Introduction
Background
In the literal sense of the word, trichotillomania (Greek for "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. Trichotillomania is one of the self-induced primary psychiatric disorders. Far more articles on trichotillomania are found in psychiatric journals than in dermatological journals. However, dermatologists are more likely to see these patients before psychiatrists, and the number of trichotillomania patients seen in dermatologic clinics seems to be far greater than the number seen in psychiatric clinics.
In fact, the first describer of the disease in history is the French dermatologist Francois Hallopeau, who coined the term trichotillomania. His patient pulled out all of his body hair. Hallopeau attributed trichotillomania to pruritus, but yet remarked that the skin and hair had a normal appearance. He described hair pulling as an attempt to seek relief from pruritus.1 The very first report by Hallopeau suggests the reason why dermatologists should be familiar with this primary psychiatric disorder.
Regardless of its pathogenesis, trichotillomania is a kind of alopecia, namely loss of hair from skin, that must be differentiated from other kinds of alopecia and is diagnosed by a dermatologist (eg, alopecia areata, traction alopecia, androgenetic alopecia, alopecia mucinosa). Furthermore, because earlier treatment yields a better prognosis and prevents complications such as trichobezoar, dermatologists have an essential role in trichotillomania diagnosis.2
In this article, the dermatological aspects of the illness and how to treat the patients seen in a dermatological clinic are discussed. Trichotillomania patients generally are children and early adolescents. The illness is 7 times as prevalent in children as in adults, with the peak age between 4 and 17 years.3
Pathophysiology
Trichotillomania is, from a dermatological standpoint, a form of traumatic alopecia. The causative trauma to the hair occurs as a result of the patient's repetitive hair-pulling behavior. The hair pulling may be one of several phenomenologically related grooming behaviors, such as nail biting and skin picking. In terms of the behavior, 2 subtypes have been described: (1) focused pulling and (2) nonfocused pulling.4
Patients in dermatological clinics, mainly children and adolescents, are largely in the nonfocused group. These patients have difficulty acknowledging the increasing tension before and the mental relief after their hair manipulations. Their actions for hair touching are automatic, nonintentional, and habitual and occur primarily devoid of the patient’s awareness.
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. According to current diagnostic criteria in the psychiatric field,5 patients with trichotillomania should have at least some aspect of the focused pulling. Trichotillomania is included among the impulse-control disorders, and patients have marked distress and/or impairment in occupational, social, or other areas of functioning. Dermatologists see these patients to make the correct diagnosis, but patients in this group are better treated by psychiatrists.
Frequency
United States
The incidence is probably underestimated because only persons who present for treatment are counted. In a psychiatric journal, the rate was determined to be only 0.6% in college students when the patients were restricted into the group having related mental tension and relief.6 Without such restrictions, the rate of hair pulling resulting in visible hair loss is 1.5% for males and 3.4% for females. A survey at an African American university (n = 248) showed that 6.3% of those surveyed had a history of pulling out their hair.7
International
In the author's clinic in South Korea, the number of the patients with trichotillomania is approximately 5% of the number of patients with alopecia areata. The incidence of alopecia areata is approximately 50% of all patients with different alopecias and the prevalence of all hair loss patients is approximately 2% of all dermatologic patients.
Mortality/Morbidity
No mortality is reported with the illness. Most of the patients with trichotillomania in dermatological clinics are children and early adolescents, and the illness is actually a concern of the parents rather than the patients. However, the patients may try to conceal the alopecic area and may have some restrictions in their school activities. In adult patients, trichotillomania may cause distress and impairment in occupational and social or marital relations.8
Race
Racial differences in incidence of trichotillomania have not been reported, and trichotillomania appears to have equal prevalence whites, blacks, and Asians.
Sex
In trichotillomania, the younger the patient is the more equal the sex distribution. In adult groups, most patients are women. In adolescents, girls are affected more often than boys. In children and infants, no sex predilection is recognized.
Age
Patient age is important regarding the treatment of 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.
Clinical
History
Patients with sharply defined alopecic lesions with broken stumps have a tendency to confess their manual hair manipulations if asked about them by a physician, while patients with poorly circumscribed alopecic lesions have a tendency to give very ambiguous answers. During the interview, the latter patients' answers may confuse an inexperienced physician, and they should not be confused with 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 that their daily time allotted to physical exercise is scant.
Patients or their parents often claim the 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.9 Many cases erroneously diagnosed as alopecia areata are thus diagnosed because of the physicians' lack of suspicion about the possibility of trichotillomania. Remember that trichotillomania can occur in people from all walks of life and in any type of person.
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 1-3).
A geometric patch of incomplete alopecia in a teenage boy.
An 11-year-old girl shows a bizarre-patterned lesion covered with short hairs (not bald).
Another typical geometric shape of trichotillomania in a 7-year-old boy. Smooth baldness of the scalp surface at this age is rare.
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 (see Media File 4).10
In eyebrow involvement, the geometrical shape is not made.
Occasionally, the hair-thinning pattern is not circumscribed and shows only a somewhat deficient volume of hair (see Media File 5).
Sometimes, the alopecia shows just a deficient volume of hair, as is the case in this 9-year-old girl.
Involvement of the entire scalp also occurs, in which a particular geometrical shape is also not recognized. At first glance, this type of trichotillomania resembles a hereditary disorder of keratinization such as monilethrix or pili torti (see Media File 6).
When the entire scalp is involved, trichotillomania looks like a keratinization disorder of hairs (eg, monilethrix).
The patches may be single or multiple. The degree of involvement may vary from only a few square centimeters to the entire scalp. An extensive involvement of the scalp, sparing only marginal areas, is termed tonsure trichotillomania, after the monks in the Middle Ages whose hair was tonsured (see Media File 7).
Tonsure trichotillomania is named after monks in the Middle Ages whose hair was tonsured with keeping only marginal hairs like a hair band. In this patient hair is preserved only in posterior margin of her scalp.
Examination of the lesions with a magnifying glass reveals various combinations of (1) newly growing short hairs with tapered ends, (2) broken short terminal hairs, (3) vellus or indeterminate hairs, (4) comedolike black dots, or (5) empty follicular orifices (see Media File 8).
The close-up picture of the lesion of usual trichotillomania shows combination of newly growing young hair, broken shafts, comedolike black dots, empty orifices and vellus or intermediate hairs.
A contrast card positioned at an involved area (ie, a white card for black hair) is helpful to detect both the broken shafts and the newly growing hairs with tapered tips (see Media File 9).
A contrast card examination is very helpful to demonstrate the nature of the alopecia to the parents of trichotillomania children. It shows broken hairs and newly growing hairs with slender tips among long intact hairs.
With the popularity of digital cameras, physicians can easily show the traumatic nature of the alopecia to the patients and parents during the interview. 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 10-11).
A woman with severe long-standing lesions.
The close-up picture of severe long-standing lesion in which the hairs are regressed to vellus or intermediate-type hairs and the scalp is rather smooth.
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 or onychophagia) frequently accompany trichotillomania, especially in children. Knuckle pads caused by frequent cracking or rubbing of the digits may also be found.
Causes
The cause of the repetitive behavior is largely unknown, but information has been gathered that may be helpful to understand the phenomenon.
In the relatively rare variant infancy-onset trichotillomania, lack of a transitional object is regarded as a cause for the hair pulling. During infancy, the baby is growing by touching a variety of transitional objects, such as the mother's skin, clothes, and toys, among other items. In a study of 9 cases of infancy-onset trichotillomania, the authors found that most of the patients had no transitional object, characterized by a lack of maternal physical contact and warmth.3
In childhood and early adolescence, most patients with trichotillomania do not have sustained, focused awareness of their hair pulling in order to control the increasing tension during the behavior. Although tension and relief in relation to the hair pulling are included in the diagnostic criteria of the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV),5 deliberate hair pulling is rare in this age group.
Reeve et al found that only one child experienced tension before hair pulling and relief associated with hair pulling among the 10 children with trichotillomania they studied.11 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 population.12 Thus, patients with trichotillomania may have some type of emotional problem in their family but far more trichotillomania patients are from intact families.
Even though hair has significant symbolic meanings in psychiatry, such as a recipient of feelings like rage and destruction or autoeroticism,13 no evidence indicates that people with trichotillomania are more nervous than those without the disorder or have a deeply rooted mental problem, at least in children and adolescents.
In adult patients, who are thought to be of a focused type in general, whether trichotillomania is a form of obsessive-compulsive disorder or not has been debated. In current DSM-IV diagnostic criteria, trichotillomania is classified as an impulse control disorder, but heterogeneity in its psychology is apparent and overlap with obsessive-compulsive disorder is suggested.
In neurobiology, a link between serotonergic activity and grooming behaviors similar to hair pulling has been reported in animals.14 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. 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.
Regardless of the neurobiological and psychiatric explanations, hair itself is a good, possibly the best, object for repetitive behavior. Hairs are free, are always available, and have a very flexible structure that is attractive. In most patients with trichotillomania, some form of stroking, twisting, or rubbing of the hair precedes the pulling behavior itself. Playing with the plucked hair (eg, rolling it in the fingers, rubbing it along the mouth) is also important for these patients. Interestingly, throughout history, females generally keep longer hair styles than males 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 trichotillomania patients. A certain force of pulling induces premature entry of the hair follicles into the catagen phase instead of immediate removal of the hair, 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. In short, unintentional and unconscious handling of hair plus in combination with physically developed damage to the hair causes patients to believe that the alopecia is caused by a disease of the hair itself, not by the trauma from their own hand. Thus, patients and their parents come to believe that the alopecia may be a real dermatological condition.
More on Trichotillomania |
 Overview: Trichotillomania |
| Differential Diagnoses & Workup: Trichotillomania |
| Treatment & Medication: Trichotillomania |
| Follow-up: Trichotillomania |
| Multimedia: Trichotillomania |
| References |
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Further Reading
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
