Trichotillomania

Background

Trichotillomania is a hair pulling disorder, manifested by an uncontrollable desire to pull out one’s hair resulting in hair loss. It is often associated with skin picking. According to estimates, trichotillomania affects around 4% of the population, and it is more common in females with a 9:1 ratio. The onset of this disorder is usually at its peak during early adolescence and during the pre-school years.

Etiology & Pathophysiology

The cause is still uncertain, but some genetic factors have been identified as possible contributors. The pathogenesis of this disease could be linked to structural abnormalities or brain’s neurotransmitter imbalance. Moreover, it has been found that trichotillomania is largely associated with obsessive-compulsive disorder. In addition, it is crucial to be aware that stress and anxiety can also contribute to trichotillomania as a coping mechanism for the individual.

Clinical features 

Various body sites can be affected by trichotillomania, including the scalp, face, arms, legs, and pubic region. The scalp, however, is the most common area for both children and adults. Due to the frequent pulling of hair at different times and at different sites over time, there is a noticeable variance in the length of the hair shafts. An individual’s pattern of hair loss can range from slightly thinning of the hair or unnoticeable hair loss patches to complete baldness.

Diagnosis

The diagnosis of trichotillomania is based upon history and physical examination.

According to the DSM-5, trichotillomania can be diagnosed as a disorder based on the following diagnostic criteria:

• Hair loss caused by repeated hair pulling
• Consistent attempts to stop or reduce hair pulling
• At least one important area of functioning is significantly impaired by hair pulling
• Hair pulls or hair loss are not associated with any other medical conditions
• Hair pulling does not appear to be explained by another mental illness 

It is essential to exclude other causes of hair loss before making a diagnosis. A skin biopsy can be performed in order to confirm the diagnosis and exclude any other causes of hair loss.

Management

The treatment should begin with reassurance and education of the parents and caregiver as well as the child. Patients are typically required to be seen by several different specialties, including primary care physicians, dermatologists, psychiatrists, and psychologists. Cognitive behavioral therapy (CBT) and habit reversal training have been found to be the most effective treatments for trichotillomania. Medications such as tricyclic antidepressants and selective serotonin reuptake inhibitors (SSRIs) may also be prescribed in resistant cases in adolescents and adults to manage symptoms.

Prognosis

Trichotillomania is typically benign and self-limited in children. An early diagnosis and treatment of the disorder improve the prognosis. In adolescents and adults, however, trichotillomania may be episodic, but tends to be chronic, making treatment more challenging.

Complications

There is a possibility that permanent hair loss may be one of the long-term complications of this disease. Moreover, an unusual but seriously dangerous complication of trichotillomania known as trichobezoar occurs when patients ingest pulled hair. There are also other complications that have been reported, such as skin infections, and blepharitis.

Written by

Ghida Altammami, medical student

Revised by

Maee Barakeh, medical student

References

National Library of Medicine

UpToDate

DermNet