Trichotillomania

Hallopeau, 1889

• Hair pulling tic
• Hair twirling
• Hair plucking
• Trichotillomania
• habitual hair pulling
• hair pulling tic
• Alopecie par grattage
• Hair pulling disorder

Mostly transient, neurological-compulsive pulling out of one's own hair. The disorder involves secondary illness gain (attention), shows self-stimulation, autoagression or may be a symptom of a psychiatric disorder.

• 0.6% of the population is affected
• Lifetime prevalence 0.5-1.5% (men)
• Lifetime prevalence 3% (women)
• Age peak: 5th and 12th year of life
• M:F = 1:5
• Manifestation age in boys: 8 years
• Age of manifestation in girls: 12 years
• Trichotillomania of the toddler affects boys more frequently

• The neurological-compulsive pulling out of all body hair occurs consciously or unconsciously.
• Dysfunctional family relationships and/or a disturbed detachment from the mother leads to an inadequate formation of ways to deal with tension and aggression in those affected. This results in disturbed impulse control and unconscious aggression problems
• Hair pulling and manipulation is a coping mechanism that is always used when there is tension
• Psychological disorders are often associated with this clinical picture. These include:
  • Compulsive disorders
  • Depression
  • Anxiety disorders
  • Impulse disorders

• Hairs of different lengths conspicuous
• There is no local, complete hair loss
• Mostly short, stubby, broken hairs are still visible in the manipulated areas
• The alopecia is usually blurred
• A sharp demarcation is possible. (CAVE: misdiagnosis of alopecia areata)
• Conspicuous scalp full of hair shafts
• Inconspicuous scalp
• Unlike scarring alopecia, hair follicles are present in trichotillomania
• Sometimes follicular haemorrhages are found
• Multiple areas of alopecia are rare
• A high proportion of anagen hairs (>90%) is found in the trichogram, as the loosely anchored telogen hairs have been pulled out
• When the disease is severe, the trichogram shows many dysplastic and dystrophic hairs
• Dysfunctional family relationships and friendships
• often poor school performance
• Trichophagy (chewing and swallowing the hair) is practised by some patients. There is a risk of intestinal obstruction here
• Ritualised plucking at a specific time or place may occur
• Persistent disease is often accompanied by the following behavioural disturbances: Thumb sucking and nail biting

• Anamnesis
  • For this condition, the medical history is not usable, as the plucking and pulling out of hair is usually denied
• Clinic
• Trichogram
  • ↓Telogenous hair, ↑Anagen hair (> 90%)
• Biopsy for evidence of trichomalacia
• No evidence of scaling
• eventual fungal cultures are negative
• Microscopy: trichoptilosis incl. greenwood fractures, trichorrhexis nodosa-like hairline fractures

• Head
• Eyelashes (in 25%)
• Eyebrows (in 25%)
• Genital hair (rare)

• often impossible to exploit, as the condition is either denied or the affected person is not aware of it
• Inquire about the ritualisation of plucking
• Clarify manipulation of the hair
• Elicit chewing and eating of hair by the patient
• Clarify school performance or aggression
• Inquire about relationship with family members and friends
• Inquire about psychiatric disorders such as schizophrenia, conduct disorder or depression

Keratin is found in the follicular ostia, but also melanin deposits. Haemorrhages are visible.

In combination with trichophagy, where hair is chewed and swallowed, trichobenzoars can develop. These are clumps of hair that, due to the indigestibility of the hair material, can accumulate in the stomach and obstruct it

If young children are affected, the disease usually disappears on its own

• The diagnosis is usually rejected by the patient or their parents
• A purely symptomatic approach is not induced
• Psychological therapy
• Behavioural therapy
• Group therapy
• If necessary, shaving the hair (plucking is thus impossible), this can be used to interrupt the tics, especially in young children
• SSRIs have been shown to have a positive effect in some studies, but their use is still controversial, as other studies have come to contradictory conclusions
• In adults, olanzapine or N-acetylcysteine showed positive results in some studies
• When pharmacological therapy is used in the context of a psychological disorder, the patient should be classified into one of the following categories: Anxiety Disorder, Depression, Psychosis, Obsessive Compulsive Disorder (OCD)

Anxiety disorder:

• Lorazepam 0.5-2mg every 6-8 hours for max. 4 weeks → indicated for acute panic attacks, sedation of patient possible
• Buspirone 15mg/day in 3 doses with possibility of escalation by increasing the dose by 5mg every 2-3 days up to a maximum of 60mg/day → induced when long-term therapy is aimed for, onset of action only 2-4 weeks after the start of treatment
• Antidepressants such as peroxetine (20-50mg/day), sertraline (25-200mg/day), doxepin (<50mg/day), fluoxetine (10-60mg/day), escilatopram (10-20mg/day) or venlafaxine (75-150mg/day)

Depression:

• Antidepressants all have a similar success rate of 60-80%
• The onset of action does not occur until 2-3 weeks after the start of treatment
• Tricyclic antidepressant such as doxepin. This also has an effect on the H1 receptor and can thus combat itching and scratching of the scalp. Dose for itching alone: 10-25mg at bedtime, dose for depression 100-300mg/day, titrating up from a starting dose by 10-25mg every 1-2 weeks. The main side effect is sedation
• SSRIs such as fluoxetine, paroxetine, sertraline, escitalopram and zitalopram can be prescribed. The side effect profile is better here. In case of non-response after 6-8 weeks, the medication should be changed or supplemented with another drug such as venlaflaxine or bupropion

Psychosis:

• Pimozide, starting dose 1mg/day, up titration of 1mg each every 1-2 weeks until desired effect occurs, but therapy success is often only visible after 2-6 months, especially helpful in parasitosis, caution! QT prolongations are possible, side effects are mainly extrapyramidal symptoms
• The following drugs show a better side effect profile with regard to QT prolongation: risperidone, olanzapine, quetiapine, aripiprazole, ziprasidone and iurasidone

OCD:

• SSRI is the medication of first choice.
• Higher doses are needed for optimal therapy than indicated for depression.
• Response usually does not occur for 4-8 weeks and may take up to 20 weeks to be optimal for the patient
• Therapy duration after reaching optimal response: 6 months to 1 year

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7. Menon V, Shaik S, Mohan P. Very early onset trichotillomania presenting with recurrent trichobezoar: Conventional wisdom questioned. Int J Trichol 2015;7:36.