Are You Confident of the Diagnosis?
What you should be alert for in the history
Trichotillomania (TTM) refers to a condition in which the individual pulls out his or her own hair. This is primarily a psychiatric disorder, and much of the relevant clinical and statistical information is in the psychiatric literature. Because of this, dermatologists may not always recognize the severity of TTM, the psychiatric components, and the profound impact that the condition may have on the health of the patient and the quality of life for the patient and the patient’s family.
Comorbid major depressive disorder, anxiety disorder, and borderline or histrionic personality disorders are common, as are eating disorders. These comorbidities should not be forgotten in the evaluation and treatment of the patient with TTM.
Characteristic findings on physical examination
Although two separate behavior patterns of hair pulling are described: “automatic” and “focused” hair pulling, clinical experience in dermatology would suggest that there is in fact a broad and continuous spectrum of pulling behavior. Psychiatric researchers have primarily studied focused pulling and have noted that there may be nail biting, skin picking, or other self-destructive habits as part of the syndrome.
Automatic pulling occurs when the patient is relaxed, absorbed in thought, daydreaming, reading, or watching television. Automatic pulling takes place out of the complete awareness of the individual. It is frequently preceded by a ritual of stroking the hair, fondling it, or twirling it between the fingers, before the actual pulling. This automatic form of hair pulling need not be associated with stress or a build-up of tension, and need not necessarily lead to evident hair loss.
Focused TTM is the most serious expression of the condition, and should be considered in the diagnosis of any patient who presents with patchy hair loss. In this condition, hair pulling is usually carried out in secret, and adamantly denied by the patient. The clinical picture, however, is a give-away. The scalp is the most common site, followed by the eyebrows, eyelashes, and pubic hair, in that order. But any hair-bearing area is at risk, and the dominant side is favored. Interestingly, these patients do not complain of pain and, indeed, may even find the activity pleasurable.
The pulling activity is preceded by an irresistible urge to pull the hair, and a mounting and unbearable tension that can be relieved only by the act of pulling. It is primarily focused pulling that leads to clinically evident TTM.
The individual patches of TTM vary in size and shape and are single more commonly than multiple. Pulling may occur at random within the patch, or may occur in waves from back to front, or centrifugally. (Figure 1, Figure 2, Figure 3). Within the involved patch are broken hairs of varying length, fine new hairs, distorted or discolored hairs, and the remnants of damaged outer root sheaths in the mouths of empty follicles. These findings, though clinically quite evident, may be made even more clear on dermoscopy.
When the pulling is “wave-like”, whether the action be from back-to-front, front-to-back, or centrifugal, there will be longer hairs in that part pulled first, progressing through shorter and shorter hairs, to those that are only very short stubble. Extreme cases of centrifugal pulling may result in the “tonsure” or “Friar Tuck” look, in which the entire top of the head is bald, and only a peripheral fringe of hair remains (Figure 4). Perhaps the most characteristic clinical sign is the stubbly feeling generated by the broken hairs as one gently passes one’s hand over the involved patch. This sign is diagnostic of TTM.
Focused pulling may be ritualized, may occur at a particular time of day, and may be incited by triggers in the environment. These triggers need not necessarily be associated with situational stress, although this is often the case. Some patients find hair pulling “energizing” and use it to relieve boredom. Others seclude themselves behind a locked door and pull out hair for several hours at a time—in one case an 8-hour spell is reported. TTM must be considered in the case of any patient who spends long periods of time hidden away in the bathroom or bedroom.
Some describe an uncomfortable sensation in a specific follicle, or a belief that the texture of a particular hair is altered. These discomforts cannot be relieved until that particular hair is located and removed. Unfortunately, to locate that special hair may take hours, and may entail the pulling of a great many other hairs before it is located, thus leading to increasing baldness.
Most commonly, the fingers are used for pulling, but some patients resort to tweezers. The pulled hairs may then be subjected to rituals such as fondling, stroking the lips, biting of the ends, or being swallowed.
Expected results of diagnostic studies
The diagnosis of TTM may be confirmed by shaving a small area within an involved patch. This can then be covered with a water-proof dressing, which is left in place for one week. Upon removal of the dressing, hair will be seen to have grown normally in the shaved area.
The biopsy findings in TTM are diagnostic. Growing hairs are seen amongst empty and distorted follicles in a noninflamed scalp. There are a high percentage of catagen and telogen follicles. There may be clefts in the hair matrix, follicular epithelium may be separated from the connective tissue sheath, and intraepithelial and perifollicular hemorrhages may be seen (Figure 5).
TTM must be differentiated from alopecia areata, tinea capitis, and secondary syphilis.
In alopecia areata, the bare scalp is smooth, with fine regrowing vellus hairs, and without broken, distorted, or discolored hairs. There is no stubbly feeling on passing the hand gently over the involved area. Exclamation point hairs may be identified at the margins of the involved patch.
Tinea capitis occurs most commonly in children, and is characterized by seborrheic-like scaling in addition to hair loss. Tinea capitis caused by Microsporum canis will fluoresce in Wood’s light, while that caused by Trichophyton tonsurans has typical black dots in the follicles. Fungal cultures are positive.
The hair loss in secondary syphilis is described as “moth-eaten,” and a physical examination will reveal other cutaneous and mucosal signs of the disease. An appropriate blood test will be positive.
Who is at Risk for Developing this Disease?
It is difficult to estimate the true incidence of TTM because there are many sufferers who do not seek help, different researchers apply different diagnostic criteria, and there are few controlled studies. The Diagnostic and Statistical Manual of the American Psychiatric Association V criteria are very stringent, and cover only the extreme psychiatrically-focused end of the spectrum.
There are, however, a number of inventories that are designed to diagnose and determine the behavioral pattern and severity of TTM in individual patients. Estimates of the incidence of hair pulling in the general population vary greatly. Figures from 1.0% to as high a 13.4% are quoted in the literature, with a 0.6-3.6% frequency in adults, while 11.3% of college-aged young adults reportedly pull their hair “at least occasionally”.
The incidence of TTM is said to be bimodal, but once again there is a spectrum.
Children under 6 years of age, reportedly, have a more benign form of TTM. This form has equal gender incidence. It is self-limited in the vast majority of cases, and primarily provides comfort for children who are anxious. Those who have suffered a significant loss, for example absence of a parent, hospitalization, or loss of a pet, or who have been deprived of tactile stimulation for some reason, may fondle and pull the hair for comfort or in frustration and anger. A small percentage of these children may continue hair pulling into adolescence or adult life, but this percentage is not known.
More significant TTM begins in adolescence or early adult life, and runs a fluctuating course. The reported female: male ratio increases with advancing age, from 3.4:1.5 in young adults, to as much as 15:1 in older individuals. For most patients there is a history of childhood abuse or other childhood difficulties.
Men are less likely than women to seek help. It has been stated that men who are balding or who elect to shave the head, cannot get sufficient purchase to pull the hair. Many in both sexes conceal their hair loss with wigs, hairpieces, scarves, and the like, so it may well be that the incidence is higher than quoted in the literature. All these possibilities may slant the ratio.
What is the Cause of the Disease?
TTM is the cutaneous expression of a psychiatric disorder, and is now included in the obsessive-compulsive spectrum. Our patients commonly have comorbid generalized anxiety disorder, panic disorder, major depressive disorder, or borderline or histrionic personality disorder. Those who are more severely impaired psychologically have more severe hair pulling, and the condition is more common in those who have a family member who also suffers. It is not clear, however, whether this reflects genetic or environmental factors.
Both the dopamine and serotonergic systems are involved, and recent studies suggest that the glutamate system may also play a part.
It is now felt that TTM is symptomatic of obsessive-compulsive disorder. Pathophysiologically, the relationship of TTM to the other psychiatric disorders with which it is comorbid is unclear.
Systemic Implications and Complications
The implications and complications of TTM may be both psychological and physical.
In childhood cases, the parents worry about the possible causes of hair loss. They are unwilling to accept the diagnosis. They fear that it reflects negatively on their child-rearing practices. Once the diagnosis is confirmed and accepted, parental anxiety may be expressed as anger and frustration, or in over-solicitousness and spoiling. Neither response is good for the emotional well-being of the child.
Commonly, children with TTM have other impulse-driven habits such as nail biting, skin picking, and rocking. Internal and parental conflict centered on these habits, lead to poor self-esteem, friction with the parents, poor school performance, teasing in school, and lack of friendships, with a goal of social isolation. These negative factors can result in a downward spiral.
Adolescent and adult patients are embarrassed, self-conscious, and diminished by the appearance of TTM. Shame caused by lack of control is common. Body image issues, body dysmorphic disorder, and eating disorders may be present. These lead to avoidance behavior, social isolation, and difficulties with family relationships, and in the workplace.
Infections in the scalp may result from manipulation. Painful and distorted fingers and carpal tunnel syndrome are reported.
Though reports vary, as many as 20-40% of patients actually swallow the hair that has been pulled. Trichophagia may cause dental erosions and gingival inflammation.
In up to 50% of those who are known to ingest hair, a hairball, or trichobezoar forms in the stomach. This ball may become too large to pass through the gastro-duodenal sphincter. Hair may then accumulate in the intestines distal to the stomach, in what has been called the “Rapunzel syndrome” (Figure 6, Figure 7). Trichophagia may cause constipation, weight loss, intestinal obstruction, intussusception, erosion of the gastric wall, obstructive jaundice, protein-losing enteropathy, and anemia.
To rule out any of these complications, patients must be examined carefully with regard to possible dental or gingival problems. One should check for other self-destructive activities, like nail biting and skin picking, to support the diagnosis. Look for tendinitis, carpal-tunnel syndrome, weight issues, jaundice, vitamin or protein deficiency, anemia, or an eating disorder. Be alert to body dysmorphic issues. Order routine baseline studies. Abdominal radiologic studies are mandatory if abdominal signs or symptoms are detected.
The occlusive dressing test is helpful, and a biopsy is diagnostic. With pediatric patients, a biopsy is often needed to convince unbelieving parents.
– Development of a therapeutic relationship
– Referral to psychiatrist or psychotherapist
– Habit-reversal therapy
– Cognitive-behavioral therapy
– Insight-oriented psychotherapy
Topical treatment for pruritus or secondary infection, including compresses, topical antibacterial agents, topical steroids, and anti-inflammatory shampoos as indicated.
– Specific serotonin reuptake inhibitors (SSRIs)
– Atypical antipsychotics
– N-Acetylcysteine – primarily in children
– Treatment for any medical complications
– Laparotomy and surgical repair in cases in which a trichobezoar has formed
– Treatment of carpal tunnel syndrome, tendinitis, etc.
– Appropriate dental care
Optimal Therapeutic Approach for this Disease
Remembering that TTM is a psychiatric disorder, and that there is no primary skin pathology, treating only the skin is not an effective option, and referral to a psychiatrist or psychotherapist must be the primary goal.
Given the common denial and negative affect usual in patient and family, a trusting therapeutic relationship is essential in order to reach a point at which referral is possible. This is inevitably time consuming. Frequent visits, even if quite short, will demonstrate interest and caring, and help to establish trust and rapport.
Once the parents are able to accept the diagnosis, empathic support of both parent and child may be all that is necessary until the problem is outgrown. After interviewing the parent and child, it is often helpful to interview the child alone. An alliance can be formed, and the patient may be more willing to speak frankly in the absence of the parent.
Take supportive measures. Give parents a guarded, but positive prognosis. Identify the triggers, and find ways to divert the child’s hands and attention. Parents should not blame themselves. Try to identify situations that the child finds stressful.
Find ways for the parents to reduce stress and to help the child better to handle stressful situations. Neither dermatologist nor parents should be impatient or judgmental. Do not let hair pulling become the focus of a power struggle. Assure the child that pulling is neither voluntary nor confrontational. Obtain information and self-help books from the Internet.
If the status fails to improve, referral to a child psychiatrist or therapist is the next step.
A good relationship with the family pediatrician or primary care doctor can help to reinforce suggestions and provide encouragement and support. Should psychiatric referral not be accepted, the pediatrician can be helpful in prescribing oral medication, and in continuing to supervise progress. In addition to the antidepressant and anti-anxiety medications, in one study N-acetylcysteine was found to be effective in 56% of children.
For adult patients, the doctor-patient relationship is a vital part of treatment. Developing a relationship is inevitably time consuming, but even short frequent visits express interest and caring. They permit trust to develop and are emotionally supportive.
An approach to the interaction, as rapport is being established, is to state that TTM is a life-long problem and then ask what made this the time to seek help. Immediate stresses can be addressed, and the patient supported in dealing with them. Has the patient consulted other doctors before? How did it go? Did the patient feel brushed off? Did the doctor seem ignorant? (This has often been a complaint from patients.)
Empathize with the patient’s disappointment, frustration, or anger. Assure the patient that self-blame is not appropriate, and that TTM is not a voluntary act. Acknowledge the patient’s feelings of shame, frustration, anger, and other negative feelings.
Do not be impatient or judgmental, and be aware of one’s own feelings, so as not to permit the patient’s negativity to arouse negativity within oneself. Help the patient to identify triggers, and try to offer alternative activities or other solutions. Try to assess the psychological status of the patient, so that comorbidities can be addressed if that is not already underway. Do not exacerbate feelings of helplessness and hopelessness.
Explain to the patient the current treatment options for TTM. These are:
– Habit reversal therapy (HRT)
– Cognitive-behavioral therapy (CBT)
– Insight-oriented psychotherapy
– One of the SSRIs
– One of the atypical antipsychotics
Once trust is established, it is important to make very clear that your recommendation is referral for psychotherapy.
The responses to HRT and CBT are essentially equal. There is little published information about insight-oriented therapy, though occasional positive reports of individual patients are encouraging. On theoretical grounds this approach should be effective, but no statistics are available, and the cost for such long-term treatment for most patients would be prohibitive.
Other than ordinary hygiene, no topical treatment is indicated for the scalp, unless there is itching or infection.
Folliculitis secondary to manipulation should be treated with a topical antibiotic ointment (triple antibiotic or mupirocin). Positive bacterial cultures should be treated accordingly.
For itching, a topical steroid lotion (betamethasone dipropionate 0.5%) may by prescribed, to be rubbed in sparingly twice daily, together with an over-the-counter dandruff shampoo (Nizoral).
Systemic treatment has not been recommended for the treatment of TTM in children, other than the N-acetylcysteine. A low dose of an SSRI may be prescribed to address comorbid anxiety or depression. These drugs are better prescribed by a pediatrician or a psychiatrist because of their greater experience, as the side effect profile in children is not wholly benign.
At this time, no drug is approved by the Food and Drug Administration specifically for TTM, though the SSRIs, antipsychotics, and naltrexone all are reported effective. Most patients are sophisticated and look up medications on the Internet, so one must present the drug of choice in a way that is acceptable to the patient. Assure the patient that you do not, for example, think he or she crazy or a drug addict, but rather that these drugs work on a number of pathways different from those that they may have read about.
Reassure the patient that dose schedules in dermatology are low. Outline the common side effects, but explain that these are rare in our patients because of the low dose schedule that we use.
As an incentive, stress again how TTM affects the patient’s quality of life.
It is important to start these drugs at a very low dose and titrate them up gradually, to keep the side effects to a minimum.
If the patient is already seeing a psychiatrist, or taking a psychotropic drug, call the prescriber, and discuss the options with him or her.
In the adolescent or adult patient, if psychiatric referral is not accepted, and if supportive treatment is inadequate to reduce hair pulling, one may prescribe one of the psychotropic drugs reported effective. If an SSRI is chosen, it will at the same time address comorbid anxiety and depression.
Reports of the effectiveness of the SSRIs are variable. Studies suggest that they reduce hair pulling in about 50% of cases. The addition of an SSRI enhances the benefits of psychotherapy. If one SSRI is not effective or not tolerated, then another may be prescribed. It may take as long as 4-6 weeks for the drug to be fully effective.
Examples of SSRIs are: fluoxetine (Prozac 10 mg once daily, with increments of 10 mg every 5-7 days as tolerated, to a maximum total dose of 60 mg given as a single dose once daily), sertraline (Zoloft 50 mg once daily, with increments of 50 mg every 3-5 days, to a maximum total dose of 200 mg, given as a single dose once daily), and citalopram (Celexa 10 mg once daily, increasing to 20 mg in 5-7 days).
Possible side effects include gastric intolerance, cholinergic effects, sweating, weight gain, and decreased libido.
Several antipsychotics are also moderately effective. An antipsychotic may take the place of an SSRI, or may be added to boost the effect of the SSRI. Pimozide (Orap 1.0-3.0 mg once daily), haloperidol (Haldol 0.5-3.0 mg once daily), risperidone (Risperdal 1.0-2.0 mg once daily at bedtime), and olanzapine (Zyprexa 5.0-10 mg daily) are reported effective.
These are relatively low doses, and side effects not only are minimal, but also can be expected to diminish over time. Sedation, fatigue, and accommodation disturbance may occur. Cardiac side effects from pimozide do not occur with a dose under 10 mg once daily, and tardive dyskinesia is not reported in the dermatology literature.
There are encouraging reports about the efficacy of olanzapine. Olanzapine may cause excessive weight gain and the metabolic syndrome. There are not yet reports of the use of aripiprazole (Abilify 2.0-10 mg once daily), but this drug has the advantages of olanzapine without the risks.
Naltrexone is an opiate antagonist that has been found effective in TTM. Perhaps by lowering the pain threshold, and at the same time diminishing the pleasure of hair pulling, naltrexone may serve to alert the patient and enhance control. In one small study, a dose of 50 mg once daily reduced hair-pulling symptoms by 50% in seven patients. In another study, the drug was beneficial as an adjunct to fluoxetine, reducing hair pulling by 30% in one 45-year-old woman.
Approximately 1% of patients who swallow hair require surgical intervention. Attempts have been made to remove trichobezoars by endoscopy, but in the majority of cases, laparotomy has been found to be necessary.
Dental care may be necessary, and appropriate treatment for tendinitis, carpal tunnel syndrome, or other complications.
The patient should be seen weekly, or at most biweekly initially, to establish rapport. This may be extended to monthly visits, when trust has developed.
If psychiatric referral is not achieved, the patient should subsequently be examined at 3-month intervals, to supervise medication and to ensure that there are no abdominal symptoms or other physical issues. These visits should be used to encourage the patient, to acknowledge any success that is achieved, and for support.
The issue of psychiatric referral must remain one’s goal, but it is important to handle this tactfully, and not make the patient defensive or permit the relationship to degenerate into a power struggle. If referral is not accepted, then one might consult a friendly neighborhood psychiatrist for advice about the patient.
Not all patients can be helped, and one cannot take this as personal failure.
Unusual Clinical Scenarios to Consider in Patient Management
Watch for the possibility of deepening depression and the possible sequelae of trichophagia.
Be aware of the patient’s mood, and address any mood-related behavioral changes.
Be aware of one’s own frustration, and do not let that interfere with one’s relationship with the patient.
Over time, a drug that initially has been effective may lose its effectiveness. Another drug of the same class may be substituted, or one of the other types of drug reportedly effective.
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- Are You Confident of the Diagnosis?
- Who is at Risk for Developing this Disease?
- What is the Cause of the Disease?
- Systemic Implications and Complications
- Treatment Options
- Optimal Therapeutic Approach for this Disease
- Patient Management
- Unusual Clinical Scenarios to Consider in Patient Management