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

1. Mazuecos J, Rodriguez-Pichardo A, Camacho F. Pubic trichotillomania in an adult man. Br J Dermatol 2001;145:1034-5.
2. Walsh KH, McDougle CJ. Trichotillomania. American Journal of Clinical Dermatology 2001;2:327-33.
3. Hautmann G, Hercogova J, Lotti T. Trichotillomania. Journal of the American Academy of Dermatology 2002;46:807-26.
4. Papadopoulos AJ, Janniger CK, Chodynicki MP, Schwartz RA. Trichotillomania. International Journal of Dermatology 2003;42:330-4.
5. 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.
6. Duke DC, Keeley ML, Geffken GR, Storch EA. Trichotillomania: A current review. Clinical Psychology Review 2010;30:181-93.
7. Menon V, Shaik S, Mohan P. Very early onset trichotillomania presenting with recurrent trichobezoar: Conventional wisdom questioned. Int J Trichol 2015;7:36.