Trichotillomania is a type of patchy hair loss which results from the compulsive pulling out or scratching of hair shafts. The cause of this compulsive behavior is not completely understood. Trichotillomania is not an uncommon condition and it can be seen in both sexes as well as different ethnic backgrounds. Its lifetime incidence is about 0.6% and may be as high as 1.5% in men or 3.4% in women.
People with trichotillomania may initially be seen by a dermatologists or hair transplant surgeons without its sufferer being aware of their pulling hair habits. Trichotillomania generally shows its first signs before the age of seventeen. Circular balding patches are the initial signs that are typically seen almost anywhere that hair grows. The balding patches are uneven and incomplete, unlike other patchy baldness conditions such as Alopecia Areata in which hair loss is almost complete in the balding patch.
Trichotillomania: Microscopic evaluation of lesions. Left: Hair shafts in different length and growth phases. Right: Hair loss and scalp skin inflammation due to scratching the skin by patient. (Parsa Mohebi, MD)
Microscopic examination of the balding patchs show broken hair and fine hair in different stages of growth. Balding patchs of trichotillomania can most-likely be found on the scalp, eyebrows and eyelashes, but almost any area of skin has the possiblity of being involved.
Denying hair pulling is very common and in most patients, the doctor or one of the family members notices their habits first. Other self injury behaviors may be accompanied in patients with trichotillomania. These self inflicting habits should be addressed by a psychiatrist for the best possible outcomes.
Diagnosis of trichotillomania is clinical and and more often than not, no labwork is required to confirm its diagnosis. Occasionally a skin biopsy may be necessary to rule out other causes of patchy hair loss, such as alopecia areata, cicatricial alopecia or fungal infections.
Most patients suffering from trichotillomania need behavioral therapy, but some may require medications such as selective serotonin reuptake inhibitors (SSRIs) to assist in breaking the habit. Medical or behavioral treatments for stress reduction is also recommended for many patients. Hair transplants are not recommended for patients suffering from trichotillomania due to the high likelihood of its sufferes pulling out the newly transplanted hair just as they had initially with their natural hair. In most patients, trichotillomania hair loss can be reversible as long as the compulsive disorder is sucessfully treated. A hair transplant can be used to restore balding or thinning patches that never completely recovered, but a hair transplant for trichotillomania is only recommended after months or years following the complete resolution of its sufferer’s compulsive hair pulling episodes.