Trichotillomania 

  • Author: Carly A Elston; Chief Editor: William D James, MD   more...
 
Updated: Aug 26, 2011
 

Background

Trichotillomania (Greek for "hair-pulling madness") is a compulsive disorder resulting in alopecia 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]

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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.

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Epidemiology

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 authors’ experience, 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.

A recent study suggests that hair-pulling sites vary with age of onset of the disorder. Patients with a very early onset of trichotillomania are more likely to pull eyelashes, while those with a later onset are more likely to pull pubic hair.[9]

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Contributor Information and Disclosures
Author

Carly A Elston  The Commonwealth Medical College

Disclosure: Nothing to disclose.

Coauthor(s)

Dirk M Elston, MD  Director, Ackerman Academy of Dermatopathology, New York

Dirk M Elston, MD is a member of the following medical societies: American Academy of Dermatology

Disclosure: Nothing to disclose.

Specialty Editor Board

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.

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.

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.

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

William D James, MD  Paul R Gross Professor of Dermatology, University of Pennsylvania School of Medicine; Vice-Chair, Program Director, Department of Dermatology, University of Pennsylvania Health System

William D James, MD is a member of the following medical societies: American Academy of Dermatology and Society for Investigative Dermatology

Disclosure: Elsevier Royalty Other

Acknowledgments

The authors and editors of Medscape Reference gratefully acknowledge the contributions of previous authors CH Rhee, MD, and Chull-Wan Ihm, MD, to the development and writing of this article.

References

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  14. 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.

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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.
In eyebrow involvement, the geometrical shape is not made.
Sometimes, the alopecia shows just a deficient volume of hair, as is the case in this 9-year-old girl.
When the entire scalp is involved, trichotillomania looks like a keratinization disorder of hairs (eg, monilethrix).
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.
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 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.
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.
Histopathologically trichomalacia (twisted pigmented soft cortex) with catagen follicles is the characteristic of trichotillomania with empty follicles.
 
 
 
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