Trichotillomania

1. Epidemiology
   1. Prevalence may be as high as 1-4%
   2. Most common cause of childhood Alopecia
   3. Younger ages affected more commonly
      1. Mean age of onset: 8 years (boys), 12 years (girls)
      2. Rarely occurs after age 40 years
   4. More common in females by ratio of 2.5 to 1
2. Symptoms
   1. Patient has irresistible desire to pull out their hair
   2. Hair pulling episodes
      1. Hair twisted or twirled around finger and pulled
      2. Duration of minutes to hours
      3. Satisfaction on pulling out an entire hair with root
      4. May be associated with eating hair (Trichophagia)
   3. Sites of hair pulling
      1. Eyebrows and eyelashes (most common)
      2. Scalp (especially frontoparietal area)
3. Signs: Alopecia
   1. Coin-sized areas of Hair Loss
      1. Uneven broken hairs
   2. Distribution
      1. Frontoparietal patches of Hair Loss (may advance posteriorly)
      2. Eyelash and eyebrow loss
   3. Tonsure Trichotillomania (severe)
      1. Completely bald except for narrow outer fringe
4. Labs: Scalp biopsy
   1. Hair Follicle shows no inflammatory signs
   2. Trichomalacia pathognomonic for Trichotillomania
5. Differential Diagnosis
   1. See Alopecia
   2. Alopecia Areata
6. Associated Conditions
   1. Obsessive Compulsive Disorder (most common)
   2. Major Depression
   3. Anxiety Disorder
   4. Eating Disorder
7. Management
   1. Hypnosis
   2. Psychotherapy with Cognitive Behavioral Therapy
   3. Behavior Modification (e.g. habit reversal)
   4. Stress Management
   5. Medications
      1. Selective Serotonin Reuptake Inhibitor (SSRI)
      2. Clomipramine (Anafranil) - sedating
      3. Olanzapine (Zyprexa)
      4. Acetylcysteine
8. Complications
   1. Skin damage and secondary Skin Infections
   2. Scarring
   3. Decreased self esteem
   4. Social avoidance
9. References
   1. Habif (1996) Clinical Dermatology, Mosby, p. 755
   2. Tasman (1997) Psychiatry, Saunders, p. 1271-8
   3. Koo (2001) Am Fam Physician 64(11):1873-78 [PubMed]
   4. Messinger (1999) Pediatr Rev 20(7):249-50 [PubMed]
   5. Phillips (2017) Am Fam Physician 96(6): 371-8 [PubMed]