eMedicine Specialties > Dermatology > Diseases of the Adnexa

Trichotillomania: Differential Diagnoses & Workup

Author: Chull-Wan Ihm, MD, Professor, Department of Dermatology, Chonbuk National University, Korea
Contributor Information and Disclosures

Updated: Aug 31, 2009

Differential Diagnoses

Alopecia Areata
Monilethrix
Tinea Capitis
Traction Alopecia

Other Problems to Be Considered

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

Workup

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,15 can be seen.

Histologic Findings

A clinical diagnosis based on an inspection of the lesion and an appropriate patient history is sufficient in most cases. Hairs collected by the patient can be examined. Trichotillomania demonstrates anagen hairs, telogen effluvium demonstrates catagen hairs, and alopecia areata demonstrates tapered fractures. Occasionally, biopsy is needed to differentiate trichotillomania from 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 uncommon.

Trichomalacia (incompletely keratinized, soft, distorted, and pigmented hair shafts) and bizarre fractured hair shafts are fairly specific for trichotillomania (see Media File 12).

Histopathologically trichomalacia (twisted pigmen...

Histopathologically trichomalacia (twisted pigmented soft cortex) with catagen follicles is the characteristic of trichotillomania with empty follicles.

[ CLOSE WINDOW ]
Histopathologically trichomalacia (twisted pigmen...

Histopathologically trichomalacia (twisted pigmented soft cortex) with catagen follicles is the characteristic of trichotillomania with empty follicles.


Note that increased numbers of catagen hairs and pigment casts within hair canals may be seen in persons with alopecia areata, syphilis, and trichotillomania. 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 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.

More on Trichotillomania

Overview: Trichotillomania
Differential Diagnoses & Workup: Trichotillomania
Treatment & Medication: Trichotillomania
Follow-up: Trichotillomania
Multimedia: Trichotillomania
References
[ CLOSE WINDOW ]

References

  1. Chamberlain SR, Odlaug BL, Boulougouris V, Fineberg NA, Grant JE. Trichotillomania: neurobiology and treatment. Neurosci Biobehav Rev. Jun 2009;33(6):831-42. [Medline].

  2. Salaam K, Carr J, Grewal H, Sholevar E, Baron D. Untreated trichotillomania and trichophagia: surgical emergency in a teenage girl. Psychosomatics. Jul-Aug 2005;46(4):362-6. [Medline].

  3. Keren M, Ron-Miara A, Feldman R, Tyano S. Some reflections on infancy-onset trichotillomania. Psychoanal Study Child. 2006;61:254-72. [Medline].

  4. Stein DJ, Christenson GA. Trichotillomania:Descriptive characteristics and phenomenlogy. In: Stein DJ, Christenson GA, Hollander E. Trichotillomania. 1. 1st. Washington,DC: American Psychiatric Press,Inc.; 1999:1-41/1.

  5. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition. 4th ed. Washington, DC: American Psychiatric Publishing; 2000.

  6. Christenson GA, Pyle RL, Mitchell JE. Estimated lifetime prevalence of trichotillomania in college students. J Clin Psychiatry. Oct 1991;52(10):415-7. [Medline].

  7. Mansueto CS, Thomas AM, Brice AL. Hair pulling and its afftective correlates in an African-American university sample. J Anxiety Disord. 4/2007;21:590-9.

  8. Diefenbach GJ, Tolin DF, Hannan S, Crocetto J, Worhunsky P. Trichotillomania: impact on psychosocial functioning and quality of life. Behav Res Ther. Jul 2005;43(7):869-84. [Medline].

  9. Murphy C, Redenius R, O'Neill E, Zallek S. Sleep-isolated trichotillomania: a survey of dermatologists. J Clin Sleep Med. Dec 15 2007;3(7):719-21. [Medline].

  10. Radmanesh M, Shafiei S, Naderi AH. Isolated eyebrow and eyelash trichotillomania mimicking alopecia areata. Int J Dermatol. May 2006;45(5):557-60. [Medline].

  11. Reeve EA, Bernstein GA, Christenson GA. Clinical characteristics and psychiatric comorbidity in children with trichotillomania. J Am Acad Child Adolesc Psychiatry. Jan 1992;31(1):132-8. [Medline].

  12. Lee YJ, Ihm CW. Clinical observation of 69 cases of trichotillomania. Korean J Dermatol. 2005;43:567-75.

  13. Koblenzer CS. Psychoanalytic Perspectives on Trichotillomania. In: Stein DJ, Christenson GA, Hollander E. Trichotillomania. 1. 1st. Washington,DC: American Psychiatric Press,Inc.; 1999:125-145/5.

  14. Randall W. Grooming reflexes in the cat: endocrine and pharmacological studies. Ann N Y Acad Sci. 1988;525:301-20. [Medline].

  15. Ihm CW, Han JH. Diagnostic value of exclamation mark hairs. Dermatology. 1993;186(2):99-102. [Medline].

  16. Bloch MH, Landeros-Weisenberger A, Dombrowski P, Kelmendi B, Wegner R, Nudel J. Systematic review: pharmacological and behavioral treatment for trichotillomania. Biol Psychiatry. Oct 15 2007;62(8):839-46. [Medline].

  17. Papadopoulos AJ, Janniger CK, Chodynicki MP, Schwartz RA. Trichotillomania. Int J Dermatol. May 2003;42(5):330-4. [Medline].

  18. Rothbaum BO, Ninan PT. Manual for the cognitive-behavioral treatment of trichotillomania. In: Stein DJ, Chistenson GA, Hollander E, eds. Trichotillomania. Washington, DC: APA Press; 1999:263-84.

  19. Keuthen NJ, Aronowitz B, Badenoch J. Behavioral treatment for trichotillomania. In: Stein DJ, Chistenson GA, Hollander E, eds. Trichotillomania. Washington, DC: APA Press; 1999:147-66.

  20. Anthony WZ. Brief intervention in a case of childhood trichotillomania by self-monitoring. J Behav Ther Exp Psychiat. 1978;9:173-5.

  21. Rahman O, Toufexis M, Murphy TK, Storch EA. Behavioral Treatment of Trichotillomania and Trichophagia in a 29-Month-Old Girl. Clin Pediatr (Phila). May 29 2009;[Medline].

  22. Swedo SE, Leonard HL, Rapoport JL, Lenane MC, Goldberger EL, Cheslow DL. A double-blind comparison of clomipramine and desipramine in the treatment of trichotillomania (hair pulling). N Engl J Med. Aug 24 1989;321(8):497-501. [Medline].

  23. [Guideline] Connolly SD, Bernstein GA. Practice parameter for the assessment and treatment of children and adolescents with anxiety disorders. J Am Acad Child Adolesc Psychiatry. Feb 2007;46(2):267-83. [Medline].

  24. [Best Evidence] Grant JE, Odlaug BL, Kim SW. N-acetylcysteine, a glutamate modulator, in the treatment of trichotillomania: a double-blind, placebo-controlled study. Arch Gen Psychiatry. Jul 2009;66(7):756-63. [Medline].

  25. Azrin NH, Nunn RG. Habit Control in a Day. New York, NY: Simon & Schuster; 1978.

  26. Begotka AM, Woods DW, Wetterneck CT. The relationship between experiential avoidance and the severity of trichotillomania in a nonreferred sample. J Behav Ther Exp Psychiatry. Mar 2004;35(1):17-24. [Medline].

  27. Christenson GA, Mackenzie TB, Mitchell JE. Characteristics of 60 adult chronic hair pullers. Am J Psychiatry. Mar 1991;148(3):365-70. [Medline].

  28. Flessner CA, Conelea CA, Woods DW, Franklin ME, Keuthen NJ, Cashin SE. Styles of pulling in trichotillomania: exploring differences in symptom severity, phenomenology, and functional impact. Behav Res Ther. Mar 2008;46(3):345-57. [Medline].

  29. Mannino FV, Delgado RA. Trichotillomania in children: a review. Am J Psychiatry. Oct 1969;126(4):505-11. [Medline].

  30. Mansueto CS, Stemberger RM, Thomas AM, Golomb RG. Trichotillomania: a comprehensive behavioral model. Clin Psychol Rev. 1997;17(5):567-77. [Medline].

  31. Muller SA. Trichotillomania: a histopathologic study in sixty-six patients. J Am Acad Dermatol. Jul 1990;23(1):56-62. [Medline].

  32. Muller SA, Winkelmann RK. Trichotillomania. A clinicopathologic study of 24 cases. Arch Dermatol. Apr 1972;105(4):535-40. [Medline].

  33. Song IM, Ihm CW. Clinicohistopathologic analysis of 28 cases of trichotillomania. Korean J Dermatol. 1997;35(6):1101-9.

  34. Sperling LC, Lupton GP. Histopathology of non-scarring alopecia. J Cutan Pathol. Apr 1995;22(2):97-114. [Medline].

  35. Tay YK, Levy ML, Metry DW. Trichotillomania in childhood: case series and review. Pediatrics. May 2004;113(5):e494-8. [Medline].

  36. Woods DW, Flessner C, Franklin ME, et al. Understanding and treating trichotillomania: what we know and what we don't know. Psychiatr Clin North Am. Jun 2006;29(2):487-501, ix. [Medline].

[ CLOSE WINDOW ]

Further Reading

[ CLOSE WINDOW ]

Keywords

trichotillomania, hair pulling, morbid hair pulling, hair-related psychosis, alopecia, psychotic alopecia, self-induced primary psychiatric disorders, self-induced psychiatric disorder, traumatic alopecia, hair loss, trichotillosis, trichomalacia

[ CLOSE WINDOW ]

Contributor Information and Disclosures

Author

Chull-Wan Ihm, MD, Professor, Department of Dermatology, Chonbuk National University, Korea
Chull-Wan Ihm, MD is a member of the following medical societies: American Academy of Dermatology and American Society of Dermatopathology
Disclosure: Nothing to disclose.

Medical Editor

Leonard Sperling, MD, Chair, Professor, Department of Dermatology, Uniformed Services University of the Health Sciences
Leonard Sperling, MD is a member of the following medical societies: American Academy of Dermatology
Disclosure: Nothing to disclose.

Pharmacy Editor

David F Butler, MD, Professor of Dermatology, Texas A&M University College of Medicine; Chair, Department of Dermatology, Director, Dermatology Residency Training Program, Scott and White Clinic, Northside Clinic
David F Butler, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Dermatology, American Medical Association, American Society for Dermatologic Surgery, American Society for MOHS Surgery, Association of Military Dermatologists, and Phi Beta Kappa
Disclosure: Nothing to disclose.

Managing Editor

Edward F Chan, MD, Clinical Assistant Professor, Department of Dermatology, University of Pennsylvania School of Medicine
Edward F Chan, MD is a member of the following medical societies: American Academy of Dermatology, American Society of Dermatopathology, and Society for Investigative Dermatology
Disclosure: Nothing to disclose.

CME Editor

Catherine M Quirk, MD, Clinical Assistant Professor, Department of Dermatology, University of Pennsylvania
Catherine M Quirk, MD is a member of the following medical societies: Alpha Omega Alpha and American Academy of Dermatology
Disclosure: Nothing to disclose.

Chief Editor

Dirk M Elston, MD, Director, Department of Dermatology, Geisinger Medical Center
Dirk M Elston, MD is a member of the following medical societies: American Academy of Dermatology
Disclosure: Nothing to disclose.

 
 
HONcode

We subscribe to the
HONcode principles of the
Health On the Net Foundation

All material on this website is protected by copyright, Copyright© 1994- by Medscape.
This website also contains material copyrighted by 3rd parties.

DISCLAIMER: The content of this Website is not influenced by sponsors. The site is designed primarily for use by qualified physicians and other medical professionals. The information contained herein should NOT be used as a substitute for the advice of an appropriately qualified and licensed physician or other health care provider. The information provided here is for educational and informational purposes only. In no way should it be considered as offering medical advice. Please check with a physician if you suspect you are ill.