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]
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.
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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