Trichotillomania Treatment & Management

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

Medical Care

In current practice, behavioral treatment seems to be the most powerful treatment, even with the patients older than age 16 years.[19]

In a broad sense, the common sense approach to stop the bad habit using parental involvement is a primitive form of behavioral therapy. It is worth trying first. In order to achieve the level of parental involvement necessary to aid in treatment, the physician should ensure that parents fully understand the entire nature of the alopecia. Some parents who have not witnessed episodes of hair pulling by their child refuse to believe that the condition is self-inflicted.[20]

In infant patients, loving care with enough maternal skin contact plus available transitional objects such as dolls or other toys would work well. For this purpose, parent-infant psychotherapy in combination with behavioral guidance may be needed.[3]

Parental involvement for the children should include enough support so that they grow well intellectually, physically, and socially. The author has found that in many cases, patients' extracurricular activities are almost solely of an intellectual nature (eg, drawing, math, language lessons) rather than balanced with social and physical activities.

Shaving or clipping hair close to the scalp may be helpful to stop the behavior and to assure the parents of the nature of the alopecia. Shaving a circumscribed area weekly (the "hair growth window") can have both diagnostic and reassurance benefits. Remember that the shaved (clipped) hairs are not all in the actively growing anagen stage and that a couple of months may be required before total regrowth is noted.

Professional cognitive behavior therapy (CBT) should be instituted if the above initial approaches do not work. The rationale for CBT is that awareness helps to overcome unwanted automated activity, and trichotillomania is a kind of unwanted automated repetition of hair manipulations. The authors recommend that dermatologists be familiar with at least a few of the many different methods of CBT. The success of therapy may depend on firm understanding of the illness and the cooperation of the family members to help the patient maintain the treatment procedures. The duration of a course of CBT is usually 2 months. Several courses may be needed.

The 3 essentials of cognitive behavioral therapy are as follows[19, 21, 22] :

  • Self-monitoring: The patient keeps records of hair-touching behavior. To help the patient comply, the author recommends a basic, not a fine detailed, recording plan. Patients simply record the daily frequency of hair touching by putting a stroke on a sheet of paper each time they touch their hair each day. Thus, the daily records are used to give the patient awareness of the habit and help the patient reduce the frequency. In the author’s experience, this very simple procedure alone is quite effective.[23]
  • Habit-reversal training: The patient should institute competing responses. The competing response should be incompatible with hair pulling (eg, making tight fists and holding for 2 min).
  • Stimulus control (organizing the patient's environment): Because hair manipulations usually occur when the patient is engaged in sedentary activities and is alone, performing daily physical exercise and being around people are helpful. Other activities that may be helpful to keep hands busy or away from the head include needlework, taking a walk, or wearing bandages on the fingers, among others.

CBT is typically effective in highly motivated and compliant patients; its efficacy has been proven for pediatric patients, and with various modifications, it can be successfully applied even in patients in very early childhood.[24, 25]

No medication has been approved for the treatment of trichotillomania. Drug therapy has largely been disappointing, although recent studies by Grant et al and Van Ameringen et al are encouraging (see Medication).[26, 27, 28] Only a minority of patients receive temporary help from the currently available pharmacotherapy. The primary agents are selective serotonin reuptake inhibitors (eg, clomipramine),[29] but a positive treatment response is not consistent. While drug monotherapy is generally not effective, combination therapy and other treatment modalities may be helpful.

In the authors’ experience, patients referred for psychoanalytical treatment often show disappointing results. However, patients whose trichotillomania is largely of the focused type should be referred for psychiatric evaluation because this type shows comorbidity with systemic psychiatric disorders.

A clinical guideline summary from the American Academy of Child and Adolescent Psychiatry, Practice parameter for the assessment and treatment of children and adolescents with anxiety disorders,[30] may be of interest.

Support groups

Support groups would be very helpful; however, currently, setting up and maintaining a support group for patients with trichotillomania is only a remote possibility in most countries because of the general lack of understanding of the disorder and because patients themselves are usually secretive about their behavior. An abundant amount of helpful information and educational tools can be found through the Trichotillomania Learning Center.

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Consultations

Consult a psychiatrist when a serious psychiatric disorder is suspected.

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Activity

Trichotillomania is primarily a psychiatric disorder. Physical exercise can provide a healthier outlet for stress. The authors have found that many of the childhood and adolescent patients with trichotillomania spend too much time in study for examinations in school, sitting at a desk, rather than participating in physical activities.

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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

  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. Flessner CA, Lochner C, Stein DJ, Woods DW, Franklin ME, Keuthen NJ. Age of onset of trichotillomania symptoms: investigating clinical correlates. J Nerv Ment Dis. Dec 2010;198(12):896-900. [Medline].

  10. 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].

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

  12. 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].

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

  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.

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

  16. Bienvenu OJ, Wang Y, Shugart YY, et al. Sapap3 and pathological grooming in humans: Results from the OCD collaborative genetics study. Am J Med Genet B Neuropsychiatr Genet. Jul 5 2009;150B(5):710-20. [Medline].

  17. Boardman L, van der Merwe L, Lochner C, et al. Investigating SAPAP3 variants in the etiology of obsessive-compulsive disorder and trichotillomania in the South African white population. Compr Psychiatry. Mar-Apr 2011;52(2):181-7. [Medline].

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

  19. 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].

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

  21. 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.

  22. 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.

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

  24. 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].

  25. Franklin ME, Edson AL, Ledley DA, Cahill SP. Behavior therapy for pediatric trichotillomania: a randomized controlled trial. J Am Acad Child Adolesc Psychiatry. Aug 2011;50(8):763-71. [Medline]. [Full Text].

  26. [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].

  27. Grant JE, Odlaug BL, Chamberlain SR, Kim SW. Dronabinol, a cannabinoid agonist, reduces hair pulling in trichotillomania: a pilot study. Psychopharmacology (Berl). May 19 2011;[Medline].

  28. Van Ameringen M, Mancini C, Patterson B, Bennett M, Oakman J. A randomized, double-blind, placebo-controlled trial of olanzapine in the treatment of trichotillomania. J Clin Psychiatry. Oct 2010;71(10):1336-43. [Medline].

  29. 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].

  30. [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].

  31. Golubchik P, Sever J, Weizman A, Zalsman G. Methylphenidate treatment in pediatric patients with attention-deficit/hyperactivity disorder and comorbid trichotillomania: a preliminary report. Clin Neuropharmacol. May-Jun 2011;34(3):108-10. [Medline].

  32. Leombruni P, Gastaldi F. Oxcarbazepine for the treatment of trichotillomania. Clin Neuropharmacol. Mar-Apr 2010;33(2):107-8. [Medline].

  33. Virit O, Selek S, Savas HA, Kokaçya H. Improvement of restless legs syndrome and trichotillomania with aripiprazole. J Clin Pharm Ther. Dec 2009;34(6):723-5. [Medline].

 
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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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