Trichotillomania
Salient features
· Recurrent pulling out
of one’s hair, most often from the scalp, eyebrows, and eyelashes
· Varying lengths of
hair are typically seen within areas of alopecia
· Often associated with
psychological stress or a personality disorder
· Incomplete and
distorted follicular anatomy is a histologic hallmark
· Behavior modification
therapy is the mainstay of treatment
Introduction
Trichotillomania (Greek: tricho = hair, tillo
= pull, mania = excessive excitement) is a form of traumatic alopecia caused by
an uncontrollable, recurrent impulse to pull out
one’s hair at the root. Some patients who pull out their hair engage in
secondary behaviours such as eating the hair or running it over the skin. The
target areas for pulling include:
Epidemiology
Trichotillomania is seen more
commonly in females than in males and in children more than adults. The
prevalence of trichotillomania in adolescents and adults in the general
population is roughly 1–2%.
Two forms of trichotillomania can be
distinguished: infantile or early onset trichotillomania, which starts in early
childhood, is typically of short duration and may resolve spontaneously or with
simple interventions. Childhood trichotillomania may be seen analogous to other
habitual infantile behaviours such as thumb sucking. Boys are more frequently
affected. Late onset trichotillomania, which starts around or after puberty,
shows a more chronic course and is usually a sign of a more severe underlying psychopathology.
It is classified as an impulse control disorder. Women are far more often
affected than men with a female: male ratio is as
high as 10: 1
Pathogenesis
Trichotillomania
is listed in the American Psychiatric Association’s diagnostic classification
system, DSM-5, as one of the “obsessive-compulsive and related disorders”.
However, many patients who chronically pull their hair do not meet all of the
DSM-5 criteria for trichotillomania.
|
DSM-5 DIAGNOSTIC CRITERIA FOR TRICHOTILLOMANIA (HAIR-PULLING
DISORDER) |
|
1.
Recurrent pulling out of one’s hair,
resulting in hair loss 2.
Repeated attempts to decrease or stop hair
pulling 3.
The hair pulling causes clinically
significant distress or impairment in social, occupational, or other
important areas of functioning 4.
The hair pulling or hair loss is not
attributable to another medical condition (e.g. a dermatological condition) 5.
The hair pulling is not better explained by
the symptoms of another mental disorder (e.g. attempts to improve a perceived
defect or flaw in appearance in body dysmorphic disorder) |
The Diagnostic and
Statistical Manual of Mental Disorders, Fifth Edition (DSM-5)
Individuals
with trichotillomania typically represent a very heterogeneous group, varying
from those with a mild habit to others who have an impulse-control disorder,
personality disorder, intellectual disability, or a psychosis. The DSM-5
criteria do recommend distinguishing trichotillomania from mental disorders
that better explain the hair pulling, e.g. body dysmorphic disorder. Often the
hair pulling that occurs during infancy and early childhood (boys>girls)
resolves without treatment.
Clinical features
Individuals
with trichotillomania usually pluck scalp hair, resulting in patchy alopecia of
the scalp. Some patients may also pluck from other hair-bearing regions such as
the eyebrows, eyelashes, extremities, or pubic region. Hair pulling typically occurs while alone or
in the presence of close family members. It may be preceded or accompanied by
anxiety or boredom, and some patients describe a prior tingling sensation.
Pulling of the hair results in gratification, pleasure, or a sense of relief in
some patients, while others display a more automatic behavior with less
conscious awareness. Pulling may be confined to a specific time of the day and
place, with ritualized manipulation of the pulled hairs prior to discarding
them. Some patients practice trichophagy, the
chewing and swallowing of the hair that has been pulled out, which can lead to
intestinal obstruction from trichobezoars. Occasionally, affected individuals
pull hair from family members, pets, dolls, sweaters, or carpets.
The clinical presentation is usually quite
distinctive with a single or multiple asymmetrical, occasionally geometrically
shaped areas of hair loss on the scalp or other areas of the body. Hairs of varying lengths distributed within the area of alopecia,
with uninvolved areas appearing completely normal; the hairs are sometimes
referred to as “irregularly irregular”. This pattern likely reflects a
hair-pulling technique of twisting multiple strands around the fingers and
pulling them simultaneously. Plucking may cause hair shaft fractures, and
emerging shafts tend to feel “rough”. The areas are not smoothly devoid
of hairs, as seen in alopecia areata but display short or bristly anagen
hair. In
severe cases, hairs in the occiput tend to be spared. Anagen hair are
plucked out, twisted and broken at various lengths. Re-growing anagen hair
needs to reach a certain length before it can be plugged out again. If single, lesions can be quite large. Patients may try to
conceal the hair loss with make-up, scarves, hats, or wigs. Usually the
vertex is affected which give rise to the “Friar Tuck sign” (traditional
Christian practice of shaving the midscalp area). The
clinical diagnosis can be supported by creating a “hair growth window” by
repeatedly (weekly) shaving a small area of involved scalp to demonstrate
normal, dense regrowth.
Many
patients admit to hair pulling, but trichoscopy (dermoscopy) and biopsy may be
helpful when the diagnosis is in doubt.
Trichoscopy reveals
irregularly broken hairs in virtually all patients. Trichoptilosis or frayed hair (split ends), the V-sign (2 broken hairs of equal length arising
from a single follicle), and black dots can also be seen. Other less constant
findings are coiled hairs, flame hairs (remnants of proximal hair shafts), and
tulip hairs (darker ends in the shape of a tulip). Exclamation point hairs,
typical of alopecia areata, are rarely observed. In such cases, histopathology
can assist in determining if both disorders are present.
Trichotillomania: Black dots (red
arrow), broken hair of different lengths (yellow arrow)
Trichotillomania:
Frayed hair (blue circle) and v shaped hair (yellow arrow)
Histological findings can
include deformed hair shafts (trichomalacia), empty follicles, and pigmented
hair casts within the follicular canal secondary to
traumatic hair removal. Inflammatory cells are
usually sparse or absent. Perifollicular hemorrhage is sometimes found in early
lesions, and perifollicular fibrosis represents a late change. If the follicle
is destroyed, a vertical fibrous tract often remains at the site.
Differential diagnosis
The
differential diagnosis includes other causes of circumscribed non-scarring
alopecia such as alopecia areata, which occasionally coexists with
trichotillomania, and tinea capitis. However, in trichotillomania there are no
exclamation point hairs, scaling is absent, and fungal cultures are negative.
Management
The prognosis and approach to
treatment of trichotillomania depend upon the age of onset and degree of
underlying psychopathology. As noted above, preschool children typically
outgrow the habit, and management usually involves bringing awareness to the
parents and patient. Onset in the pre-adolescent to young adult years often
portends a chronic, relapsing course requiring more intervention. Later adult
onset is frequently associated with psychopathology that requires psychiatric
referral.
No
specific treatment approach has been established as effective in any large
controlled study. Hypnosis, behavioral modification therapy, insight-oriented
psychotherapy, and pharmacologic therapy have all been tried, but success rates
are low. Behavior modification therapy
(e.g. habit reversal training, cognitive behavioral therapy) is the mainstay of
treatment. This includes awareness training, teaching the patients to do
something else whenever they feel the urge to pull their hair, relaxation
techniques, and positive reinforcement. In addition, a family and peer support
network may be helpful. If pharmacological therapy is considered, the
recommended first-line medication is clomipramine. Selective serotonin reuptake
inhibitors (SSRIs) have been tried without convincing success. In other
randomized controlled studies, treatment with olanzapine or N-acetylcysteine (a glutamatergic agent;
1200–2400 mg/day) led to more improvement in adults with trichotillomania.
Especially if patients deny the
self-inflicting nature of their hair loss, a referral to a psychiatrist or psychologist
is usually refused and treatment becomes difficult.
