What should I do if my 15-month-old child is pulling their hair out?

Hair Pulling in a 15-Month-Old Child

In a 15-month-old child pulling their hair out, this is most likely a benign self-soothing behavior or normal exploratory activity rather than trichotillomania, which typically onsets around age 11 years, and reassurance with watchful waiting is the appropriate initial approach.

Understanding the Context

At 15 months of age, hair pulling is developmentally normal and distinct from pathological trichotillomania:

• Trichotillomania has a mean onset age of 8-13 years (average 11.3 years), with occurrence in the first year of life comprising less than 1% of cases 1
• Hair pulling in infants and toddlers is typically an automatic, self-soothing behavior during relaxed states or when tired 1
• This age group engages in repetitive behaviors as part of normal development and sensory exploration 2

Differential Considerations

Benign Developmental Behavior (Most Likely)

• Self-soothing or exploratory behavior is the most common cause at this age 1
• Often occurs during relaxed situations like before sleep or while watching television 1
• Not associated with psychological distress or underlying psychiatric conditions in toddlers 3

Medical Causes to Exclude

Examine the scalp carefully for:

• Tinea capitis: Look for scaling, erythema, broken hairs, and consider fungal culture if suspected 1, 4
• Alopecia areata: Presents with smooth, round patches of complete hair loss with exclamation point hairs at margins 1
• Cutaneous markers of spinal dysraphism: Check for midline hypertrichosis (focal hair tuft), infantile hemangiomas, subcutaneous masses, or dimples over the spine that would warrant imaging 5

Recommended Management Approach

Initial Assessment

• Observe the pattern and location of hair loss to distinguish self-inflicted pulling from medical causes 4
• Document whether hair is of variable length (suggests pulling) versus complete smooth patches (suggests alopecia areata) 1
• Assess for environmental stressors: recent changes in family dynamics, new sibling, separation from caregivers, or changes in routine 1

Conservative Management

• Reassure parents that this behavior is typically self-limited in toddlers and often resolves without intervention 3
• Redirect the child's hands when pulling is observed, offering alternative sensory activities 3
• Ensure adequate attention and minimize potential stressors in the child's environment 1
• Avoid drawing excessive attention to the behavior, as this may inadvertently reinforce it 3

When to Escalate Care

Refer for further evaluation if:

• Hair loss is progressive or extensive despite behavioral interventions 3
• Scalp shows signs of inflammation, scaling, or scarring suggesting infectious or autoimmune etiology 4
• High-risk cutaneous markers are present (hypertrichosis, infantile hemangioma, subcutaneous lipoma over the spine) that could indicate underlying spinal cord malformation 5
• The behavior persists beyond age 3-4 years or intensifies rather than diminishes 1, 3

Important Caveats

Do not diagnose trichotillomania in this age group without compelling evidence, as the diagnostic criteria require awareness of tension before pulling and relief afterward—cognitive capacities not present in 15-month-olds 1. The behavior at this age lacks the obsessive-compulsive features and psychological distress that characterize true trichotillomania 5.

Trichoscopy or dermoscopy can aid diagnosis if the clinical picture is unclear, showing features like variable hair length and broken hairs in trichotillomania versus specific patterns in other conditions 4. However, biopsy is rarely needed in children for hair loss evaluation 4.

The prognosis for hair pulling beginning in early childhood (preschool age) is generally favorable, with most cases resolving spontaneously as the child matures and develops alternative coping mechanisms 1, 3.