Trichotillomania

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

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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Stein DJ, Flessner CA, Franklin M, Keuthen NJ, Lochner C, Woods DW. Is Trichotillomania a Stereotypic Movement Disorder? An Analysis of Body-Focused Repetitive Behaviors in People with Hair-Pulling. Annals of Clinical Psychiatry 2008;20:194-8.
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Menon V, Shaik S, Mohan P. Very early onset trichotillomania presenting with recurrent trichobezoar: Conventional wisdom questioned. Int J Trichol 2015;7:36.

Differential diagnoses