Pediatric Trichotillomania Clinical Presentation

Trichotillomania can be difficult to diagnose. Symptoms may include pulling hair (resulting in alopecia), denying hair-pulling behavior, pulling hairs from other objects or people, avoiding social situations, experiencing increased stress and anxiety levels, and experiencing GI complaints related to trichobezoar formation.

• Pulling hair: Patients may report hair loss related directly to hair pulling or plucking. However, unexplainable alopecia or hair loss is frequently the complaint, as the behavior is typically conducted in private and subsequently denied.
• Denying hair pulling: Children often deny hair pulling. Because the behavior is usually not conducted in the presence of adults or others, it is often difficult to diagnose as self-inflicted hair loss.
• Pulling hairs from other objects or people: Occasionally, patients may engage in hair pulling or plucking from other people, pets, dolls, or other fibrous materials (eg, carpets).
• Avoiding social situations: Some individuals may avoid social situations to maintain the privacy to engage in hair-pulling behavior and to escape the embarrassment such behavior may bring.
• Experiencing increased stress levels and/or anxiety: Although hair pulling can occur during periods of relaxation, increased stress frequently precipitates or exacerbates trichotillomania. Furthermore, patients may present with anxiety, which they may not report, associated with their hair-pulling behavior.
• Experiencing GI complaints: Trichobezoar formation or hair casts can lead to complaints of abdominal pain, nausea and/or vomiting, constipation or other symptoms of bowel obstruction, and GI bleeding.

Physical signs of trichotillomania may include variable patterns of alopecia or hair thinning, hair abnormalities, and trichobezoar formation.

• Alopecia: The area(s) of alopecia can range from barely noticeable areas of hair loss to total baldness. The scalp is the most common area of hair pulling; however, hairs may be pulled from the eyebrows, eyelashes, pubic and perirectal areas, axilla, limbs, torso, and face. In addition, the absence of eyebrows and eyelashes can indicate a more serious form of trichotillomania.

  • Friar Tuck sign: This common presentation of trichotillomania includes areas of hair loss with broken hairs of varying lengths arranged in a circular pattern. Thus, unaffected hairs surround an area of hair loss.
  • Hair regrowth: Patients may exhibit signs of variable lengths of hair during the regrowing phase.
  • Absence of skin abnormalities or inflammation: Individuals with trichotillomania do not typically exhibit signs of excoriation or other dermatologic pathology that may be common in individuals with tinea capitis.
• Hair abnormalities

  • Empty and/or damaged hair follicles
  • Twisted and/or broken hairs of varying length
  • Wavy, wrinkled, or corkscrew-shaped hair shafts
• Trichobezoars

  • Trichobezoars can result from the ingestion of plucked hairs.
  • Trichobezoars are hair casts and are typically found in the stomach and intestines of patients who chew or mouth their pulled hairs.
  • As a result, anemia, abdominal pain, hematemesis, nausea and/or vomiting, bowel obstruction, perforation, GI bleeding, pancreatitis, and obstructive jaundice may occur.

The etiology of trichotillomania continues to be unknown. However, the following explanations are proposed hypotheses for the onset and maintenance of the hair-pulling behavior:

• Serotonin deficiency: A link may exist between a deficiency of the neurotransmitter serotonin (5-hydroxytryptamine [5-HT]) and trichotillomania; this hypothesis is due to the success of selective serotonin reuptake inhibitors (SSRIs) in treating some people with trichotillomania.
• Structural brain abnormalities: Magnetic resonance imaging (MRI) studies have demonstrated that some individuals with trichotillomania have abnormalities of the lenticulate.
• Abnormal brain metabolism: Positron emission tomography (PET) scans have revealed that some individuals with trichotillomania have a high metabolic glucose rate in the global, bilateral, cerebellar, and right superior parietal areas.
• Psychological theories: Several psychological theories, including psychodynamic, behavioral, and ethological theories, have attempted to explain trichotillomania in children. Such theories include stress reduction, emotional regulation, and sensory stimulation.^{[7, 8]}