Page 221 - The Netter Collection of Medical Illustrations - Integumentary System_ Volume 4 ( PDFDrive )

Plate 7-10 Hair and Nail Diseases

TRICHOTILLOMANIA

Trichotillomania is defined as the compulsive act of
deliberate hair plucking, pulling, or twisting that causes
hair breakage. There has been a push to rename this
condition trichotill to remove the negative connotation
of “mania” from the diagnosis. Two subgroups of
patients with trichotillomania exist. The first is a
younger population of mostly elementary school–aged
children, and the second is the adult population. The
younger the patient is at the time of diagnosis, the
better the overall prognosis for a cure.
Clinical Findings: Patients present with bizarre con-
figurations of hair loss. This is often the first clue to the
diagnosis. On close inspection, the hairs are often
broken off close to the surface of the skin. A white 3 ×
5 inch card can help as a background to appreciate the
damage to the hairs. Many broken hairs of varying
lengths are present. Hair shafts may show a twisting
morphology. If the patient is evaluated soon after the
hair pulling has been performed, pinpoint amounts of
hemorrhage may be appreciated at the follicular open-
ings. Microscopic examination of the ends of the hairs
may show fracturing of the hair shaft and trichorrhexis
nodosa. Most patients are not aware of the actions that
are causing their hair loss. It is imperative to not be
judgmental during patient visits, and the importance of
developing a good rapport cannot be overestimated.
One useful request that can be asked of patients is,
“Show me how you manipulate your hair.” Often
patients unconsciously start to twist or tug at their hair.
It is important to educate the parents to observe their
child for any evidence of hair manipulation. After this
form of education, the parents often become aware of
the manipulation. It is important for them not to scold
the child when this is taking place but rather to try to
distract the child with positive reinforcement. Almost
all children eventually outgrow the condition, and their Bizarre area of hair loss in a child caused by trichotillomania
hair then returns to normal.
Adults with trichotillomania have a much more
chronic course. They typically have no insight into
their condition. They commonly go from one doctor
to another seeking therapy. In adults, biopsies are
critically important to obtain objective diagnostic
information. Referral to a psychologist or psychiatrist
should be strongly considered for adult patients with
trichotillomania.
Histology: Histopathological evaluation show a non-
inflammatory, nonscarring alopecia. Characteristic to Trichomalacia is one of the histological
this diagnosis is the presence of trichomalacia, which is hallmarks of trichotillomania.
seen as follicular damage within the hair follicle.
Varying degrees of follicular red blood cell extravasa-
tion are appreciated. Melanin pigment casts within the
hair follicle are commonly seen. Overall, the number of
hair shafts is normal. The performance of a scalp biopsy
is advocated by many to give the patient or family
objective information about the diagnosis.
Pathogenesis: Trichotillomania is a self-induced
form of hair loss that is caused by intentional twisting,
plucking, pulling or other forms of direct damage to the
hair shaft. This can be a conscious or an unconscious
behavior. Most cases involve some form of emotional
disturbance, and one must be cognizant of this when
addressing the patient and family. a means to help the child become aware of the patients never develop insight into their disease. Under-
Treatment: Trichotillomania may be considered in hair manipulation. Negative punishment tends to be lying psychological conditions may be at the root of
the spectrum of obsessive-compulsive disorders. Most ineffective. In some cases, a child psychologist or the issue, and cognitive therapy in the care of a psychia-
children eventually abandon the actions that have psychiatrist can be extraordinarily helpful in treating trist or psychologist may be instrumental in helping
caused their hair loss. Most cases in children are pre- these patients. these patients. The use of medications traditionally
cipitated by emotional stress, and they tend to improve Adults with trichotillomania have an entirely differ- prescribed for obsessive-compulsive disorders may be
as that stress resolves. Positive reinforcement can be ent clinical course. Most cases are chronic, and most warranted in the adult patient.

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