( 1). In 1987, almost a century later, it was recognized as a distinct disorder by the American Psychiatric Association ( 2). The lifetime prevalence is < 1 % if strict criteria from the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision (DSM-IV-TR) are applied ( 3). There is a female predominance ( 4). The scalp is the most common site of involvement; however, hair may be pulled from any area, including the eyelashes, eyebrows, legs, and pubic region ( 5). The disorder can begin in childhood, adolescence, or adulthood. One third of children with trichotillomania have onset before age 10. If hair pulling begins before age 8, the disorder is generally self-limited ( 4). Disease that begins in adolescence is usually chronic and is more likely to be associated with comorbid psychiatric disorders (depression, anxiety, obsessive-compulsive disorder, body dysmorphic disorder, eating disorders, and substance abuse) ( 2, 6). Adult onset is associated with a chronic course and poor prognosis for disease resolution. Two clinical subtypes of trichotillomania have been defined: automatic/sedentary and focused. The automatic/sedentary type is more common and is characterized as hair pulling while engaging in other activities. Patients are usually unaware that they are pulling their hair. In contrast, the focused type involves setting aside time and attention specifically for hair pulling. Prepulling tension is relieved after pulling ( 2, 7). Trichotillomania is listed in the DSM-IV-TR under “Impulse-Control Disorders Not Elsewhere Classified.” The DSM-IV-TR criteria include the following: - Recurrent pulling out of one's hair resulting in noticeable hair loss.
- An increasing sense of tension immediately before pulling out the hair or when attempting to resist the behavior.
- Pleasure, gratification, or relief when pulling out the hair.
- The disturbance is not better accounted for by another mental disorder and is not due to a general medical condition (e.g., a dermatological condition).
- The disturbance causes clinically significant distress or impair ment in social, occupational, or other important areas of functioning (8).
Controversy exists regarding these criteria because there is no distinction between children and adults. Children often do not meet DSM-IV-TR criteria because they do not have the tension/ relief component ( 9, 10). It has been suggested that trichotillomania be included under anxiety disorders because it shares some features of obsessive-compulsive disorder (e.g., compulsive urges and ritualistic behaviors) ( 11). A new diagnostic category, displacement activity disorder, has also been proposed that would include “nervous habits” such as trichotillomania, face picking, and nail biting ( 9, 12). Associations Children with trichotillomania have been described as “fiddlers” and obtain a calming effect from tactile stimulation via the fingertips. Pulling the hair of siblings, pets, dolls, and stuffed animals has also been reported ( 9). Family psychosocial stressors are present in many patients with trichotillomania. Commonly reported stressors include separation from a familiar object (e.g., moving to a new house) or person (e.g., when parents divorce), birth of a younger sibling (sibling rivalry), recent illness/hospitalization, school, and sexual abuse ( 9). Child abuse has also been associated with trichotillomania ( 13). Approximately 30% of patients with trichotillomania engage in trichophagia (eating hair) ( 2). In 1% of trichophagia patients, a trichobezoar develops that requires surgical removal ( 2). If the tail of the bezoar extends into the small intestine, numerous complications may occur, such as anemia, intestinal obstruction, intussusception, ulceration, and perforation ( 9). Differential diagnosis Alopecia is clinically and histologically categorized as scarring or nonscarring depending on whether or not hair follicles are destroyed. The scarring alopecias include diseases such as lupus erythematosus, lichen planopilaris, pseudopelade of Brocq, and folliculitis decalvans ( 14). The most common nonscarring alopecias include androgenetic alopecia (male-pattern baldness), telogen effluvium (e.g., associated with childbirth, thyroid disorders, drugs, or stress), alopecia areata, tinea capitis, traction alopecia, and alopecia caused by medication such as chemotherapy. Additionally, some alopecias can be nonscarring but in chronic cases can become scarring if interventional therapy is not successful for disease control (e.g., tinea capitis with secondary bacterial infection, trichotillomania). Diagnosis History and physical examination can establish the diagnosis of the most common nonscarring alopecias (Table). An appropriate hair loss workup can be quite expensive and may include thyroid function tests, fungal scrapings and culture, hair pull, a complete blood count, and antinuclear antibody titers. A scalp biopsy may be helpful in equivocal diagnoses; however, it is wise to refer the patient to a hair expert so the correct type of biopsy and the correct biopsy site are chosen. Additionally, clinicopathologic correlation is of the utmost importance; therefore, biopsies should be evaluated by a hair expert or a dermatopathologist. | TableNonscarring alopecias commonly seen in the clinical setting |
On physical examination, clues for diagnosing trichotillomania include hairs of varying lengths, broken short hairs, vellus or indeterminate hairs, and empty follicular orifices. Trichotillomania biopsies reveal trichomalacia (an incompletely keratinized, distorted, and pigmented hair shaft), empty follicles, and dilated ostia with minimal inflammation. Treatment No medication is approved specifically for the treatment of trichotillomania. Given the similarity of trichotillomania to obsessive-compulsive disorder ( 11), it is not surprising that anti depressants such as selective serotonin reuptake inhibitors ( 15, 16), buspirone, trazodone, and bupropion ( 17) are most commonly used. The use of lithium in the treatment of trichotillomania has also been reported ( 18, 19). Additionally, antipsychotics such as pimozide ( 20) and olanzapine ( 21) have been useful. Habit reversal therapy is a type of cognitive behavior therapy that has proven effective in the treatment of trichotillomania. A study done in 1980 by Azrin et al showed a decrease in hair pulling of 74% ( 22). This therapy involves teaching patients about their disorder and providing relaxation techniques and specific muscle-tensing activities. Theoretically, the habit of muscle tensing replaces the habit of hair pulling. Finally, hypnotherapy has been reported useful by some authors ( 23). 1. Hallopeau H. Alopecie par grattage (trichomanie ou trichotillomanie). Ann Dermatol Syphiligr. 1889;10:440–441. 2. Frey AS, McKee M, King RA, Martin A. Hair apparent: Rapunzel syndrome. Am J Psychiatry. 2005;162:242–248. [PubMed] 3. O'Sullivan RL, Mansueto CS, Lerner EA, Miguel EC. Characterization of trichotillomania. A phenomenological model with clinical relevance to obsessive-compulsive spectrum disorders. Psychiatr Clin North Am. 2000;23:587–604. [PubMed] 4. Walsh KH, McDougle CJ. Trichotillomania. Presentation, etiology, diagnosis and therapy. Am J Clin Dermatol. 2001;2:327–333. [PubMed] 5. Ko SM. Under-diagnosed psychiatric syndrome. I: Trichotillomania. Ann Acad Med Singapore. 1999;28:279–281. [PubMed] 6. George S, Moselhy H. Cocaine-induced trichotillomania. Addiction. 2005;100:255–256. [PubMed] 7. du Toit PL, van Kradenburg J, Niehaus DJ, Stein DJ. Characteristics and phenomenology of hair-pulling: an exploration of subtypes. Compr Psychiatry. 2001;42:247–256. [PubMed] 8. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. Fourth Edition, Text Revision. Washington, DC: American Psychiatric Association; 2000. 9. Tay YK, Levy ML, Metry DW. Trichotillomania in childhood: case series and review. Pediatrics. 2004;113:e494–e498. [PubMed] 10. Oranje AP, Peereboom-Wynia JD, De Raeymaecker DM. Trichotillomania in childhood. J Am Acad Dermatol. 1986;15(4 Pt 1):614–619. [PubMed] 11. Lochner C, Seedat S, du Toit PL, Nel DG, Niehaus DJ, Sandler R, Stein DJ. Obsessive-compulsive disorder and trichotillomania: a phenomenological comparison. BMC Psychiatry. 2005:5–2. [PubMed] 12. McElroy SL, Hudson JI, Pope H, Jr, Keck PE, Jr, Aizley HG. The DSM-III-R impulse control disorders not elsewhere classified: clinical characteristics and relationship to other psychiatric disorders. Am J Psychiatry. 1992;149:318–327. [PubMed] 13. Saraswat A. Child abuse and trichotillomania. BMJ. 2005;330:83–84. [PubMed] 14. Braun-Falco O, Imai S, Schmoeckel C, Steger O, Bergner T. Pseudopelade of Brocq. Dermatologica. 1986;172:18–23. [PubMed] 15. van Minnen A, Hoogduin KA, Keijsers GP, Hellenbrand I, Hendriks GJ. Treatment of trichotillomania with behavioral therapy or fiuoxetine: a randomized, waiting- list controlled study. Arch Gen Psychiatry. 2003;60:517–522. [PubMed] 16. Bhatia MS, Sapra S. Escitalopram in trichotillomania. Eur Psychiatry. 2004;19:239–240. [PubMed] 17. Bhanji NH, Margolese HC. Alternative pharmacotherapy for trichotillomania: a report of successful bupropion use. J Clin Psychiatry. 2004:65–1283. 18. Christenson GA, Popkin MK, Mackenzie TB, Realmuto GM. Lithium treatment of chronic hair pulling. J Clin Psychiatry. 1991;52:116–120. [PubMed] 19. Berk M, McKenzie H, Dodd S. Trichotillomania: response to lithium in a person with comorbid bipolar disorder. Hum Psychopharmacol. 2003;18:576–577. [PubMed] 20. Lorenzo CR, Koo J. Pimozide in dermatologic practice: a comprehensive review. Am J Clin Dermatol. 2004;5:339–349. [PubMed] 21. Pathak S, Danielyan A, Kowatch RA. Successful treatment of trichotillomania with olanzapine augmentation in an adolescent. J Child Adolesc Psychopharmacol. 2004;14:153–154. [PubMed] 22. Azrin NH, Nunn RG, Frantz SE. Treatment of hair pulling (trichotillomania): a comparative study of habit reversal and negative practice training. J Behav Ther Exp Psychiatry. 1980;11:13–20. 23. Iglesias A. Hypnosis as a vehicle for choice and self-agency in the treatment of children with trichotillomania. Am J Clin Hypn. 2003;46:129–137. [PubMed]
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). The child was taking no medications and had no significant past medical history. Her hairstyling did not include repetitive, tight braids (Figure (Figure22
). On physical examination, her scalp had no scaling or pustules. She had no palpable occipital lymphadenopathy. The result of a Wood's light examination was negative.