What is trichotillomania?

Trichotillomania: A Body-Focused Repetitive Behavior Disorder

Trichotillomania is a body-focused repetitive behavior disorder characterized by recurrent hair pulling from any region of the body, resulting in noticeable hair loss, and causing significant distress or functional impairment. 1

Clinical Features

Trichotillomania typically presents with:

• Bizarre pattern of nonscarring patchy alopecia with short hairs of variable length 2
• Negative hair pull test along the edges of alopecia 3
• Predominantly affects the scalp (75%), but may also involve eyebrows (42%), eyelashes (53%), beard (10%), and pubic area (17%) 3
• Distinctive trichoscopic findings showing abnormalities from stretching and fracture of hair shafts 2

Epidemiology and Onset

• Prevalence ranges from 0.6% to 4% in the general adult population 2, 4
• Higher prevalence in females (3.4%) compared to males (1.5%), with women showing 5-10 times higher rates overall 4
• Mean age of onset is pre-pubertal, typically between 8-13 years (average 11.3 years) 3
• Three age-related subsets: preschool children, preadolescents to young adults, and adults 3

Diagnostic Criteria

According to DSM-5, trichotillomania is classified under Obsessive-Compulsive and Related Disorders 5, 1 and is characterized by:

1. Recurrent pulling of one's hair resulting in noticeable hair loss
2. Repeated attempts to decrease or stop the hair pulling behavior
3. The hair pulling causes clinically significant distress or impairment in social, occupational, or other important areas of functioning
4. The hair pulling is not attributable to another medical condition or mental disorder 3

Differential Diagnosis

Key conditions to distinguish from trichotillomania include:

• Alopecia areata: Shows complete hair loss in patches, positive pull test, and exclamation mark hairs at the periphery 5
• Tinea capitis: Presents with scalp inflammation and scaling 5
• Telogen effluvium: Diffuse hair loss without broken hairs 3
• Early scarring alopecia: Shows signs of inflammation and scarring 5
• Systemic lupus erythematosus: May have other systemic symptoms 5
• Secondary syphilis: Requires serological testing 5

Diagnostic Approach

When trichotillomania is suspected:

• Perform trichoscopy to identify characteristic features of hair pulling 2
• Consider skin biopsy in cases where diagnosis is uncertain, which typically shows increased catagen and telogen hairs without inflammation 3
• Assess for comorbid conditions, particularly other psychiatric disorders 1

Comorbidities

Trichotillomania frequently co-occurs with:

• Other body-focused repetitive behaviors like excoriation (skin-picking) disorder 1
• Attention Deficit Hyperactivity Disorder (ADHD) 1
• Anxiety disorders, including separation anxiety disorder (20.6%) 1
• Oppositional defiant disorder (36%) 1
• Tic disorders (12.7%) 1

Treatment Approaches

First-Line Treatment

• Cognitive-behavioral therapy (CBT), particularly habit reversal training, has the strongest evidence for effectiveness 2, 6
• Components include awareness training and teaching specific physical actions that make hair pulling impossible 1

Pharmacological Options

• N-acetylcysteine is a good first-line pharmacological option due to significant benefits and low risk of side effects 2
• Clomipramine (a tricyclic antidepressant) has shown the most effectiveness in clinical trials 6
• Selective serotonin reuptake inhibitors (SSRIs) are commonly prescribed despite limited evidence of efficacy 6

Management Considerations

• A comprehensive, interdisciplinary approach involving dermatologists, psychiatrists, and psychologists is essential 2
• Physicians should maintain a nonjudgmental, empathic attitude toward patients 2
• For pediatric patients, family education is crucial, emphasizing that negative feedback and punishment for hair pulling are counterproductive 2
• Social support is a significant factor in successful treatment outcomes 2

Prognosis

Without appropriate treatment, trichotillomania tends to follow a chronic course with waxing and waning of symptoms. Early intervention with evidence-based treatments offers the best chance for symptom reduction and improved quality of life 7.

Complications

Rare but serious complications include:

• Secondary bacterial infections with regional lymphadenopathy from picking and scratching 3
• Trichobezoar (hairball in stomach) in patients who ingest pulled hair (trichophagia), which occurs in approximately 5-30% of adult patients 3

Trichotillomania represents a significant psychiatric condition that often first presents to dermatologists. Recognition of its distinctive clinical features and prompt referral for appropriate psychological and pharmacological management are essential for optimal outcomes.