PSYCHOCUTANEOUS MEDICINE Trichotillomania: A Review and Case Report Michelle A. Nuss, MD; David Carlisle, MD; Mary Hall, MD; Srinivas C. Yerneni, MD; Rodney Kovach, MD Although patients with trichotillomania typically This article reviews trichotillomania from both present to dermatologists, the diagnosis and dermatologic and psychiatric perspectives. It pre- treatment lie in the field of psychiatry. We report sents the case of a 33-year-old African American an unusual case of a 33-year-old woman with woman with multiple family members experiencing severe trichotillomania. We review common clin- trichotillomania. In addition, our patient has pulled ical and pathologic findings of this often chronic out the hair of other family members. Finally, her and socially debilitating disorder. In addition, son developed an area of scalp alopecia as a result of we discuss treatment options for dermatologists her pulling out his hair. He himself also was devel- and how collaboration with psychiatrists is the oping signs and symptoms consistent with trichotil- most effective management for these difficult-to- lomania. While a review of the literature revealed a treat patients. report of several patients pulling out the hair of Cutis. 2003;72:191-196. other family members, no report was found describ- ing alopecia in another person. t has become increasingly apparent that there exists a clinical interface between dermatology Case Report I and psychiatry. Psychocutaneous medicine has A 33-year-old African American woman was been recognized for decades and includes diseases referred to our dermatology clinic by her primary such as delusions of parasitosis, lichen simplex care physician for evaluation of alopecia. Her chief chronicus, chronic urticaria, body dysmorphic dis- complaint was a 3-month history of an increasingly order, trichotillomania, psoriasis, and dermatitis repetitive urge to pull out her hair. Previously, her artefacta, to name a few. These can be classified as primary care physician had prescribed fluvoxamine; disorders in which the body image is distorted, self- however, she reported no change in her symptoms. esteem is impaired, comorbid dysregulation of She readily admitted to the self-induced nature affect exists, and somatopsychic relationships are of the hair pulling. The patient remembered present, which reflects the emotional toll of beginning to pull out her hair at the age of 10 or chronic skin diseases.1 Women outnumber men in 11 years, upon awakening from a dental procedure all the psychocutaneous diseases. For dermatolo- that had required sedation. She did not remember gists, these diseases pose a challenge, especially in this to be a traumatic event; however, she recalled treatment. Patients are drained emotionally and having a sense of increased anxiety. Months before can be difficult to manage without the additional the dental procedure, the patient reported frequent help provided by psychologists or psychiatrists. and escalating sexual abuse by her father. This Pharmacology may relieve symptoms only partially, began as fondling and inappropriate touching and and other nonpharmacologic treatments usually progressed to penetration. By the age of 16 years, are indicated, including hypnosis, biofeedback, the abuse was occurring on an almost daily basis. relaxation therapy, and psychotherapy.2 According to the patient, the abuse was never revealed to her mother. She stated that her mother was a “strict disciplinarian” and her knowing about Accepted for publication November 25, 2002. the abuse would only “hurt her mother,” whom she From the Department of Medicine, West Virginia University School loved very much. Indeed, it may be that the hair of Medicine, Morgantown. Reprints: Michelle A. Nuss, MD, Department of Medicine, West pulling was an unconscious expression of internal Virginia University School of Medicine, One Medical Center Dr, rage toward the mother. In fact, the patient may PO Box 9160, Morgantown, WV 26506 ([email protected]). have been struggling with the possible loss of love VOLUME 72, SEPTEMBER 2003 191 Psychocutaneous Medicine Figure 1. A tonsure pattern of scalp alopecia consisted Figure 2. The patient’s eyebrows and eyelashes were of a sparse distribution of long and short hairs through- symmetrically absent. out the scalp, except for a rim of normal-appearing hair at the periphery. or fear of punishment by the mother. The abuse to rule out organic causes of alopecia. Findings finally came to an end when her older sister, who revealed a deformed hair shaft, with pigmentary was also being abused, threatened to reveal the debris in the follicle (Figure 3). abuse to their mother. There were several specific aspects of the While the degree of hair pulling in our patient patient’s hair pulling that were particularly striking. has waxed and waned since initial onset, an almost The patient reported a family history of hair pulling global scalp alopecia had been present since shortly that included 2 maternal cousins, a maternal aunt, after the birth of her first child, 9 years ago. She and a maternal grandmother. On several occasions admitted to pulling out her scalp hair, followed by the patient had pulled out the facial hair of her hus- the eyebrows, eyelashes, extremities, and pubic hair. band and father, with their permissions. Most In addition, she describes a methodical pattern of revealing is the repetitive pulling out of a patch of “sucking out” the root end, which she described as her son’s scalp hair, which she states had a reddish “deveining it,” and then eating the root. She cast at one time. Her son now has an area of scalp described increasing tension before the hair pulling. alopecia in that region. This was confirmed on phys- Also, our patient experiences intense pleasure and ical examination. She was referred to the univer- relief when the act is completed. She had no other sity’s medical-psychiatric clinic, where it was significant medical issues and denied any tics; recommended that she begin psychotherapy and obsessions; or compulsions, such as checking, increase her dose of fluvoxamine. The psychiatrist counting, or washing. also suggested that olanzapine or pimozide be added At the time of evaluation, a tonsure pattern of to the fluvoxamine therapy. Unfortunately, the scalp alopecia was present. This consisted of a sparse patient’s insurance status precluded psychotherapy, distribution of long and short hairs throughout the and she subsequently failed to keep several follow-up scalp, except for a rim of normal-appearing hair at visits. When we last spoke by telephone, she was the periphery (Figure 1). Eyebrows and eyelashes still pulling out her hair, which she has done now for were symmetrically absent (Figure 2). Although she almost 22 years. admitted to having pulled out her pubic hair in the past, she recently began shaving this area. No clini- Comment cal evidence of an inflammatory, fungal, or scarring Trichotillomania is classified psychiatrically under process was evident at the time of the physical the impulse control disorders. Dermatologically, it examination. The dermatologist performed a biopsy is a cause of alopecia secondary to repeatedly 192 CUTIS® Psychocutaneous Medicine pulling out one’s own hair. Onset can occur at any often is reluctant to admit to a self-inflicted cause. age but most commonly presents during the pre- The diagnosis usually can be made by history and teen years. While often a self-limited disorder in physical findings; however, histologic studies are children, trichotillomania frequently follows a helpful to rule out other causes and to help support chronic relapsing course in adults.3 The patient the diagnosis.4,5 Patients often have a concurrent diagnosis or history of other psychiatric problems, such as depression or anxiety. Although trichotillo- mania has several similarities with obsessive- compulsive disorder (OCD), it remains a separate clinical diagnosis, with devastating social implica- tions and potentially life-threatening complications if the hair is ingested. The Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) outlines 5 crite- ria that must be met for the psychiatric diagnosis of trichotillomania: (1) recurrent pulling out one’s hair resulting in noticeable hair loss; (2) an increased sense of tension immediately before pulling out hair or when attempting to resist the behavior; (3) pleasure, gratification, or relief when pulling out hair; (4) the disturbance cannot be bet- ter accounted for by another mental disorder and is not due to a general medical condition; (5) the dis- turbance causes clinically significant distress or impairment in social, occupational, or other impor- tant areas of function.6 The prevalence of trichotillomania has been dif- ficult to establish; however, the incidence is more common than once thought. Christenson et al7 found that 0.6% of the college students they studied met DSM-IV criteria for trichotillomania, while 2.5% were found to pull out their hair to the point of visible hair loss. Rothbaum and associates8 conducted 2 studies with college-aged students and A Figure 3. A deformed hair shaft with pigmentary debris in the follicle (A and B) B (H&E, original magnifications ϫ4 and ϫ10). VOLUME 72, SEPTEMBER 2003 193 Psychocutaneous Medicine found that 0.5% and 1%, respectively, pulled out frequently patterned, ill-defined, or sharply out- their hair on a regular basis for other than cosmetic lined areas of nonscarring hair loss. Classic patterns reasons and described significant stress with this can be linear patches or even the tonsure appear- activity. However, 10% and 13% of the students ance as described in our patient. Eyebrow and eye- admitted to pulling out their hair without any asso- lash involvement is usually symmetric. In a study of ciation with stress. Findings like these have led to 60 adults, Christenson et al3 described an asymmet- questioning the rigidity of the DSM-IV criteria. ric pattern of scalp alopecia in 60% of subjects. This The average age of onset consistently shows that group also reported pulling out their hair from more hair pulling is more common in the early teenaged than one area 62% of the time.