History
Trichotillomania can be difficult to diagnose. Reported symptoms may include the following:
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Pulling hair: Patients may report hair loss related directly to hair pulling or plucking; however, they frequently complain of unexplainable alopecia or hair loss, because they typically conduct the pulling or plucking behavior in private and often deny engaging in it.
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Denial of hair pulling: Children are particularly likely to 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.
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Pulling hairs from other objects or people: Occasionally, patients engage in hair pulling or plucking from other people, pets, dolls, or other fibrous materials (eg, carpets). [19]
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Avoidance of social situations: Some individuals with trichotillomania tend to avoid social situations so that they can maintain the privacy to engage in hair-pulling behavior and escape the embarrassment such behavior may bring.
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Increased levels of stress 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.
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Gastrointestinal (GI) complaints: Trichobezoar (hair cast) formation can lead to complaints of abdominal pain, nausea and vomiting, constipation or other symptoms of bowel obstruction, and GI bleeding.
To obtain an effective history, a high index of suspicion for the diagnosis is essential. Many cases erroneously diagnosed as alopecia areata are thus misdiagnosed because of the physicians’ lack of suspicion about the possibility of trichotillomania. It is important to keep in mind that trichotillomania can occur in all types of people from all walks of life.
Conditions that may increase suspicion of trichotillomania based on the reported associations include psychiatric disorders such as anxiety disorder, attention-deficit disorder, obsessive-compulsive disorder, mood disorder, tic disorder, and body-focused repetitive behaviors such as skin picking, nail biting, or lip/check bitting. They have been reported to increase with the age of the patient.
Patients with sharply defined alopecic lesions with broken stumps tend to confess their manual hair manipulations if asked about them by a physician, whereas patients with poorly circumscribed alopecic lesions tend to give very ambiguous answers. During the interview, the latter patients’ answers may confuse an inexperienced physician, leading to potential confusion with malingering.
It should be kept in mind 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. A sleep-isolated variant has been recognized. [20]
In many cases, patients or their parents claim that the hair does not grow longer than approximately 1.5 cm; these patients or parents believe the hairs are suffering from periodic 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.
In the authors’ experience, trichotillomania does not always occur in isolation and can coexist with inflammatory alopecias. The authors have encountered patients with lichen planopilaris and alopecia areata with repetitive hair pulling triggered by discomfort from the underlying inflammatory disorder. In our experience, patients with a concurrent inflammatory disorder are more forthcoming about hair-pulling behaviors when queried. A high index of clinical suspicion based on clinical morphology with histologic confirmation is important for diagnosis in these cases, and management of both conditions is critical for optimal treatment response.
Physical Examination
Physical signs of trichotillomania may include the following:
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Alopecia: This can range from barely noticeable areas of hair loss to total baldness; the scalp is the most common area, though hairs may also be pulled from the eyebrows, eyelashes, pubic and perirectal areas, axilla, limbs, torso, and face; the absence of eyebrows and eyelashes can indicate a more serious form of trichotillomania.
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Friar Tuck sign: This common presentation consists of areas of hair loss with twisted and broken hairs of varying lengths arranged in a circular pattern, with unaffected hairs surrounding the area of hair loss. In contrast with inflammatory alopecias such as alopecia areata, the affected areas are “irregularly irregular” with areas of sparing.
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Hair regrowth: Hairs of varying lengths may be noted during the regrowing phase.
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Absence of skin abnormalities or inflammation: The signs of excoriation or other dermatologic pathology that may be common in individuals with tinea capitis are typically absent in people with trichotillomania.
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Hair abnormalities: These may include empty and/or damaged hair follicles; twisted or broken hairs of varying length, and wavy, wrinkled, or corkscrew-shaped hair shafts
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Trichobezoars: These are typically found in the stomach and intestines of patients who chew or mouth their pulled hairs and may give rise to anemia, abdominal pain, hematemesis, nausea and vomiting, bowel obstruction, perforation, GI bleeding, pancreatitis, or obstructive jaundice.
For dermatologists who pay close attention to morphology, diagnosing trichotillomania usually is not difficult. The general morphology of an individual lesion, showing a geometric shape and incomplete nonscarring alopecia of the involved area, typically identifies the condition (see the images below). In longstanding cases, scarring may occur. [21]
Typical geometric shape trichotillomania in a 7-year-old boy. Smooth baldness of scalp surface at this age is rare.
However, if the lesion is limited to an eyebrow or eyelash, the characteristic geometric shape may not develop; this lack of a geometric pattern sometimes draws suspicion away from a diagnosis of traumatic alopecia (see the image below). [22]
Occasionally, the hair-thinning pattern is not circumscribed and shows only a somewhat deficient volume of hair (see the image below).
Sometimes, alopecia is not circumscribed but simply shows deficient hair volume, as in this 9-year-old girl.
Involvement of the entire scalp also occurs, in which a characteristic 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 the image below).
When entire scalp is involved, trichotillomania resembles keratinization disorder of hairs (eg, monilethrix).
The patches may be single or multiple. The degree of involvement may range from a few square centimeters to the entire scalp. An extensive involvement of the scalp, sparing only marginal areas, is termed tonsure trichotillomania because of its resemblance to the tonsuring practiced by monks in the Middle Ages (see the image below).
Tonsure trichotillomania (so named because of its similarity to medieval monks' tonsures). In this patient, hair is preserved only in posterior margin of her scalp.
Examination of the lesions with a magnifying glass or dermatoscope (see the image below) reveals various combinations of the following:
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Newly growing short hairs with tapered ends
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Broken short terminal hairs
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Vellus or indeterminate hairs
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Comedolike black dots
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Empty follicular orifices
A 2015 article reviewed the role of dermoscopy in adult and childhood hair disorders and noted fraying of ends, breakage at different lengths, and scratching and hemorrhaging as possible signs of trichotillomania. Black dots, yellow dots, coiled hair, and exclamation-mark hairs are nonspecific since they are present in alopecia areata. [23]
Close-up picture of lesion of usual trichotillomania shows combination of newly growing young hair, broken shafts, comedolike black dots, empty orifices, and vellus or intermediate hairs.
Positioning an appropriate contrast card (eg, a white card for black hair) at an involved area is helpful for detecting both the broken shafts and the newly growing hairs with tapered tips (see the image below).
Contrast card examination helps demonstrate nature of the alopecia to parents of children with trichotillomania. It shows broken hairs and newly growing hairs with slender tips among long intact hairs.
In severe long-standing lesions, the hairs are regressed to vellus type hairs, and the lesional surface is almost smooth, similar to that seen a scarring alopecia (see the images below).
Close-up picture of severe long-standing lesion in which hairs are regressed to vellus or intermediate-type hairs and scalp is rather smooth.
In addition to scalp lesions, other hairy areas (eg, 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.
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Geometric patch of incomplete alopecia in teenage boy.
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Bizarre-patterned lesion covered with short hairs in 11-year-old girl.
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Typical geometric shape trichotillomania in a 7-year-old boy. Smooth baldness of scalp surface at this age is rare.
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In eyebrow involvement, the characteristic geometric shape is not made.
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Sometimes, alopecia is not circumscribed but simply shows deficient hair volume, as in this 9-year-old girl.
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When entire scalp is involved, trichotillomania resembles keratinization disorder of hairs (eg, monilethrix).
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Tonsure trichotillomania (so named because of its similarity to medieval monks' tonsures). In this patient, hair is preserved only in posterior margin of her scalp.
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Close-up picture of lesion of usual trichotillomania shows combination of newly growing young hair, broken shafts, comedolike black dots, empty orifices, and vellus or intermediate hairs.
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Contrast card examination helps demonstrate nature of the alopecia to parents of children with trichotillomania. It shows broken hairs and newly growing hairs with slender tips among long intact hairs.
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Woman with severe long-standing lesions from trichotillomania.
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Close-up picture of severe long-standing lesion in which hairs are regressed to vellus or intermediate-type hairs and scalp is rather smooth.
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Histopathologically, trichomalacia (twisted pigmented soft cortex) with catagen follicles is characteristic of trichotillomania with empty follicles.
