Diagnostic Considerations
In children, symptoms of trichotillomania must be assessed over a period of several months to confirm that the diagnosis is correct. Because children can acquire a short-term habit of hair pulling that closely resembles trichotillomania, establishing the diagnosis commonly requires several visits.
A record of hair pulling or the saving of plucked hairs may be required to confirm a diagnosis of trichotillomania. However, patient self-reporting or records from children should be regarded with a degree of caution; some children engage in trichophagia and consume pulled hairs or pluck hairs in privacy to hide the severity of the disorder.
In addition to the conditions listed in the differential diagnosis, other problems to be considered include the following:
-
Pili torti
-
Pressure alopecia due to headgear or helmet
-
Temporal triangular alopecia
-
Androgenetic alopecia
-
Telogen effluvium secondary to medical or nutritional causes (eg, infections, medications, febrile illnesses, crash diets)
-
Other psychological disorders
-
Anxiety disorder (habit)
-
Factitious disorder with predominately physical signs and symptoms
-
Short-term habit in children
Differential Diagnoses
-
Geometric patch of incomplete alopecia in teenage boy.
-
Bizarre-patterned lesion covered with short hairs in 11-year-old girl.
-
Typical geometric shape trichotillomania in a 7-year-old boy. Smooth baldness of scalp surface at this age is rare.
-
In eyebrow involvement, the characteristic geometric shape is not made.
-
Sometimes, alopecia is not circumscribed but simply shows deficient hair volume, as in this 9-year-old girl.
-
When entire scalp is involved, trichotillomania resembles keratinization disorder of hairs (eg, monilethrix).
-
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.
-
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.
-
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.
-
Woman with severe long-standing lesions from trichotillomania.
-
Close-up picture of severe long-standing lesion in which hairs are regressed to vellus or intermediate-type hairs and scalp is rather smooth.
-
Histopathologically, trichomalacia (twisted pigmented soft cortex) with catagen follicles is characteristic of trichotillomania with empty follicles.
