Hair Loss Due To Hair Pulling – Trichotillomania
Trichotillomania, characterized by hair pulling, may be a syndrome by itself, or may be a symptom of several other psychiatric disorders including obsessive-compulsive disorder, impulse control disorder, body dysmorphic disorder, depression and personality disorders. Hair pulling in early childhood may be a separate condition because it is often self-limited and a response to a stressful situation. When the condition occurs in adolescence and adulthood it is usually chronic, difficult to treat and associated with underlying psychopathology. Women are more commonly affected than men by a ratio of 3.5:1.
The scalp is most commonly affected, however patients may also pull out eyebrows, eyelashes, pubic hairs and body hairs. The pulling results in areas of hair loss that contain broken-off hairs of varying lengths. Patients with trichotillomania often deny any type of hair manipulation. Parents of adolescents with the condition often participate in the denial. For this reason, I usually perform a scalp biopsy in patients suspected of having trichotillomania. It is helpful for patients and parents to have an objective test result confirming the more subjective clinical impression of trichotillomania. The differential diagnosis of trichotillomania usually includes regrowing alopecia areata. Both conditions result in areas of alopecia that may contain hairs of differing lengths, and both conditions may have stubble-like hairs giving a rough sensation when touched.
The major role of the dermatologist for patients with trichotillomania is establishing the diagnosis. Once this is done, the patient (and family) needs to be informed that the hair loss is caused by hair pulling. Some patients seem to be relieved that their hair pulling behavior is but in the open while others continue to deny any hair manipulation. The next step is referral to a psychiatrist or psychologist. For some families, referral to the school therapist is an acceptable first step down the road to acceptance and treatment of the condition. Treatment modalities given by psychologists and psychiatrists include behavior therapy, hypnosis, psychotherapy and pharmacotherapy. Support groups may also be beneficial.