Trichotillomania

K Siddappa

 Dept. of Skin & STD, JJM Meidcal College, Davangere - 577 004, Karnataka, India

Correspondence Address:
K Siddappa
"Prakruthi", 2830, 4th Main, MC Colony, 'B' Block, Davangere - 577 004, Karnataka
India

Trichotillomania from the Greek Thrix, hair; tillein, pulling out; mania, madness is one of the types of traumatic alopecia and accidental alopecia. While in trichotillomania alopecia results from deliberate (although at times unconscious) efforts of the patients, who is under tension or is psychologically disturbed, the cosmetic and accidental alopecias result from cosmetic procedures applied incorrectly or with misguided and excessive vigour or frequency and accidental trauma respectively.[1] It belongs to the primary psychiatric disorders (in which the skin manifestations are self-induced), which is one of the 5 categories of psychodermatologic disorders.[2]

Patients with hair pulling represent an extremely heterogeneous group. In broad spectrum of psychopathologies (from a transient mild habit, through impulse control disorder, the OCD spectrum, various personality disorders (e.g borderline personality, histrionic personality), body dysmorphic disorder, mental retardation to psycosis) hair pulling may be present as symptom in these disorders.[3] The term, trichotillomania, was originally used by Hallopeau in 1889 and its literal meaning is that of a morbid craving to pull out the hairs.[4] It is considered as a neglected psychiatric disorder with dermatologic expression.

What is trichotillomania?

It is defined as the irresistible urge to pull out the hair, accompanied by a sense of relief after the hair has been plucked. The textbook descriptions emphasize the appearance of chronic hair loss with broken-off hairs and localized patches of hair loss more often in areas of handed dominance .[4]

Epidemiology

The epidemiology is not completely clear.[5] Earlier it was thought to be quite rare, but on the basis of clinical data, now it appears to be far morn common than previously believed. Also because the media attention is increasing awareness o treatments for trichotillomania, affected person! are increasingly seeking medical care.[3]

The prevalence of the condition has no been studied in general population. While c questionnaire survey in U.S.A. of approximately 2,500 fresh college students with a 97.9°i response rate indicated prevalence of 0.6% in both male and female students, the prevalence increased to 3.4% of female students and 1.5°i of male students when the investigators ignore( the diagnostic criteria referring to tension, pleasure and gratification.[6] A similar survey of 700 fresh college students found that 11 % pulled their hair on a regular basis for other than cosmetic reasons.[7] Nonclinical hair pullers are very common in the general population compared to ′clinical′ hair pulling, with clinical evidence of patches of hair loss.

If is noted predominantly in girls and women and occurs more commonly in children than in adults. It occurs more than twice as frequently in females as in males.[8] The preponderance may be due in part to women′s greater willingness to seek medical care; men may hide their hair pulling better by masking if as male pattern baldness and shaving their mustaches and beards.[3] Affected children may be seven times more than adults.[1] The age of onset is usually between 5 and 12 years with equal sex distribution or early childhood to adolescence.[9] When it occurs later in life, during adulthood or in older patients, it is associated with psychopathology and with c poorer prognosis.[3]

There appear to be two distinct -populations: a) those who present in childhood[10] (who probably represent the bulk of cases) are acute cases, and b) those who present in adults (who are fewer) are chronic cases.[11] The adult age groups are associated with greater psychopathology and show distinct female preponderance,[11],[12] with no differences among races.[13],[14]

The hair-pulling behavior is recognized as senseless and undesirable but is performed it response to several emotions, such as increasing anxiety or unconscious conflicts with resultant tension relief. The scalp is the most common site for hair-pulling followed by the eyebrows, eyelashes, pubic area, trunk and extremities.[3]

Clinical Features

Scalp is involved in majority of cases Eyebrows, eyelashes, facial hairs, pubic, axillary, chest, abdominal or extremity hairs are involved in some.[9],[11] The hair pulling develops gradually and unconsciously but is not usually denied by the patient in the younger age group. In more severe form, the patient usually consistently denies plucking his or her hair. Most frequently hair is plucked from one fronto-parietal region, which is on the side of manual dominance. The temporal and occipital regions are usually spared. Typically the hairs are short, irregular, broken at various distance and distorted. On scalp an ill-defined patch develops in majority, but the full scalp may be involved in some. The clinical presentation of the lesion is characteristic. The linear or circular patches with irregular borders containing hairs of the varying length, the shortest being those most frequently plucked, result due to plucking of hairs either in a wavelike fashion across the scalp or centrifugally from a single point[3] [Figure - 1]. Less severely affected patients may have only small areas of baldness or imperceptible thinning over the entire head.[3] In severe from the tonsural pattern of baldness results involving the entire scalp sparing the hairs at the margins (the temporal and occipital regions)[1] [Figure - 2]. The process of plucking frequently fractures the hair shaft above or within the follicle so that the emerging hair has a fractured end. This gives a bristle-like feel as the hand is passed gently over the involved area.[3]

Patients pullout the hairs only because of irreresistible urge and accompanying anxiety. Also many patients report the hair pulling as being pleasurable. Patients with trichotillomania only pull their hairs; they do not substitute other compulsive rituals for this behavior.[3] Patients commonly try to conceal the alopecia with creative hair styling wigs, hair pieces, and constant use of hats o bandanas, makeup or false eyelashes.[15]

The disorder usually has periods a exacerbation and remission.[16] Some researcher; have emphasized the disturbed family relations it these patients,[9],[16],[17] and they have reported poor marital relations, family tension, faulty mother child interaction patterns characterized by ambivalence hostility and separation anxiety. Some patient: compulsively pick at the scalp, in addition to pulling the hair, resulting in numerous painfull traumatic lesions. Some patients use the dominant hand others the nondominant hand or both hands it pulling .[3]

Types

According to some authors, there are two forms of trichotillomania: (a) acute form and (b chronic form.[10]

Acute form: This form usually involves children or adolescents and is more likely to be c stress-induced habit response. Usually scalp is involved, initially asymmetrically, later may involve both sides of the scalp and in time the eyebrow: and eyelashes. The clinical course is frequently episodic with periods of complete remission occurring 2-3 times a year. The form is reported to be benign and self- limited.[10],[18]

Chronic form: This form usually involves adults and older patients and is associated with significant psychopathology. Usually involves the scalp, face and also secondary sexual hairs. The clinical course is progressive and chronic with a poorer prognosis.[3]

In many patients, a specific time and location are reserved for hair pulling. Some o the high risk situations for hair pulling include watching television, reading, talking on the phone lying in bed, driving and writing.[3]

Associated conditions

There is an association with anxiety and dysthymia,[19] learning disability and iron deficiency In the childhood and adolescent group emotional problems tend to be less severe; it is more a stressful life event.[16] The adult and older patients show more diverse psychopathology with depression anxiety disorders, obsessive compulsive disorder (OCD) and panic attacks prominent substance abuse and eating disorders may also be evident [11],[10]

Chewing or biting hair, rubbing hair around the mouth, licking the hair or ingesting i (trichophagy) are the oral behaviors associated with hair pulling.[3]

Other medical behaviors and complications

Trichotillomania appears to be commonly associated with other problematic behaviors such as nail biting, skin picking the acne lesions, nose picking, lip biting and cheek chewing.[11],[20]

Medical complications are uncommon but sometimes may be serious Trichobezoar (gastric or intestinal hair ball) is rare but potentially life threatening. It may cause intestinal obstruction gastric or intestinal bleeding or perforation, acute pancreatitis, or obstruction, jaundice, as well a! discomforting symptoms such as abdominal pain nausea, vomiting, constipation, diarrhoea flatulence, anorexia and foul breath.[9]

Other unusual complications include skin infection at the site of pulling, blepharitis, chronic neck, shoulder or back pain of prolongec abnormal pulling postures; carpal tunnel syndrome and avoidance of health care to escape shame.[21]

Clinical Assessment

Various methods are adopted for clinical assessment of the cases but in accordance with Koran[22] engaging the patient in any assessment method that increases awareness of pulling behavior and enhances accountability for the amount of hair pulled may be useful in treatment

Investigations

(1) Hair microscopy -may help to show the broken off and fractured hairs with blunt end.[4]

(2) Scalp biopsy.[3],[1]

Histopathologic changes vary according to the severity and duration of hair plucking.

(a) The most relevant histologic features is the presence of normally growing hairs among empty hair follicles in a non-inflammatory dermis.[23]

(b) Follicular plugging with keratin debris can be prominent.

(c) There are dystrophic features of the follicular epithilium with dystrophic cells. The hair shaft is often broken or reduced to little dark bodies.

(d) Strands of basaloid-appearing cells may be present in the base of plucked follicles.

(e) Clefts separating the cells of the matrix from one another, evidence of trichomalacia (distortion and curling of the bulb) seen deep in the follicle which is almost a sign of pulling-evidence of traumatic damage is often seen on the retained portion of partially extracted hairs.

(f) Separation of the follicular epithelium from the surrounding connective tissue sheath and areas of intraepithelial and perifollicular haemorrhage in a notable absence of inflammatory cells seen if the trauma extraction is severe.

(g) Many follicles are in catagen with very few or no follicles in telogen.

(h) The presence of normal anagen follicles in the affected area is evidence against an underlying disease.

(3) Full blood count and ferritin.[4]

There is a relationship to iron deficiency and full blood count and ferritin levels are useful indicators of associated aggravating factors such as anorexia/bulimia and pica.

(4) Investigations for trichobezoar.[4]

Diagnosis

Normally detail history and clinical examination establishes the diagnosis. If necessary hair microscopy and scalp biopsy will be useful.

Differential diagnosis

(1) Alopecia areata: This is the most common condition to be differentiated from trichotillomania. Presence of an initial area of almost total hair loss, Presence of "exclamation point" hairs, pulling large numbers of hairs by gentle pulling from the periphery of lesions are all characteristic of alopecia areata.

(2) Tinea capitis-can be ruled out by microscopic examination of scrapings.

(3) Absence of inflammatory changes both clinical and microscopic rules out inflammatory dermatoses.

(4) Alopecia caused by medications.

(5) Alopecia caused by poisons such as thallium. (6) Alopecia toxica (loss febrile illness)

(7) Alopecia traumatica (loss from excessive use of hair "softeners" or hot combs)

(8) Alopecia syphilitica (seen in secondary syphilis).

(9) Alopecia secondary to irradiation.

(10) Alopecia mucinosa.

(11) Myxedematous alopecia.

Treatment

Treatment begins with taking a detail history of the disorder and its effects and inquiring about possible comorbid conditions. There is no established effective treatment approach in a large controlled trial.[3] Various therapeutic modalities which have been considered include:[3],[4] (a) Supportive psychotherapy, (b) Directive and autogenic training. (c) Behavior therapy which involves various techniques-self monitoring; coping strategies; motivation enhancement; awareness training; competing response; relaxation training. (d) Hypnotic therapy, (e) Psychotherapy and (f) Pharmacotherapy.

Obviously all the non medicals require specialized training.

For children with acute trichotillomania identification of stressful episodes (with the help of patients parents) with accompanying support and parent education is usually all that is necessary. Elucidation of the stress and corrective counseling (about the common psychological factors) usually relieve the problem.[4] Encourage child to transfer plucking tie to hairs of a fuzzy stuffed animal and consider child psychologist if parent child relationship is disturbed. Prescribe clomipramine when necessary.[4],[5],[24]

Behavior therapy

Behavior therapy is said to be useful. The first report of behavioral intervention foi trichotillomania consisted of self-monitorinc accompanied with response chain interruption where in-patients monitored their hair-pullinc attempts and consciously stopped pulling hairs.[25],[26] In other interventions counting and recording hail pulls,[25],[27] denial of privileges and applying some greasy topical agents to stop pulling, averse self-stimulation with a rubber band,[28],[29] and punishments via sit-us whenever a pull attempt is made were used. At the end of treatment patients in these reports had zero hair pulling rates.

Others combined self-monitoring, hail counting and measuring hair length with taken re. inforcement,[30] self-denial of privileges,[31] and behavioral contracting.[32] The addition of these techniques increased treatment success rate.[25]

In addition to self-monitoring other behavior therapies have been applied. Moderate to positive improvement has resulted from cover desensitization,[33] attention reflection and response prevention by cutting hair close to the scalp,[34] attention reflection combined with punishment,[35] covering the patients face and hair with a soft cloth (facial screening)[36] and multiple componen treatment package consisting of self-monitoring hair collection, goal setting, relaxation and stimulus control.[37]

The most successful self-management treatment in the mediation of hair pulling is habit reversal. Habit reversal introduced by Azrin and Nunn[38] showed remarkable results by then and other researches have also found similarly encouraging results. Some researchers have found good results with a modified form of habit reversal derived from the behavioral literature.[22]

Not every element needs to be utilized with each patient.

Hypnotic therapy

A variety of hypnotic suggestions that have been applied usually as adjuncts to other behavioral or psychotherapeutic treatment elements included pain of touching the scalp or pulling hair,[39] increased awareness of hair pulling behavior through associated hand warming,[37] and rituals other than hair pulling to decrease anxiety.[40] In the absence of controlled studies and in view of heterogeneity of techniques, no conclusion can be drawn about the utility of hypnosis in the treatment of trichotillomania.

Psychotherapy

For chronic cases with remissions and exacerbations, who do not repond to other modalities of therapy, psychotherapy offers best long-term prognosis.

Pharmacotherapy[3],[4],[41]

Many drugs appear promising but actually the only drug which is found effective in controlled trials appears to be clomipramine. Response to imipramine, isocarbazed, trazodone and sertraline and isolated cases that responded to amitriptyline and buspirone are reported.

Efficacy for the combination of serotonergic reuptake inhibitors (SSRIS) (flavoxetine, paroxetine, sertraline, citaloprem) and neuroleptics (haloperidol, pimozide, risperidone) is observed in uncontrolled studies. There are reports of successful treatment of trichotillomania with sertraline Hcl 50mgs at bed time and fluxetine 10 mgs daily. Fluocinolone shampoo 0.01 % twice weekly has been found bseneficial in some cases.

Because clomipramine (50-200mgs/day) appears to be the drug whose effectiveness has been demonstrated in a double blind trial, it deserves primary consideration. Thus the first-line strategy should be a trial of clomipramine.

Venlafaxine and mitrazapine (which strongly enhance both serotonergic and noradrenergic functioning) may become alternative drugs.

The addition of low dose (2-3mgs/day) of pimozide risperidone (1 mg/day) or haloperidol can be considered in cases with a partial or unsustained response to clomipramine.

If pruritus motivates pulling a short trial of topical steroid to a partially effective regimen may be indicated.

Uncontrolled observation of long-term benefit from lithium and other drugs, that diminish neuronal excitability such as valproate or gabopentin are worth investigating in patients who complain of overwhelming impulses to pull.

A trial of the opiate antagonist naltrexone may be considered in patients whose pulling is strongly motivated by pleasurable sensation.

While treating patients of trichotillomania with comorbid conditions, the clinician should choose a drug which is beneficial to both the conditions.

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