What are the treatment options for a child with trichotillomania (hair-pulling disorder) and trichophagia (hair-chewing habit)?

Treatment Options for Trichotillomania (Hair-Pulling) and Trichophagia (Hair-Chewing) in Children

Behavioral therapy should be the first-line treatment for children with trichotillomania, with habit reversal training and stimulus control techniques forming the core of treatment. 1

Understanding Trichotillomania in Children

Trichotillomania (TTM) is defined as repetitive pulling of one's hair resulting in noticeable hair loss. It typically begins in pre-adolescence, with an average onset age of 11.3 years 2. The condition affects approximately 0.5-2% of the population 3 and can cause significant distress and functional impairment.

Common characteristics in children include:

• Hair pulling from the scalp (most common), eyebrows, or eyelashes
• Variable length hairs in affected areas
• Absence of inflammation or scarring
• Possible association with emotional triggers or stressors
• May occur during relaxed states, often when alone

Assessment Approach

When evaluating a child with suspected trichotillomania:

1. Rule out medical causes of hair loss:

   • Differentiate from alopecia areata, tinea capitis, and other dermatological conditions 2
   • Consider trichoscopy to confirm diagnosis

2. Identify potential triggers:

   • Family stressors (parental separation, birth of sibling)
   • School performance issues
   • Sibling rivalry
   • Changes in living situation 2
   • Underlying anxiety or depression 4

3. Assess for associated behaviors:

   • Trichophagia (hair eating) - present in 5-30% of cases 2
   • Skin picking
   • Nail biting
   • Other body-focused repetitive behaviors 5

4. Screen for comorbid conditions:

   • Anxiety disorders
   • Depression
   • ADHD
   • Obsessive-compulsive traits 5

Treatment Algorithm

First-Line Treatments:

1. Behavioral Interventions:

   • Habit Reversal Training (HRT): Teaches awareness of hair pulling urges and substitutes competing responses 1
   • Stimulus Control: Modifies environments and situations that trigger pulling 1
   • These approaches are particularly effective when pulling occurs with lowered awareness

2. Parent Education and Involvement:

   • Educate about the condition (not deliberate misbehavior)
   • Avoid punishment or excessive attention to the behavior
   • Help identify and address underlying stressors 2

Second-Line Treatments:

1. Enhanced Behavioral Approaches (for cases with emotional triggers):

   • Acceptance and Commitment Therapy (ACT): Helps manage emotional triggers 1
   • Dialectical Behavior Therapy (DBT): Teaches emotional regulation skills 1

2. Pharmacological Options (for severe cases or when behavioral therapy fails):

   • N-acetylcysteine (NAC): Consider for all severity levels due to moderate benefit with low side effects 1
   • Selective Serotonin Reuptake Inhibitors (SSRIs): Consider when comorbid anxiety or depression exists 1

For Trichophagia (Hair Chewing/Eating):

• Increased monitoring for complications
• Education about potential risks including trichobezoars (hairballs in stomach) 6
• Regular medical follow-up to check for signs of trichobezoar (pallor, nausea, vomiting, weight loss) 2
• Prompt evaluation if gastrointestinal symptoms develop

Special Considerations

Psychological Support

• Consider referral to child psychologist for comprehensive evaluation 5
• Address underlying psychological issues that may trigger or maintain the behavior
• Provide support for altered body image and self-esteem issues 4

School Interventions

• Educate teachers about the condition to prevent bullying
• Consider accommodations if the child is experiencing social difficulties
• Involve school counselors when appropriate 4

Prevention of Complications

• Monitor for signs of trichophagia to prevent trichobezoar formation
• Watch for secondary bacterial infections from scalp manipulation
• Address potential social isolation and psychological impact 2

Pitfalls to Avoid

1. Misdiagnosis as alopecia areata or other hair loss conditions
2. Punitive approaches which may increase anxiety and worsen the behavior
3. Focusing only on the hair-pulling without addressing underlying emotional issues
4. Overlooking trichophagia and its potential serious complications
5. Expecting immediate results - treatment often requires time and persistence

Prognosis

With appropriate intervention, many children show improvement in trichotillomania symptoms. However, the condition may wax and wane over time, requiring ongoing support and possibly intermittent treatment. The psychological impact of the condition should be monitored, as it can affect self-esteem and social functioning.