History

Fact Explanation
Pulling or plucking hair This is an impulse control disorder in which pulling or plucking his or her own hair is the characteristic feature. Patients experience tension when they try to refrain and resist the behavior, and they feel pleasure or relief when it is done. This is usually causing significant distress and impairment in social functions. [1,3]
Patches of hair loss Patients may pluck their hair leading to patchy areas of hair loss. [1]
Skin irritation At the site of hair loss, skin irritation develops secondary to hair plucking and minor traumatic injuries caused by repetitive plucking of hair. [1]
Symptoms due to trichobezoars Some patients swallow the plucked hair (trichophagia). The hair accumulates in the stomach and in intestine forming trichobezoars, which can present with anemia, abdominal pain, hematemesis and gastrointestinal bleeding, nausea and vomiting, bowel or gastric outlet obstruction, intestinal perforation (pressure effects of the trichobezoars cause ischemic necrosis of the bowel wall), pancreatitis, and obstructive jaundice. [4]
Presence of other comorbid disorders Trichotillomania is seen with anxiety disorders, mood disorders, substance use disorders, eating disorders and personality disorders. [1,2]
References
  1. FRANKLIN ME, ZAGRABBE K, BENAVIDES KL. Trichotillomania and its treatment: a review and recommendations Expert Rev Neurother [online] 2011 Aug, 11(8):1165-1174 [viewed 03 June 2014] Available from: doi:10.1586/ern.11.93
  2. CHRISTENSON GA, MACKENZIE TB, MITCHELL JE. Characteristics of 60 adult chronic hair pullers. Am J Psychiatry [online] 1991 Mar, 148(3):365-70 [viewed 03 June 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/1992841
  3. PERALTA L, MORAIS P. Photoletter to the editor: The Friar Tuck sign in trichotillomania J Dermatol Case Rep [online] , 6(2):63-64 [viewed 04 June 2014] Available from: doi:10.3315/jdcr.2012.1103
  4. GORTER RR, KNEEPKENS CM, MATTENS EC, ARONSON DC, HEIJ HA. Management of trichobezoar: case report and literature review Pediatr Surg Int [online] 2010 May, 26(5):457-463 [viewed 04 June 2014] Available from: doi:10.1007/s00383-010-2570-0

Examination

Fact Explanation
Alopecia There can be diffuse and non-scarring hair loss, patchy hair loss or in severe cases, baldness. Hair loss can be in eyebrows, eyelashes, axilla, limbs, torso pubic and perirectal areas, and face in some patients. Noticeable hair loss is one of the diagnostic criteria. [1]
Friar tuck sign [1] Friar tuck sign or the “tonsure pattern” is characteristic of trichotillomania. [2]
Trichoscopy Trichoscopy gives a magnified view of decreased hair density, broken hairs, varying lengths of hair shafts, black dots, and old minor hemorrhages are diagnostic of trichotillomania. [1]
References
  1. PERALTA L, MORAIS P. Photoletter to the editor: The Friar Tuck sign in trichotillomania J Dermatol Case Rep [online] , 6(2):63-64 [viewed 04 June 2014] Available from: doi:10.3315/jdcr.2012.1103
  2. THAKUR BK, VERMA S, RAPHAEL V, KHONGLAH Y. Extensive tonsure pattern trichotillomania-trichoscopy and histopathology aid to the diagnosis. Int J Trichology [online] 2013 Oct, 5(4):196-8 [viewed 04 June 2014] Available from: doi:10.4103/0974-7753.130400

Differential Diagnoses

Fact Explanation
Alopecia areata [1] Trichoscopy will show exclamation mark hairs.
Androgenetic alopecia [1] This is the commonest cause of hair loss. In males hairline recession at the temples and vertex balding is seen. Women normally tend to have diffusely thin hair over the top of their scalps.
Tinea capitis [1] This is the dermatophyte infection of the scalp.
Monilethrix This is a diffuse keratinization disorder of hair. It shows autosomal dominant inheritance. When trichotillomania involves the entire scalp it may mimic monilethrix. [2,3]
Pili torti This is a hair shaft abnormality, resulting in twisted and flattened hair. [4]
Pressure alopecia Pressure alopecia results due to prolonged immobilization of the head. Commonly seen in small children and in debilitated adults. Both scarring and non-scarring alopecia can occur. [5]
Temporal triangular alopecia (Brauer nevus) This is a circumscribed alopecia. Typically non-scarring and seen over the temporal region. [6]
Traction alopecia This is due to excessive traction on hair which causes hair loss. [8]
Systematic diseases Cancer, leukemia, Hodgkin disease, cirrhosis, hypothyroidism, autoimmune disorders, systemic infection and tuberculosis are systemic causes which might present with hair loss. [7]
References
  1. PERALTA L, MORAIS P. Photoletter to the editor: The Friar Tuck sign in trichotillomania J Dermatol Case Rep [online] , 6(2):63-64 [viewed 04 June 2014] Available from: doi:10.3315/jdcr.2012.1103
  2. VIKRAMKUMAR AG, KURUVILA S, GANGULY S. Monilethrix: A Rare Hereditary Condition Indian J Dermatol [online] 2013, 58(3):243 [viewed 04 June 2014] Available from: doi:10.4103/0019-5154.110869
  3. BEARE JM. Monilethrix Ulster Med J [online] 1956 Nov, 25(2):98-84.3 [viewed 04 June 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2480306
  4. SRINIVAS SM, HIREMAGALORE R, SURYANARAYAN S, BUDAMAKUNTALA L. Netherton Syndrome with Pili Torti Int J Trichology [online] 2013, 5(4):225-226 [viewed 04 June 2014] Available from: doi:10.4103/0974-7753.130424
  5. DAVIES KE, YESUDIAN P. Pressure Alopecia Int J Trichology [online] 2012, 4(2):64-68 [viewed 04 June 2014] Available from: doi:10.4103/0974-7753.96901
  6. GUPTA LK, KHARE A, GARG A, MITTAL A. Congenital Triangular Alopecia: A Close Mimicker of Alopecia Areata Int J Trichology [online] 2011, 3(1):40-41 [viewed 04 June 2014] Available from: doi:10.4103/0974-7753.82135
  7. SPRINGER K, BROWN M, STULBERG DL. Common hair loss disorders. Am Fam Physician [online] 2003 Jul 1, 68(1):93-102 [viewed 04 June 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/12887115
  8. MORGAN HV. Traction Alopecia Br Med J [online] 1960 Jul 9, 2(5192):115-117 [viewed 04 June 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2096823

Management - Specific Treatments

Fact Explanation
Conservative management [5] This might be effective in children. The skin lesions are managed conservatively while psychopharmacotherapy is in progress. [9]
Cognitive–behavioral interventions [1,4] This is the main mode of treatment. Often treatment should be combined with pharmacological management. Habit Reversal Training and Stimulus Control is considered the most effective treatment modality and it is often combined with pharmacological treatment. Patients are educated about the disease. Patients should be self-monitoring throughout the treatment process. Patients are counseled to raise the awareness of the habit and to resist as an urge to pull hair is felt. The stress associated with urge suppression is dealt with relaxation techniques such as: deep breathing and progressive muscular relaxation. [8]
Selective serotoninergic receptor reuptake inhibitors (SSRIs) SSRIs are considered as a first line treatment in trichotillomania. [7]
Naltrexone An opioid antagonist used in the treatment of trichotillomania which gives promising results without any significant side effects. This is often combined with other treatment options for a better outcome. [2,8]
N-acetylcysteine [NAC] NAC is a glutamate modulator effective in treating trichotillomania. This is really effective in treating trichotillomania in children. [1,3,6]
Clomipramine This is a tricyclic antidepressant with serotonergic actions. It is considered a second line treatment option, because of its unfavorable side effects. [1]
Olanzapine Olanzapine is also used in treatment due to its neuroleptic effects. [1]
Treatment of trichobezoars Surgical removal (laparoscopy or laparotomy) or endoscopic removal of the trichobezoars are practiced. [10]
References
  1. FRANKLIN ME, ZAGRABBE K, BENAVIDES KL. Trichotillomania and its treatment: a review and recommendations Expert Rev Neurother [online] 2011 Aug, 11(8):1165-1174 [viewed 03 June 2014] Available from: doi:10.1586/ern.11.93
  2. DE SOUSA A. An open-label pilot study of naltrexone in childhood-onset trichotillomania. J Child Adolesc Psychopharmacol [online] 2008 Feb, 18(1):30-3 [viewed 03 June 2014] Available from: doi:10.1089/cap.2006.0111
  3. 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 [online] 2009 Jul, 66(7):756-63 [viewed 03 June 2014] Available from: doi:10.1001/archgenpsychiatry.2009.60
  4. VAN MINNEN A, HOOGDUIN KA, KEIJSERS GP, HELLENBRAND I, HENDRIKS GJ. Treatment of trichotillomania with behavioral therapy or fluoxetine: a randomized, waiting-list controlled study. Arch Gen Psychiatry [online] 2003 May, 60(5):517-22 [viewed 03 June 2014] Available from: doi:10.1001/archpsyc.60.5.517
  5. PERALTA L, MORAIS P. Photoletter to the editor: The Friar Tuck sign in trichotillomania J Dermatol Case Rep [online] , 6(2):63-64 [viewed 04 June 2014] Available from: doi:10.3315/jdcr.2012.1103
  6. BLOCH MH, PANZA KE, GRANT JE, PITTENGER C, LECKMAN JF. N-Acetylcysteine in the treatment of pediatric trichotillomania: a randomized, double-blind, placebo-controlled add-on trial. J Am Acad Child Adolesc Psychiatry [online] 2013 Mar, 52(3):231-40 [viewed 04 June 2014] Available from: doi:10.1016/j.jaac.2012.12.020
  7. JONKER M, NOOIJ FJ. The internal image-like anti-idiotypic response to a CD3-specific monoclonal antibody in primates is dependent on the T cell-binding properties of the injected antibody. Eur J Immunol [online] 1987 Oct, 17(10):1519-22 [viewed 04 June 2014] Available from: doi:10.1002/eji.1830171022
  8. DE SOUSA A. An open-label pilot study of naltrexone in childhood-onset trichotillomania. J Child Adolesc Psychopharmacol [online] 2008 Feb, 18(1):30-3 [viewed 04 June 2014] Available from: doi:10.1089/cap.2006.0111
  9. VARYANI N, GARG S, GUPTA G, SINGH S, TRIPATHI K. Trichotillomania and Dermatitis Artefacta: A Rare Coexistence Case Rep Psychiatry [online] 2012:674136 [viewed 04 June 2014] Available from: doi:10.1155/2012/674136
  10. GORTER RR, KNEEPKENS CM, MATTENS EC, ARONSON DC, HEIJ HA. Management of trichobezoar: case report and literature review Pediatr Surg Int [online] 2010 May, 26(5):457-463 [viewed 04 June 2014] Available from: doi:10.1007/s00383-010-2570-0