Trichotillomania

and
Psychocutaneous disorders
Presented by:
Priyesh Lohani
 Trichotillomania
• Derived from Greek as thrix (hair), tillein (pull out), and mania (madness).
• Also known as trichotillosis or neuromechanical alopecia.
• A neurosis characterized by an abnormal urge to pull out the hair.
• Seven times more common in children than in adults.
• Girls are affected (2.5x) more often than boys.

• Often develops in the setting of psychosocial stress

• school problems, sibling rivalry, moving to a new house, hospitalization of a
parent, or a disturbed parent-child relationship.
 Revised DSM-IV diagnostic criteria:
A. Recurrent pulling out of one’s own hair resulting in hair loss

B. An increasing sense of tension immediately before pulling out hair or when

attempting to resist behaviour

C. Pleasure, gratification or relief when pulling out the hair

D. Disturbance is not better accounted for by another mental disorder

E. Disturbance provokes clinically marked distress and/or impairment in occupational,

social or other areas of functioning
 Clinical Features
• Sites involved (dominant side due to ease of access)
• generally the frontal region of the scalp, eyebrows, eyelashes, and beard.
• The classic presentation is the “Friar Tuck” form of vertex and crown alopecia.
• Irregular areas of hair loss, which may be linear or bizarrely shaped.
• Infrequently, adults may pull out pubic hair.
• Hairs are broken and show differences in length.
• Plucking activity are centrifugal from a single starting point or linear, in a
wave-like activity.
 “Friar Tuck” sign

The character Friar Tuck from Robin Hood (A) Round patch of incomplete alopecia on the vertex demonstrating the
"tonsure pattern" or "Friar Tuck sign". No inflammation or scale was
present on examination.
(B) Detail of the alopecic area.
Other features
• The pulled hair may be ingested, and occasionally the tricho-bezoar
will cause obstruction.
• abdominal pain, nausea, vomiting, and constipation

• Rapunzel syndrome: ball-like aggregations of hair in stomach with tail

extending to the small/large intestine.

• The nails may show evidence of onychophagy (nail biting).

 Differentials
• Alopecia areata
• Trichotillosis has varying lengths of broken hairs, no nail pitting, with microscopic
appearance of the twisted or broken hairs.

• Other organic disorders to consider

• Androgenic alopecia, tinea capitis, monilethrix, pili torti, pseudopelade of Brocq,
traction alopecia, syphilis, nutritional deficiencies, and systemic disorders such as
lupus and lymphoma.

• Also need to look for underlying comorbid psychopathology

• obsessive-compulsive disorder (most common), depression, or anxiety.
Diagnosis
• Trichoscopy: Reveals broken hairs of varying lengths; some may be
frayed, longitudinally split, or coiled.

• Biopsy (if necessary):

• Reveals traumatized hair follicles with perifollicular hemorrhage, fragmented hair
in the dermis, empty follicles, and deformed hair shafts (trichomalacia).
• Multiple catagen hairs are typically seen.

• Barium contrast and CT scan: For gastrointestinal tricho-bezoars.

Trichoscopy

Trichoscopy showing decreased hair

density, broken hairs with different shaft
lengths (black arrows), short vellus hairs
(white arrows), signs of haemorrhage
(square box), and an absence of
exclamation mark hairs.

Note a recently fractured hair (arrow head).

 Management
• In children
• Diagnosis should be addressed openly, and referral to a child psychiatrist for cognitive-
behavioural therapy (CBT) should be encouraged.
• Habit-reversal training is often part of the treatment.

• In adults
• Pharmacotherapy with Clomipramine is the most effective of the studied medications
• SSRIs are most often prescribed and may help any associated depression or anxiety
• N-acetylcysteine also shows promise; relatively inexpensive and well tolerated

• Trichobezoars require surgical removal.

 Other psychocutaneous disorders
• Dermatitis artefacta
• A form of factitious disorder where patients produce skin lesions through
their own actions.
• Despite the self-induced nature of the lesions, they typically deny any role in
their production.
• Lesions often have bizarre shapes, irregular outlines, or geographic
patterning.

• Neurotic excoriation
• These patients are more likely to admit to manipulation of the skin than those
with factitial dermatitis.
• Complain of an uncontrollable urge to scratch, rub, or pick at their skin.
• Localized or generalized excoriation covered by a serosanguineous crust.
• Delusions of parasitosis
• Patients are convinced their skin is infested by parasites, regardless of
any evidence to the contrary.
• Often present with small bits of excoriated skin, debris, insects, or insect
parts that they show as evidence of the infection.
• Samples of alleged parasites enclosed in assorted containers, paper tissue,
or sandwiched between adhesive tape referred to as the “matchbox” sign.

• Obsessive-Compulsive Disorders
• Compulsive repetitive handwashing may produce an irritant dermatitis
of the hands.
• Other common behaviours include compulsive pulling of scalp,
eyebrow, or eyelash hair; biting of the nails and lips, tongue, and cheeks.
• Dysmorphophobia
• Patients are rich in symptoms but poor in signs of organic disease.
• Self-reported “complaints” or “concerns” usually occur in 3 main areas: face, scalp, and
genitals.
• Mostly men preoccupied with body build, genitals, and hair thinning.
• Mostly women preoccupied with the appearance of their hips or their weight, to pick their
skin, to camouflage defects with makeup, and to have comorbid bulimia nervosa.

• Psychogenic Pruritus
• Poorly defined entity in which the patient has intractable or persistent itch, not ascribed to
any physical or dermatological illness.
• Pruritic episodes are unpredictable with abrupt onset and termination, predominantly
occurring at the time of relaxation.
• There are cycles of stress leading to pruritus as well as of the pruritus contributing to
stress (itch-scratch-itch cycle)
• Bromidrosiphobia
• Monosymptomatic delusional state in which a person is convinced that his or her
sweat has a repugnant odour that keeps other people away.
• Unable to accept any evidence to the contrary.
• May be an early symptom of schizophrenia.

Onychophagia. Dermatitis caused by lip licking.

References
• Andrew’s Diseases of the Skin, 12th Edition

• PubMed
• https://www.ncbi.nlm.nih.gov/books/NBK519704/table/ch3.t27/
• https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4143797/
• https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3399682/
• https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1911167/
Can’t have hair pathology if you have no hair -_-