Nonsuicidal Self Harm—Superficial Cutting. Superficial cutting with inscribing the word “Die” in a patient with intermittent suicidal ideations. (Photo contributor: Kevin J. Knoop, MD, MS.)
Trichotillomania (“hair pulling disorder”) is an impulse control disorder resulting in compulsive hair pulling, which leads to noticeable hair loss. This disorder is often seen in patients who exhibit characteristics of obsessive-compulsive behaviors. Hair is repeatedly twisted around the finger and then pulled out or rubbed until it breaks off. Various body sites may be involved, but the scalp is most commonly affected. A hallmark of the hair loss is variable lengths of hair within the region of hair loss.
Other locations commonly affected include the beard line, face, arms, legs, eyebrows, and eyelashes. Young children, adolescents, and women are most commonly affected.
Management and Disposition
Psychiatric referral for habit reversal therapy is first-line management of trichotillomania in children. N-Acetylcysteine is more effective than placebo in treating trichotillomania. Tinea capitis, alopecia areata, malnutrition, monilethrix, and other medical causes of hair loss should be considered. Evaluation for behavior such as ingestion of hair, forming a trichobezoar (hairball), is important. A trichobezoar is a rare complication that can result in intestinal or gastric obstruction and often requires surgical removal. Computed tomography (CT) imaging is necessitated when symptoms of obstruction are present.
Trichotillomania. Note complete hair loss (alopecia) is not present, but rather patchy incongruent areas of hair loss are noted with variable lengths of hair within the affected area. (Photo contributor: Timothy D. McGuirk, DO.)
Trichotillomania. Lateral upper and lower lid eyelashes have been pulled with mild blepharitis as a complication of eyelash pulling. (Image appears with permission from VisualDx [www.visualdx.com].)
Trichotillomania. Both eyebrows and eyelashes are missing in this patient with impulse control disorder. (Image appears with permission from VisualDx [www.visualdx.com].)
Hallmarks of trichotillomania include marked areas of hair loss on the face and scalp with variable lengths of hair present in the affected area.
Trichotillomania is most often present with other obsessive-compulsive disorders, and the management of such associated conditions is paramount in correcting this behavior disorder.
Ingestion of hair may result in a trichobezoar, which can cause obstructive gastrointestinal symptoms.