Trichotillomania

Trichotillomania is the compulsive pulling of one's hair. It affects women more commonly. It is frequently connected with depressive and obsessive-compulsive disorders (1).

This condition presents as irregular single patches of hair loss, with hair present in the patches of varying lengths and some strands twisted. Usually a history of playing or twirling of the hair is obtained. Patches are seen most frequently on the scalp but can also involve the eyelashes, eyebrows, pubic hair, body hair, and facial hair (2).

The mean age of onset is around 12-13 years. Hair pulling in early childhood (<5 years of age) is considered to be self limiting and usually disappears without intervention (2).

Extreme forms may indicate and underlying psychiatric disease.

According to the 'Diagnostic and Statistical Manual of Mental Disorders (DSM-IV)' the diagnostic criteria of tricotillomania 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 caused by a general medical condition (eg, a dermatologic condition)
• E - The disturbance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning (2)

Patients may present with additional "nervous habits" such as - nail biting, knuckle cracking, touching or playing with pulled hair, and hair eating (trichophagia which can lead to intestinal obstruction) (2).

Medical complications of tricotillomania include:

• infection
• permanent hair loss
• repetitive stress injury
• carpal tunnel syndrome
• GI obstruction with bezoars due to trichophagia (2)

Management

• a systematic review noted (3) that there was insufficient evidence from meta-analysis (12 studies; n=347) to confirm or refute efficacy of any agent or class of medication
  • preliminary evidence suggests there may be beneficial treatment effects for N-acetylcysteine, clomipramine and olanzapine in adults

Reference:

• 1. Papazisis G et al. Practice corner: managing trichotillomania - no need to pull your hair out. Evidence-Based Medicine 2008;13:66-67
• 2. Samuel R et al.Lifting the Veil on Trichotillomania. Am J Psychiatry 2007;64:568-574
• 3. Hoffman J, Williams T, Rothbart R, Ipser JC, Fineberg N, Chamberlain SR, Stein DJ. Pharmacotherapy for trichotillomania. Cochrane Database of Systematic Reviews 2021, Issue 9. Art. No.: CD007662. DOI: 10.1002/14651858.CD007662