How to manage a patient with Trichotillomania and Trichophagia?

Management of Trichotillomania and Trichophagia

Diagnosis and Assessment

The management of trichotillomania (hair pulling) with trichophagia (hair eating) requires a comprehensive psychiatric and medical approach focusing on preventing serious complications like trichobezoars that can significantly impact morbidity and mortality.

When evaluating a patient with suspected trichotillomania and trichophagia, look for:

• Pattern of hair loss: Incomplete alopecia with hairs of variable length, often in accessible areas like the frontoparietal and parietotemporal regions 1
• Diagnostic features on trichoscopy: Broken hairs of different lengths, absence of exclamation mark hairs (distinguishing from alopecia areata) 2
• Associated behaviors: Evidence of trichophagia (hair eating), which occurs in approximately 5-30% of patients with trichotillomania 1
• Psychological factors: Anxiety, depression, obsessive-compulsive traits, body image concerns, and triggers like family stressors or sibling rivalry 1

Treatment Approach

Psychiatric Management (Primary Intervention)

1. Cognitive Behavioral Therapy (CBT) is the first-line treatment for trichotillomania 3, 1

   • Habit reversal training
   • Stimulus control techniques
   • Cognitive restructuring

2. Pharmacological options:

   • N-acetylcysteine (NAC): 1200-2400 mg/day in divided doses
   • Clomipramine: Starting at low doses and titrating up as needed 4
   • SSRIs: May be beneficial, particularly when comorbid depression or anxiety exists

3. Family therapy is essential, especially for children and adolescents, to address underlying family dynamics and provide education 1

Medical Surveillance for Trichophagia

For patients with confirmed or suspected trichophagia, implement a monitoring protocol:

1. Regular endoscopic follow-up at 6,12, and 24 months to detect early trichobezoar formation 5

2. Monitor for warning signs of trichobezoar:

   • Abdominal pain
   • Early satiety
   • Nausea and vomiting
   • Weight loss
   • Palpable epigastric mass 6, 7

3. Imaging studies when trichobezoar is suspected:

   • Abdominal X-ray
   • Ultrasonography
   • CT scan for definitive diagnosis 7

Management of Trichobezoar (If Present)

Surgical intervention is the treatment of choice for established trichobezoars 6, 7:

1. Conventional laparotomy with gastrotomy is most effective for large trichobezoars or Rapunzel syndrome (where the bezoar extends into the small intestine) 6

2. Endoscopic removal may be attempted for smaller bezoars, but success rates are limited 6

3. Post-surgical psychiatric follow-up is mandatory to prevent recurrence 6, 7

Prevention of Recurrence

1. Ongoing psychiatric treatment is essential to address the underlying trichotillomania and trichophagia

2. Regular monitoring for hair pulling behaviors and signs of trichophagia

3. Family education about warning signs and the importance of continued treatment

4. Consider group therapy or support groups to help with coping strategies and reduce isolation

Special Considerations

• Children and adolescents: Focus on family-based interventions and addressing potential triggers like sibling rivalry or school stressors 1

• Patients with developmental delays: May require more structured behavioral interventions and closer monitoring for trichophagia 4

• Comorbid psychiatric conditions: Treatment should address other conditions like anxiety disorders, depression, or obsessive-compulsive disorder 3

Prognosis

The prognosis for trichotillomania is variable. Without treatment, the condition tends to be chronic with waxing and waning severity. With appropriate psychiatric intervention, many patients can achieve significant symptom reduction, but ongoing monitoring is essential, particularly for those with trichophagia due to the risk of serious medical complications like trichobezoars.