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Trichotillomania
Evidence Levels: A Double-blind study B Clinical trial ≥ 20 subjects C Clinical trial < 20 subjects D Series ≥ 5 subjects E Anecdotal case reports
Trichotillomania, or hair-pulling disorder, is the impulsive, repetitive action of pulling out hair, resulting in significant hair loss. Any region of the body with hair can be involved, with the eyebrows, eyelashes, and scalp comprising the most common sites. The reported prevalence of trichotillomania is approximately 0.6% in the general population with a mean age of onset between 11 and 13 years. It is predominantly observed in females.
The Diagnostic and Statistical Manual of Mental Disorders, 5th edition (DSM-5), categorizes trichotillomania as an ‘obsessive-compulsive disorder,’ which is a change from the DSM-4, which categorized trichotillomania as an ‘impulse disorder.’ Obsessive-compulsive disorders include intrusive thoughts or urges that are experienced as unwanted (obsession), often necessitating repetitive behaviors or rituals to help alleviate the otherwise intolerable anxiety (compulsion). The DSM-5 diagnostic criteria for trichotillomania are:
- A.
Recurrent pulling out of one’s hair resulting in noticeable hair loss
- B.
An increasing sense of tension immediately before pulling out the hair or when attempting to resist the behavior
- C.
Pleasure, gratification, or relief when pulling out the hair
- D.
The disturbance is not better accounted for by another mental disorder and is not due to general medical conditions
- E.
The disturbance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning
Patients with trichotillomania often admit to hair pulling; however, some patients are unwilling or ashamed to acknowledge the self-inflicted nature of their skin findings, whereas others are not conscious of their hair pulling. Some patients practice specific rituals after hair pulling including rolling the hair between the fingers, running the hair over the lips or through the teeth, and biting the hair. In rare cases, the patient may also eat the hair root (trichorhizophagia) as a secretive activity, and in even rarer cases the whole hair is eaten (trichophagia). It is possible to develop gastrointestinal hairballs (trichobezoars), which have a high morbidity and can be fatal. Children with trichotillomania who present with episodes of obscure abdominal pain, weight loss, nausea, vomiting, anorexia, and foul breath should be investigated for gastric trichobezoars.
Many patients with trichotillomania have underlying psychiatric disease. It is estimated that up to 80% of patients with trichotillomania have comorbid psychiatric disease, most commonly anxiety and depression. Patients with trichotillomania may have other types of obsessive-compulsive disorders, specifically body-focused repetitive behavioral disorders, such as skin picking and nail biting. The patient may be delusional in cases such as trichophobia, in which an individual has an irrational ideation that something must be picked out of the skin in order for their hair to grow normally, resulting in a clinical presentation of psychogenic excoriation.
Diagnosis
Patients with trichotillomania present with alopecia that is generally irregular and non-scarring. Broken, sparse hair on a background of excoriations is often observed. Hairs are broken at different lengths on the scalp. The diagnosis of trichotillomania can be made on a clinical basis with careful examination of the scalp. Dermatologic differential diagnoses that should be ruled out include alopecia areata, androgenic alopecia, alopecia mucinosa, tinea capitis, lichen planopilaris, folliculitis decalvans, and discoid lupus erythematosus. Tinea capitis may be ruled out by the absence of scaling and negative fungal scraping or culture. Laboratory investigations such as complete blood count, thyroid function tests, and iron levels may also be indicated. Dermoscopy can be useful to detect black dots (‘exclamation point hair’), or broken or curled hairs. A skin biopsy may be warranted if the dermoscopy findings of trichotillomania overlap with other causes of hair loss. Trichotillomania presents histologically as empty follicles, follicular keratin debris, melanin pigment casts, an increased number of catagen hairs, and traumatized hair bulbs in the absence of perifollicular inflammation (trichomalacia).
Management Strategy
Trichotillomania can cause significant social isolation and psychological disability; therefore, treatment of this disorder is important to restore the patient’s quality of life. There are currently no US Food and Drug Administration treatments approved for trichotillomania. However, there are psychotherapeutic and pharmacologic treatments that are effective in alleviating symptoms of trichotillomania. Psychotherapy , including behavioral therapy, has been shown to be the most effective treatment in both pediatric and adult populations. Habit-reversal training is a form of behavioral therapy that focuses on four key aspects: awareness (increase consciousness of hair-pulling behavior), competing response training (perform a specific action when there is an urge to pull hair), social support or contingency management (a person who reinforces the former), and stimulus control (minimize the influence of environmental factors on pulling behavior). Habit-reversal training has been shown to decrease repetitive, self-inflicted behaviors, and can especially benefit children from disease progression into adulthood.
Effective pharmacologic treatments involve treating any underlying psychiatric disease. The first-line pharmaceutical approach depends on the underlying causes of trichotillomania, such as obsessive-compulsive disorder, anxiety, depression, substance abuse, or eating disorders.
Studies of pharmacologic therapy for the treatment of trichotillomania have been limited. N-acetylcysteine (NAC) has shown reduction of hair pulling in adults in a 12-week double-blind, placebo-controlled study using a dose of 1200 mg/day for 6 weeks and 2400 mg/day for the remaining 6 weeks. However, this improvement in symptoms has not been demonstrated in a pediatric controlled trial. NAC is an ideal first-line pharmacologic therapy because its side effect profile is mild (e.g., flatulence and bloating). The tricyclic antidepressant clomipramine, indicated for obsessive-compulsive disorder, has been shown to reduce the frequency of hair-pulling urges. Clomipramine is started at a dose of 25 mg/day and is titrated up to 125–250 mg/day. Side effects include headache, orthostatic hypotension, anticholinergic effects, QT prolongation, and seizures.
High-dose selective-serotonin reuptake inhibitors (SSRIs) , such as paroxetine, fluoxetine, or sertraline, can also be used to treat trichotillomania. Although SSRIs alone have not shown significant evidence to effectively treat trichotillomania, the combination of pharmacotherapy and habit-reversal training has been shown to be effective in decreasing the frequency of hair pulling. Paroxetine is typically started at 20 mg daily and then increased by 10 mg weekly to up to 50–60 mg/day. Fluoxetine is started at a dose of 10 mg/day and is titrated up to an effective dose, which usually ranges from 20 to 80 mg/day. The usual starting dose of sertraline is 50 mg/day, with an effective dose ranging typically from 50 to 200 mg/day. Side effects of SSRIs include gastrointestinal upset, headache, sexual dysfunction, and suicidality. Atypical antipsychotics such as olanzapine and aripiprazole have been reported to be successful in case reports.
Specific Investigations
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