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Trichotillomania: Advice from a Psychiatrist Although Seemingly Rare, Trichotillomania May Be More Common in Pediatric Dermatology Than Previously Thought

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Trichotillomania: Advice from a Psychiatrist Although Seemingly Rare, Trichotillomania May Be More Common in Pediatric Dermatology Than Previously Thought [ Pediatric Management] Trichotillomania: Advice from a Psychiatrist Although seemingly rare, trichotillomania may be more common in pediatric dermatology than previously thought. Here are approaches to treatment. By Pamela Chayavichitsilp and Victoria Barrio, MD with Brett Johnson, MD richotillomania is a psychiatric priate from a psychiatric standpoint is disorder characterized by repeti- crucial whether you decide to treat Ttive or compulsive hair pulling. these patients yourself or refer to psy- The reported prevalence is 0.6 to one chiatry for long-term treatment. percent of the population.1 However, According to Dr. Johnson, the most the actual percentage of the population important thing is to maintain as non- affected is probably much higher, espe- judgmental a stance as possible. These cially in the pediatric population. This patients are often already prone to feel is mostly because parents tend not to shame and guilt; letting them know bring children into the pediatric office that they are not alone may help relieve until hair loss becomes noticeable. By these feelings. and large, trichotillomania is an under- recognized condition that is only now Reversing the Habit starting to receive attention from both The first and probably most effective physicians and researchers. Johnson, MD, a child psychiatrist at intervention in the treatment of tri- University of California San Diego, chotillomania is called Habit Reversal Impulse Control believes that under these DSM IV crite- Therapy (HRT). This behavioral thera- The common age of onset of trichotil- ria, many cases of trichotillomania will py emphasizes self-monitoring and lomania is six- to 13-years-old. It is dif- be missed. He suggests that a broader teaches patients to use an alternative, ferent from other psychiatric disorders definition should be applied in order to non self-injurious action to replace hair (such as schizophrenia) insofar that an include those who have clinically appar- pulling. It has been used with good suc- earlier onset means a better prognosis. ent hair loss and/or those with social dis- cess in skin picking and tic disorders. When present at a very young age, the ruption or isolation as a result of any Below are four steps summarizing HRT: condition is termed “baby trich” which type hair pulling, not simply in order to 1. Assessment and functional suggests its earlier age of onset, its relieve tension. This will allow physi- analysis. Work with your patient to milder form, and its tendency to cians to diagnose more patients affected identify “high-risk times” during which resolve as the baby grows up. by trichotillomania and treat them the patient is most likely to pull out According to DSM IV criteria, physi- accordingly. his/her hair (for example, watching TV, cians can make the diagnosis of trichotil- Dermatologists often are the first- reading, times of high stress, etc). Take lomania if a patient has an increasing line clinicians to see patients with tri- a thorough history including what pre- sense of tension that is relieved by chotillomania, although these patients cedes the pulling and what actions pulling out the hair. Recurrent hair may need psychiatric treatment in the result. As many as 50 percent of pulling must also result in noticeable long run. In more severe cases, a refer- patients engage in oral rituals after hair hair loss. The disorder is classified under ral to a child psychiatrist who special- pulling, e.g. “trichophagia” (eating “Impulse Control Disorder Not izes in trichotillomania or OCD is hair). Therefore, it is also important to Elsewhere Classified.” This is a “waste- appropriate. Unfortunately, there is inquire about GI symptoms so as to basket” term that includes many other often a long waitlist, which can worsen catch and/or prevent “trichobezoar” conditions such as pyromania, patholog- your patient’s condition. Therefore, (hairball in the GI tract). ic gambling, and kleptomania. Brett knowing what interventions are appro- 2. Self-monitoring. Ensure that the 46 Practical Dermatology December 2007 [ Pediatric Management] patient keeps a log of her/his hair Atypical anti-psychotics. These are helping the irritation and itching that pulling activity including what he/she used as add-ons to SSRI’s when only results from new hair growth or chron- uses to pull out hair (fingers, pincer partial response is achieved and used as ic inflammation. grasps, tools), how long the hair pulling a monotherapy only when the condi- lasts, and what they do after. Parents tion is completely refractory to SSRIs. Behavioral Dermatology should also watch patients during their Risperidone is an example of an atypi- It is important to realize that complete leisure time for hair pulling that the cal antipsychotic that is recommended cure in trichotillomania is extremely patients themselves may not notice. for use in trichotillomania. rare. In most cases, it is a chronic Another tip: have patients/parents look Clomipramine. This is the only tri- disease that will require a life-long for hair on the patient’s pillow every cyclic antidepressant that is commonly behavioral approach with or without morning. used in trichotillomania. It is not a psychiatric medications. Therefore, 3. Stimulus control. Use techniques first-line medication because of many providers should educate patients and to prevent hair pulling such as wearing severe adverse effects including cardiac parents about the chronic nature of gloves or putting a piece of tape or a rhythm disturbances due to calcium the disease. Behavioral therapy takes band-aid on the finger used to pull. channel blocking properties. Generally, time to implement and most derma- These techniques must be socially it is used in cases refractory to both tologist visits do not allow for this acceptable and not cause embarrass- SSRI’s and atypical anti-psychotics. opportunity. If patients cannot see a ment for the patient. Mood stabilizers. Examples of psychiatrist for any reason, a psycholo- 4. Competing response interven- appropriate mood stabilizers include gist who practices cognitive behavioral tion. Develop an activity to substitute lithium and the valproates. Lithium therapy can also be useful for patients when the urge to pull hair occurs. has dermatologic side effects, including to receive help and start working on Some examples include deep muscle cystic acne and alopecia, therefore, it is their therapy. relaxation or taking a walk. If the not recommended for use in trichotil- 1. Bloch MD, Landeros-Weisenberger A, Dombrowski P et al. patient has a strong urge to pull on lomania. Systemic Review: Pharmacological and Behavioral Treatment for something, pulling on a “koosh ball” Low-potency topical steroids. Trichotillomania. Biol Psychiatry 2007;62:839-46. (as shown in the picture) is also an Topical steroids such as hydrocortisone 2. Gupta MA, Guptat AK. The use of antidepressant drugs in der- appropriate competing response. 1% are acceptable in matology. J Eur Acad Dermatol Venereol. 2001 Nov;15(6):512-8. Oral Therapies Habit reversal therapy may not be appropriate in certain populations such In Your Practice as in very young, developmentally New delayed, or autistic children. In these cases and other cases refractory to Pump Up the Cloderm! There’s a potentially more patient-friendly version behavioral therapy, oral medications of Cloderm cream, Coria recently announced. Cloderm (clocortolone pivalate) are acceptable. Below are some med- Cream 0.1% will be available in the easy-to-use Cloderm Pump that automati- ications commonly used by psychia- cally controls the amount of topical therapy dispensed for greater precision and trists in trichotillomania. safety, while encouraging patient compliance, the comapny says. • According SSRI’s. These anti-depressants are to results of a new study reported at a roundatable (Academy ‘07), Cloderm considered first-line treatments, not has the lowest potential off any mid-potency steroid to cause an allergic skin because of their higher efficacy than reaction. Subjects (n=39) who had a history of sensitization to steroids were other classes of drugs, but because of patch tested for 10 steroids in a petrolatum base on the skin initially for 48 the milder side effect profile.2 Dr. hours. Each site was evaluated for a sensitivity reaction after 48 and 96 hours. Johnson recommends fluoxetine in Cocortolone pivalate had the lowest rate of sensitivity reactions at 48 and 96 hours; one individual reported a reac- pediatric patients. It is also impor- tion at 96 hours compared with three for hydrocortisone-17-butyrate. tant to let your patient know that Winning Combo. The combination of adapalene with benzoyl peroxide in a fixed-dose gel formulation appears SSRI’s may take from eight to 12 effective for acne vulgaris (November, JAAD). Subjects (n= 517) were randomized to receive the fixed combination weeks to take effect. Also, paroxe- of adapalene 0.1% with BPO 2.5%, adapalene alone, BPO alone, or vehicle alone, all once daily. As early as the tine should generally be avoided in first week of the 12-week study, there were significant differences in total lesion counts between the combination trichotillomania because it has very and monotherapy groups. little effect on dopamine. December 2007 Practical Dermatology 47.
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