Trichotillomania

1. Epidemiology
   1. Prevalence may be as high as 1%
   2. Most common cause of childhood Alopecia
   3. Younger ages affected more commonly
      1. Mean age of onset: 8 years (boys), 12 years (girls)
      2. Rarely occurs after age 40 years
   4. More common in females by ratio of 2.5 to 1
2. Symptoms
   1. Patient has irresistible desire to pull out their hair
   2. Hair pulling episodes
      1. Hair twisted around finger and pulled
      2. Duration of minutes to hours
      3. Satisfaction on pulling out an entire hair with root
      4. May be associated with eating hair (Trichophagia)
   3. Sites of hair pulling
      1. Eyebrows and eyelashes (most common)
      2. Scalp (especially frontoparietal area)
3. Signs: Alopecia
   1. Coin-sized areas of Hair Loss
   2. Tonsure Trichotillomania (severe)
      1. Completely bald except for narrow outer fringe
4. Labs: Scalp biopsy
   1. Hair Follicle shows no inflammatory signs
   2. Trichomalacia pathognomonic for Trichotillomania
5. Differential Diagnosis
   1. See Alopecia
   2. Alopecia Areata
6. Associated Conditions
   1. Obsessive Compulsive Disorder (most common)
   2. Major Depression
   3. Anxiety Disorder
   4. Eating Disorder
7. Management
   1. Behavior Modification (e.g. habit reversal)
   2. Hypnosis
   3. Psychotherapy
   4. Stress Management
   5. Medications
      1. Selective Serotonin Reuptake Inhibitor (SSRI)
      2. Clomipramine (Anafranil) - sedating
8. References
   1. Habif (1996) Clinical Dermatology, Mosby, p. 755
   2. Tasman (1997) Psychiatry, Saunders, p. 1271-8
   3. Koo (2001) Am Fam Physician 64(11):1873-78
   4. Messinger (1999) Pediatr Rev 20(7):249-50