AUTHOR AND EDITOR INFORMATION

Section 1 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Follow-up
• Miscellaneous
• Multimedia
• References

INTRODUCTION

Section 2 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Follow-up
• Miscellaneous
• Multimedia
• References

Background

In the literal sense of the word, trichotillomania (Greek, hair-pulling madness) is applied only for a limited number of the patients who show alopecia resulting from repetitive hair manipulations by the patient's own hand. While trichotillomania is categorized in the self-induced primary psychiatric disorders and given that every movement of a human body is controlled by that person’s psyche, using psychometrically sound measures to assess the range of the psychiatric contribution to the cause of the hair pulling is difficult.¹ Far more articles on trichotillomania are found in psychiatric journals than in dermatological journals, and the patients undergoing treatment within the 2 specialties are considerably different. In short, dermatologists tend to deal with quite common, relatively benign childhood and adolescent patients, while psychiatrists deal with the relatively rare adult patients with poor prognoses.

Dermatologists are more likely to see these patients before psychiatrists, and dermatologists should be knowledgeable about trichotillomania at least for the following 2 reasons:

• It is a type of alopecia that must be differentiated from other types of alopecia.
• Earlier treatment yields a better prognosis and prevents serious psychosocial malfunctioning in the future or prevents complications such as trichobezoar.

In this article, the author deals mainly with the dermatological aspects of the illness, with some basic mentions of its underlying psychological explanations and treatments.

The Medscape Mental Health and Psychiatric Nursing Resource Center may be of interest. 

Pathophysiology

Trichotillomania, a primary psychiatric disorder, is, from a dermatological standpoint, one of traumatic alopecia. The causative trauma to the hairs occurs as a result of the patient's repetitive hair-pulling behavior. In terms of the behavior, 2 subtypes have been described: (1) focused pulling and (2) nonfocused pulling. Focused pulling is an intentional act to control negative emotional states such as anxiety or anger. The compulsion is characterized by increasing tension that is finally relieved when the hair is pulled. Nonfocused pulling is an automatic nonintentional, habitual-type of pulling that occurs primarily devoid of the patient’s awareness.

In adult patients, the focused pulling is more frequent than the nonfocused pulling, although most patients actually range between the 2 extremes. Those adult patients whose alopecia is likely to have already been diagnosed in a dermatologic clinic are better cared for in a psychiatric clinic. Patients in dermatological clinics are mainly children and adolescents. They are largely in the nonfocused group.

The 2 subtypes of hair-pulling behavior are well known, but assessing the degree of the subtypes is difficult. In most patients, the subtypes overlap to some degree. In order to make better assessments of the degree of intentional or nonintentional hair pulling using more sound psychometric measures, investigators in the field are making inventories for the subtypes of trichotillomania, for both adults and children, by calculating scores of both focused and automatic  pulling scales. In this type of evaluation, patients are supposed to self-report whether the hair pulling is focused or automatic, thus revealing the subtype. Investigators are trying to measure levels of each hair-pulling style, focused and automatic, along with the severity of the trichotillomania in adolescent and adult subjects. According to the results, the patients with high scores in both subtypes have greater severity, psychological impact, and functional impact.²

Frequency

United States

The prevalence is difficult to determine. If the prevalence rate is determined based on strict involvement of the person's psychological affectation, such as an increase in mental tension before hair pulling and then a reduction in mental tension after hair pulling, the rate has been determined to be only 0.6% in college students.³ However, without such restrictions based on the person's psychological affectation, the rate of hair pulling resulting in visible hair loss is 1.5% for males and 3.4% for females.

International

Practicing dermatologists in developed countries see more than several patients each year. If all the various diagnostic levels of trichotillomania are included, dermatologists likely see far more trichotillomania patients each year than psychiatrists.

Sex

In adult groups, most patients are women. In adolescents, girls are affected more often than boys. In children, the sex distribution is uncertain, but it appears that the younger the sample, the more equal the sex distribution.

Age

Patient age is important regarding treatment of the trichotillomania. In general, children have a time-limited disorder with an excellent prognosis. Adolescents  have more severe disease, and the prognosis should be considered guarded. Adult patients, many of whom were diagnosed before reaching adulthood, have a poor prognosis. Trichotillomania is 7 times as prevalent in children as in adults.

CLINICAL

Section 3 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Follow-up
• Miscellaneous
• Multimedia
• References

History

Patients appear to be indifferent or to have poor insight into the cause of their alopecia. During the interview, patients' answers are often ambiguous and may confuse an inexperienced physician. It is different from malingering. Remember that hair manipulations frequently occur while patients are engaged in sedentary activities, such as reading, writing, watching television, or driving a car, and their daily time allotted to physical exercise is scant.

Patients or their parents often claim their hair does not grow longer than approximately 1.5 cm; these patients or parents believe the hairs are suffering from periodical loss. Some patients may report pruritus of the scalp without visible dermatoses or may confess that they tried to remove nits or had a curiosity about hair roots and wanted to make an observation of the roots.

To obtain an effective history, a high index of suspicion for the diagnosis is essential. Also be aware that sleep-isolated trichotillomania is a recognized variant.⁴ Many cases erroneously diagnosed as alopecia areata are thus diagnosed because of the physicians' lack of suspicion about the possibility of trichotillomania.

Physical

For dermatologists who pay close attention to morphology, the diagnosis of trichotillomania is usually not a difficult one. The general morphology of an individual lesion, showing a geometrical shape and incomplete nonscarring alopecia of the involved area, is typical of trichotillomania (see Media Files 1-2). However, if the lesion is limited to an eyebrow or eyelash, the characteristic geometrical shape may not develop; this lack of a geometric pattern sometimes draws suspicion away from a diagnosis of traumatic alopecia.⁵ Occasionally, the hair-thinning pattern is not as circumscribed and shows only a somewhat deficient volume of hair (see Media File 3).

The patches may be single or multiple. The degree of involvement may vary from only a few square centimeters to extensive involvement of the scalp, sparing only marginal areas, which is termed tonsure trichotillomania after monks in the Middle Ages whose hair was tonsured (see Media File 4). Involvement of the entire scalp is also possible. In such cases, at first glance, the condition resembles a hereditary disorder of keratinization such as monilethrix or pili torti (see Media File 5). See Monilethrix for more information on this topic.

Examination of the lesions with a magnifying glass reveals that most show various combinations of (1) newly growing short hairs with tapered ends, (2) broken short hairs, (3) vellus or indeterminate hairs, (4) comedolike black dots (see Media File 6), or (5) empty follicular orifices. A contrast paper positioned at an involved area (ie, a white-and-black felt examination) is helpful to detect both the broken shafts and the newly growing hairs with tapered tips (see Media File 7). In severe long-standing lesions, the hairs are regressed to vellus type hairs, and the lesional surface is almost smooth, similar to a scarring alopecia (see Media Files 8-9).

In addition to scalp lesions, other hairy areas, such as eyebrows, eyelashes, or the pubic area, may be involved. Additionally, extremely short fingernails (from nail biting) frequently accompany trichotillomania, especially in children.

In trichotemnomania, a rare condition, the scalp looks similar to one affected by an alopecia totalis, but all follicle openings are uniformly filled with hair material. The condition is an obsessive-compulsive habit of cutting or shaving the hair and is different from trichotillomania. This condition demonstrates the extreme capacity for manipulation that human hair can endure.⁶

Causes

The cause of the repetitive behavior is largely unknown but some insight has been gained, as described below.

In neurobiology, a link between serotonergic activity and grooming behaviors similar to hair pulling has been reported in animals.⁷ Serotonergic dysfunction is also suggested in persons with obsessive-compulsive disorder characterized by unwanted repetitive behavior. However, only very limited numbers of patients with trichotillomania have obsessive-compulsive disorder, in which obsessions are a central feature. Most patients with trichotillomania do not have sustained, focused awareness of hair pulling to control increasing tension during the behavior. Deliberate hair pulling is rare, especially in childhood patients. Reeve et al⁸ found that only one child experienced tension before hair pulling and relief associated with hair pulling among the 10 children with trichotillomania they studied. Reports also suggest a possible association between neurodegenerating diseases, such as Parkinson disease, and trichotillomania; however, too few cases are reported to warrant an evaluation.

Chronic hair pulling (along with motor and phonic tics) is also one of the symptoms of Tourette syndrome, which is a disease of the nervous system. However, most patients with trichotillomania do not have detectible neurological disorders.

In psychiatry, hair has an unconscious symbolic meaning and has the quality of a transitional object that can represent the mother. In a study of 9 cases of infancy-onset trichotillomania,⁹ the authors found that 7 of the 9 patients had no transitional object. Similar to the mother, the hair may be the recipient of an entire spectrum of feelings that may include rage and destruction. Even though hair has significant symbolic meaning in psychiatry, no evidence indicates that people with trichotillomania are more nervous than those without the disorder. No evidence indicates that trichotillomania is indicative of a deeply rooted mental problem, at least in children and adolescents.
 
Trichotillomania occurs in people from all walks of life and in any type of person. However, in the author's 32 childhood and adolescent cases, the percentage of patients whose parents, one side or both sides, were absent was 12.5%, compared with an age-matched rate of 1.9% in general society. In the infancy-onset trichotillomania study,⁹ impaired mother-child interactions, characterized by a lack of maternal physical contact and warmth, were noted in all cases.

Regardless of the neurobiological and psychiatric explanations, hair itself as a material is a good object for repetitive behavior by men. Hairs are free, are always available, and have a very flexible structure that is attractive to the vast majority of men, including patients with trichotillomania. In most patients with trichotillomania, some form of stroking, twisting, or rubbing of the hair precedes the pulling behavior itself. Playing with the hair after plucking it (eg, rolling it in the fingers, rubbing it along the mouth) is also important for these patients. Interestingly, females generally have longer hairs than males in most cultures, and the number of female patients with trichotillomania far exceeds the number of male patients.

Although the name trichotillomania suggests the act of plucking or pulling out, actual plucking seems to be a minor component in the total hair manipulations of the patients. A certain force of pulling, instead of immediate removal of the hair, induces premature entry of the follicles into the catagen phase, which subsequently leads to increased hair loss. Likewise, repeated minor trauma to the hair makes the already-manipulated hair more vulnerable to subsequent injury, resulting in hair that is more easily broken. Thus, psychologically unintentional and unconscious handling of hair plus the physically developed vulnerability of the hair may cause patients to believe that the alopecia is caused by a disease of the hair itself, not by the trauma from their own hand. Subsequently, patients are first likely to visit a dermatologist to treat their hair disease.

DIFFERENTIALS

Section 4 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Follow-up
• Miscellaneous
• Multimedia
• References

Other Problems to be Considered

Pili torti
Pressure alopecia due to headgear or helmet
Temporal triangular alopecia

WORKUP

Section 5 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Follow-up
• Miscellaneous
• Multimedia
• References

Other Tests

• Trichogram: Microscopic findings of plucked hairs (trichogram) vary according to the area examined. In areas where the hairs are all short with tapered tips (regrowing hairs), the trichogram may show all anagen roots (telogen count = 0). In other areas, especially those that demonstrate broken shafts of various lengths, an increased number of club hairs (>20%), and even exclamation-mark hairs typical of alopecia areata,¹⁰ can be seen.

Histologic Findings

A clinical diagnosis based inspection of the lesion and an appropriate patient history is sufficient in most cases. Occasionally, biopsy is needed to differentiate trichotillomania from alopecia areata (see Alopecia Areata). Multiple sections, either vertically or transversely oriented, are recommended to observe characteristic findings, especially because both may show numerous catagen hairs and pigment casts. In general, the biopsy specimen should be taken from a new lesion. The most frequent findings are empty anagen follicles (especially in transverse sections), increased numbers of noninflamed catagen follicles, and pigment casts in hair canals. Distorted or torn away follicles are infrequent.

Trichomalacia (incompletely keratinized, soft, distorted, and pigmented hair shafts), which was once regarded specific for trichotillomania (see Media File 10), is not found in all patients and is also seen in persons with acute alopecia areata. If transverse rather than routine vertical sectioning is used, all of these histologic features are identified in higher frequency and with greater ease.

Note that increased numbers of catagen hairs and pigment casts within hair canals may be seen in persons with alopecia areata, syphilis, and trichotillomania (see Syphilis). Care should be taken to search for clues to the diagnosis of alopecia areata or syphilis, such as peribulbar lymphoid infiltrate or peribulbar eosinophils. Lymphocytes, pigment, or eosinophils within fibrous tract remnants are also associated with alopecia areata and syphilis. Plasma cells, especially in apical scalp biopsy specimens, are a common sign of syphilis. In biopsy specimens from the occipital scalp, plasma cells are common regardless of the etiology of hair loss.

Because both trichotillomania and chronic traction alopecia are the result of applied external force, the resulting histopathological pictures are similar and sometimes identical (see Traction Alopecia).

TREATMENT

Section 6 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Follow-up
• Miscellaneous
• Multimedia
• References

Medical Care

No single treatment is effective for all patients. Treatment can be considered in 5 categories: a common sense approach with parental involvement, medication, psychoanalytically oriented therapy, cognitive behavioral therapy, and support groups.

Common sense approach

Common sense approaches to stop the bad habit using parental involvement appear to be effective for children whose lesions may otherwise spontaneously resolve after a certain period, although just occasional scolding for the habit rarely works.

Parental involvement should include enough support so that the children grow well not only intellectually but also physically and socially. The author has experienced that sometimes the patients' extracurricular activities are almost solely of an intellectual nature (eg, drawing, math or language lessons) rather than balanced with social and physical activities. In order to achieve the level of parental involvement necessary to aid in treatment, the physician should ensure that parents fully understand the entire nature of the alopecia.

Shaving or clipping hair close to the scalp may be helpful to stop the behavior and to assure the parents of the nature of the alopecia. Shaving a circumscribed area weekly (the "hair growth window") can have both diagnostic and reassurance benefits. Remember that the shaved (clipped) hairs are not all in the actively growing anagen stage and that more than several weeks may be required before total regrowth is noted.

Medication

No medication has been approved for the treatment of trichotillomania. Drug therapy has largely been disappointing. Only a minority of patients receive temporary help from the currently available pharmacotherapy.

The primary agents are selective serotonin reuptake inhibitors (eg, clomipramine), but a positive treatment response is not consistent. The atypical neuroleptic olanzapine has been reported to have some favorable results for self-inflicted dermatoses and trichotillomania.^{11, 12} Even though drug monotherapy is generally not effective, combination therapy and other treatment modalities may be helpful.

The Medscape CME course Medication Errors in Psychiatric Care: Incidence and Reduction Strategies may be of interest.

Psychoanalytical treatment

In the author's experience, patients referred for psychoanalytical treatment have always shown disappointing results.

Cognitive behavioral treatment

Cognitive behavioral treatment is increasingly being reported as more effective than the psychotherapy or the combination of psychotherapy and pharmacological therapy. The author recommends that dermatologists be familiar with the behavioral therapy. The basic rationale of behavioral therapy is that the hair pulling itself is defined as a problem behavior rather than as a symptom of a deep-seated, masked, unconscious conflict.

The initial step in treatment is to increase patient awareness about his or her automatic habitual behavior. The therapy is, therefore, typically effective in highly motivated, capable, and compliant patients who are able to perform self-administered techniques, including self-monitoring. The success of the therapy may depend on, in addition to the responsible physician, dedicated family members allotting their daily time to help the patient maintain the treatment procedures. Family members and the physicians must actively participate in the patient's care and should implement regular monitoring with the aid of checklists.

The 3 essentials of cognitive behavioral therapy are as follows¹³:

• Self-monitoring: In order to increase the patient's awareness of the hair-pulling behavior, the patient should record the time and situation of hair manipulation and the number of hairs pulled. For the best chance of patient compliance, the author does not recommend an extremely detailed recording plan. Because most of the patients in dermatological clinics are school-aged children, the author recommends a plan that divides a day into just 3 time zones for monitoring (ie, hours in regular school classes, hours in all extracurricular activities, and free time in home). Patients record the frequency of their hair pulling in each time zone in a notebook, and the records are checked daily, weekly, and monthly. The results are evident on individual hairs, with an increased hair mass in the involved area. Self-monitoring alone may yield good results. One course of monitoring usually lasts 2 months.
• Habit-reversal training: The patient should institute competing responses. The competing response should be incompatible with hair pulling (eg, making tight fists and holding for 2 min).
• Stimulus control (organizing the patient's environment): Because hair manipulations usually occur when the patient is engaged in sedentary activities and is alone, performing daily physical exercise and being around people are helpful. Other activities that may be helpful to keep hands busy or away from the head include needlework, taking a walk, or wearing bandages on the fingers, among others.

Support groups

Support groups would be very helpful; however, currently, setting up and maintaining a support group for patients with trichotillomania is only a remote possibility in most countries because of the general lack of understanding of the disorder and because patients themselves are usually secretive about their behavior. An abundant amount of helpful information and educational tools can be found through the Trichotillomania Learning Center.

Consultations

Consult a psychiatrist when a serious psychiatric disorder is suspected.

Activity

Trichotillomania is primarily a psychiatric disorder. Physical exercise is always advisable. The author has found that many of the childhood and adolescent patients with trichotillomania spend too much time in study for examinations in school, sitting at a desk, rather than participating in physical activities.

FOLLOW-UP

Section 7 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Follow-up
• Miscellaneous
• Multimedia
• References

Prognosis

• In very young children, the prognosis is excellent.
• In late childhood and adolescence, the prognosis is usually good but should be considered guarded. The alopecia quite often continues for months or a couple of years and then recurs after a variable time.
• In adult patients, the prognosis is poor and permanent recovery is uncommon.

MISCELLANEOUS

Section 8 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Follow-up
• Miscellaneous
• Multimedia
• References

Medical/Legal Pitfalls

• Biopsy findings of trichotillomania overlap significantly with those of alopecia areata and syphilis. Scalp biopsy specimens are best interpreted by someone with considerable expertise.
• Consultation with a psychiatrist may be appropriate in some patients.

MULTIMEDIA

Section 9 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Follow-up
• Miscellaneous
• Multimedia
• References

Media file 1:  A geometric patch of incomplete alopecia in a teenage boy.
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Media file 2:  An 11-year-old girl shows a bizarre-patterned lesion covered with short hairs (not bald).
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Media file 3:  Sometimes, although the hair thinning is apparent, the lesion is not well defined, as is the case in this 9-year-old girl.
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Media file 4:  Tonsure trichotillomania is named after monks in the Middle Ages whose hair was tonsured.
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Media file 5:  When the entire scalp is involved, trichotillomania looks like a keratinization disorder of hairs (eg, monilethrix).
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Media file 6:  In the lesion of trichotillomania, comedolike black dots are sometimes the predominant follicular change.
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Media file 7:  A contrast paper positioned at the involved area easily demonstrates broken hairs and newly growing hairs with slender tips among long, intact hairs. Same patient as in Media File 3.
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Media file 8:  Woman with severe long-standing lesion.
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Media file 9:  Severe long-standing lesion in which the hairs are regressed to vellus or intermediate-type hairs and the scalp is rather smooth.
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Media file 10:  Trichomalacia is an incompletely keratinized, distorted, and pigmented hair shaft. It is one of the characteristic histopathological changes of trichotillomania. It can also be seen in persons with acute alopecia areata.
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Media type:  Photo

REFERENCES

Section 10 of 10

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Follow-up
• Miscellaneous
• Multimedia
• References

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Article Last Updated: Apr 24, 2008