Trichotillomania is defined as the compulsive act of deliberate hair plucking, pulling, or twisting that causes hair breakage. There has been a push to rename this condition trichotill to remove the negative connotation of “mania” from the diagnosis. Two subgroups of patients with trichotillomania exist. The first is a younger population of mostly elementary school–aged children, and the second is the adult population. The younger the patient is at the time of diagnosis, the better the overall prognosis for a cure.
Clinical Findings: Patients present with bizarre configurations of hair loss. This is often the first clue to the diagnosis. On close inspection, the hairs are often broken off close to the surface of the skin. A white 3 × 5 inch card can help as a background to appreciate the damage to the hairs. Many broken hairs of varying lengths are present. Hair shafts may show a twisting morphology. If the patient is evaluated soon after the hair pulling has been performed, pinpoint amounts of hemorrhage may be appreciated at the follicular openings. Microscopic examination of the ends of the hairs may show fracturing of the hair shaft and trichorrhexis nodosa. Most patients are not aware of the actions that are causing their hair loss. It is imperative to not be judgmental during patient visits, and the importance of developing a good rapport cannot be overestimated. One useful request that can be asked of patients is, “Show me how you manipulate your hair.” Often patients unconsciously start to twist or tug at their hair. It is important to educate the parents to observe their child for any evidence of hair manipulation. After this form of education, the parents often become aware of the manipulation. It is important for them not to scold the child when this is taking place but rather to try to distract the child with positive reinforcement. Almost all children eventually outgrow the condition, and their hair then returns to normal.
Adults with trichotillomania have a much more chronic course. They typically have no insight into their condition. They commonly go from one doctor to another seeking therapy. In adults, biopsies are critically important to obtain objective diagnostic information. Referral to a psychologist or psychiatrist should be strongly considered for adult patients with trichotillomania.
Histology: Histopathological evaluation show a noninflammatory, nonscarring alopecia. Characteristic to this diagnosis is the presence of trichomalacia, which is seen as follicular damage within the hair follicle. Varying degrees of follicular red blood cell extravasation are appreciated. Melanin pigment casts within the hair follicle are commonly seen. Overall, the number of hair shafts is normal. The performance of a scalp biopsy is advocated by many to give the patient or family objective information about the diagnosis.
Pathogenesis: Trichotillomania is a self-induced form of hair loss that is caused by intentional twisting, plucking, pulling or other forms of direct damage to the hair shaft. This can be a conscious or an unconscious behavior. Most cases involve some form of emotional disturbance, and one must be cognizant of this when addressing the patient and family.
Treatment: Trichotillomania may be considered in the spectrum of obsessive-compulsive disorders. Most children eventually abandon the actions that have caused their hair loss. Most cases in children are precipitated by emotional stress, and they tend to improve as that stress resolves. Positive reinforcement can be a means to help the child become aware of the hair manipulation. Negative punishment tends to be ineffective. In some cases, a child psychologist or psychiatrist can be extraordinarily helpful in treating these patients.
Adults with trichotillomania have an entirely different clinical course. Most cases are chronic, and most patients never develop insight into their disease. Under-lying psychological conditions may be at the root of the issue, and cognitive therapy in the care of a psychiatrist or psychologist may be instrumental in helping these patients. The use of medications traditionally prescribed for obsessive-compulsive disorders may be warranted in the adult patient.