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Trichotillomania

Trichotillomania (hair-pulling disorder (HPD)) is defined as repetitive pulling of one’s hair resulting in hair loss that may be visible to others. This disorder is classified under obsessive-compulsive and related disorders, as there is tension prior to the act that is relieved after the hair-pulling. Diagnosis is made clinically through history taking and physical exam. Treatment is multimodal, using behavioral interventions to recognize and properly respond to the tension and pharmacotherapy, which is beneficial in some cases.

Last updated: 14 Mar, 2022

Editorial responsibility: Stanley Oiseth, Lindsay Jones, Evelin Maza

Overview

Definition

Trichotillomania, also known as hair-pulling disorder, is characterized by a repetitive or deliberate desire to pull one’s hair, done unconsciously.

  • Can cause visible hair loss 
  • Requires clinically significant levels of distress or functional impairment

Most people suffering from trichotillomania tend to pull out hair from their head, eyelashes, eyebrows, legs, arms, face, and pubic region Pubic region Anterior Abdominal Wall: Anatomy.

Epidemiology

  • Presents in 1%–3% of the population
  • Occurs more often in women than in men (9:1)
  • Onset: childhood–adolescence, frequently associated with a stressful event
  • Roughly 10%–20% of patients Patients Individuals participating in the health care system for the purpose of receiving therapeutic, diagnostic, or preventive procedures. Clinician–Patient Relationship also ingest the hair, which can develop into hazardous bezoars (hairballs that can block the GI tract).

Clinical Presentation and Diagnosis

Clinical features

2 types of hair pulling:

  • Focused: where unpleasant personal experiences are addressed via conscious pulling of hair 
  • Automatic: occurs during sedentary activity mostly outside of person’s awareness

Oral manipulation often occurs:

Trichotillomania lesions on scalp

Trichotillomania lesions on the vertex of the scalp

Image: “Trichotillomania lesions on vertex of scalp” by Department of General Medicine, Institute of Medical Sciences, Banaras Hindu University, Varanasi 221005, India. License: CC BY 3.0

Diagnostic approach

  • Clinical diagnostic criteria:
    • Persistent pulling out of one’s hair leading to visible hair loss
    • Repeated attempts to stop or reduce hair pulling
    • Hair pulling is not due to any other medical condition.
    • Exclude any other mental disorders.
    • Causes significant distress or functional impairment to the patient
  • On exam:
    • Hair-growth pattern is notable by hair with varying lengths and stages of regrowth. 
    • No other abnormalities of skin Skin The skin, also referred to as the integumentary system, is the largest organ of the body. The skin is primarily composed of the epidermis (outer layer) and dermis (deep layer). The epidermis is primarily composed of keratinocytes that undergo rapid turnover, while the dermis contains dense layers of connective tissue. Skin: Structure and Functions or scalp 
  • Punch biopsy Biopsy Removal and pathologic examination of specimens from the living body. Ewing Sarcoma can confirm the diagnosis but is not required. In trichotillomania, punch biopsy Biopsy Removal and pathologic examination of specimens from the living body. Ewing Sarcoma shows:
    • Nonscarring, noninflammatory alopecia Alopecia Alopecia is the loss of hair in areas anywhere on the body where hair normally grows. Alopecia may be defined as scarring or non-scarring, localized or diffuse, congenital or acquired, reversible or permanent, or confined to the scalp or universal; however, alopecia is usually classified using the 1st 3 factors. Alopecia
    • Evidence of trauma to the follicle ( distortion Distortion Defense Mechanisms of anatomy)
    • Normal density of hair follicles
  • If patient is found to ingest the pulled hair, radiologic studies (or even invasive procedures) are needed to visualize the location of a potential bezoar.
Intragastric trichobezoar

Swallowed hair: endoscopic image of an intragastric trichobezoar

Image: “Intragastric trichobezoar” by Department of Surgery, School of Medicine, University of Campinas (Unicamp), Rua Tessália Vieira de Camargo, 126 – Cidade Universitária Zeferino Vaz, Campínas – SP – CEP: 13083-887, Brazil. License: CC BY 3.0

Management

Management usually involves collaborative care between dermatologists and psychiatrists.

Psychotherapy Psychotherapy Psychotherapy is interpersonal treatment based on the understanding of psychological principles and mechanisms of mental disease. The treatment approach is often individualized, depending on the psychiatric condition(s) or circumstance. Psychotherapy

Cognitive-behavioral therapy Cognitive-behavioral therapy Cognitive-behavioral therapy corrects faulty assumptions and tries to replace maladaptive behavior with healthier alternatives. Psychotherapy (habit-reversal training):

  • Patients Patients Individuals participating in the health care system for the purpose of receiving therapeutic, diagnostic, or preventive procedures. Clinician–Patient Relationship are trained to recognize their impulse to pull hair. 
  • Patients Patients Individuals participating in the health care system for the purpose of receiving therapeutic, diagnostic, or preventive procedures. Clinician–Patient Relationship are educated to redirect to a healthier coping mechanism (stress-reducing techniques).
  • Social support

Behavioral treatments such as self-monitoring and biofeedback Biofeedback The therapy technique of providing the status of one’s own autonomic nervous system function (e.g., skin temperature, heartbeats, brain waves) as visual or auditory feedback in order to self-control related conditions (e.g., hypertension, migraine headaches). Psychotherapy also have exhibited some effectiveness.

Pharmacotherapy

  • No FDA-approved medication therapy at this time 
  • Medication(s) providing some benefit:
  • Topical steroids Steroids A group of polycyclic compounds closely related biochemically to terpenes. They include cholesterol, numerous hormones, precursors of certain vitamins, bile acids, alcohols (sterols), and certain natural drugs and poisons. Steroids have a common nucleus, a fused, reduced 17-carbon atom ring system, cyclopentanoperhydrophenanthrene. Most steroids also have two methyl groups and an aliphatic side-chain attached to the nucleus. Benign Liver Tumors and hydroxyzine Hydroxyzine A histamine h1 receptor antagonist that is effective in the treatment of chronic urticaria, dermatitis, and histamine-mediated pruritus. Unlike its major metabolite cetirizine, it does cause drowsiness. It is also effective as an antiemetic, for relief of anxiety and tension, and as a sedative. Antihistamines HCl HCL Hairy cell leukemia (HCL) is a rare, chronic, B-cell leukemia characterized by the accumulation of small mature B lymphocytes that have “hair-like projections” visible on microscopy. The abnormal cells accumulate in the peripheral blood, bone marrow (causing fibrosis), and red pulp of the spleen, leading to cytopenias. Hairy Cell Leukemia (an anxiolytic with antihistamine activity) are used to treat psychodermatologic disorders.

Prognosis Prognosis A prediction of the probable outcome of a disease based on a individual’s condition and the usual course of the disease as seen in similar situations. Non-Hodgkin Lymphomas

  • Onset in early childhood (< age 6) is more self-limiting Self-Limiting Meningitis in Children
  • Onset in adulthood or adolescence (> age 13), especially with another psychiatric disorder, has longer-lasting symptoms.

Differential Diagnosis

  • Body dysmorphic disorder Body dysmorphic disorder Body dysmorphic disorder (BDD) is a psychiatric disorder characterized by a patient’s preoccupation with minor or imagined flaws in their physical appearance. The obsession over the perceived defect leads to compulsive behaviors to cover it up, either with cosmetic therapy or social avoidance. Body Dysmorphic Disorder ( BDD BDD Body dysmorphic disorder (BDD) is a psychiatric disorder characterized by a patient’s preoccupation with minor or imagined flaws in their physical appearance. The obsession over the perceived defect leads to compulsive behaviors to cover it up, either with cosmetic therapy or social avoidance. Body Dysmorphic Disorder): psychiatric disorder characterized by a patient’s preoccupation Preoccupation Body Dysmorphic Disorder with minor or imagined flaws in their physical appearance. The obsession over the perceived defect leads to compulsive behaviors to cover it up, either with cosmetic therapy or social avoidance. Those with trichotillomania are not necessarily pulling their hair because of a perceived defect or flaw in the appearance of their hair. 
  • Alopecia Alopecia Alopecia is the loss of hair in areas anywhere on the body where hair normally grows. Alopecia may be defined as scarring or non-scarring, localized or diffuse, congenital or acquired, reversible or permanent, or confined to the scalp or universal; however, alopecia is usually classified using the 1st 3 factors. Alopecia: loss of hair in areas anywhere on the body where hair normally grows. Alopecia Alopecia Alopecia is the loss of hair in areas anywhere on the body where hair normally grows. Alopecia may be defined as scarring or non-scarring, localized or diffuse, congenital or acquired, reversible or permanent, or confined to the scalp or universal; however, alopecia is usually classified using the 1st 3 factors. Alopecia may be defined as scarring Scarring Inflammation or nonscarring, localized or diffuse, congenital Congenital Chorioretinitis or acquired, reversible or permanent, or confined to the scalp or universal. Alopecia Alopecia Alopecia is the loss of hair in areas anywhere on the body where hair normally grows. Alopecia may be defined as scarring or non-scarring, localized or diffuse, congenital or acquired, reversible or permanent, or confined to the scalp or universal; however, alopecia is usually classified using the 1st 3 factors. Alopecia has several etiologies, such as infectious Infectious Febrile Infant (fungal infection from tinea capitis Tinea capitis Ringworm of the scalp and associated hair mainly caused by species of Microsporum; Trichophyton; and Epidermophyton, which may occasionally involve the eyebrows and eyelashes. Dermatophytes/Tinea Infections), autoimmune ( alopecia areata Alopecia Areata Loss of scalp and body hair involving microscopically inflammatory patchy areas. Alopecia), or traction-related. These conditions must be ruled out prior to the diagnosis of trichotillomania being made. Physical exam will reveal wide variation in lengths of remaining hair in those with trichotillomania. 

References

  1. Sadock, B. J., Sadock, V. A., Ruiz, P. (2014). Obsessive-compulsive and related disorders. Chapter 10 of Kaplan and Sadock’s synopsis of psychiatry: Behavioral sciences/clinical psychiatry, 11th ed. Philadelphia: Lippincott Williams and Wilkins, pp. 431–434.
  2. Thomas, E. (2017). Trichotillomania (hair pulling disorder). DeckerMed Medicine. https://pubmed.ncbi.nlm.nih.gov/30745687/
  3. Thompson, J. W., Jr., Winstead D. K. (2019). Impulse-control disorders. Chapter 27 of Ebert M. H., Leckman J. F., Petrakis I. L. (Eds.), Current Diagnosis & Treatment: Psychiatry, 3rd ed. McGraw-Hill. https://accessmedicine.mhmedical.com/content.aspx?bookid=2509&sectionid=200806368

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