A 7-year-boy presented with a 6-month history of hair loss in 2 focal areas on his scalp. The patient and his mother denied associated pruritus, redness, scale, hair loss, or rashes in other areas. Two cats and 1 dog in the home that tended to sleep with the patient also developed focal hair loss at the same time as the patient. A biopsy of 1 cat's scalp showed empty hair ducts, melanin casts associated with hair follicles, keratin plugs in hair follicles, focal dilated follicular infundibula, empty clefts around some hair follicles, and distortion of hair bulbs (Figure 1). A fungal stain was negative.
On examination, the patient had a 2 x 10-cm strip of nonscarring alopecia down the midline of his scalp and a 5 x 6-cm area of nonscarring alopecia on the left parietal scalp (Figure 2). Within both of these areas, there were several short hairs growing in some of the follicles. There were also multiple smaller areas (less than 1 cm) of nonscarring alopecia on the posterior portion of the scalp. His eyebrows and eyelashes were intact. A complete blood cell count was normal, as were the thyroid studies.
A punch biopsy of an alopecic patch on his scalp showed pigment casts with keratinous debris in the follicles, distortion of the hair shafts, and an increased number of catagen hairs (Figures 3 and 4). Figure 4, at higher magnification, also demonstrated trichomalacia. There was no lymphocytic infiltrate within the dermis or surrounding the hair follicles. There was some perifollicular fibrosis.
What is your diagnosis?
Pathologic Diagnosis: Trichotillomania
Trichotillomania was first described in 1889 by the
French dermatologist Hallopeau as "the morbid impulse to pull one's own hair." In the Diagnostic and Statistical Manual of Mental Disorders, 4th ed, trichotillomania is characterized as an impulse-control disorder with criteria including (1) the recurrent pulling out of ones hair resulting in noticeable hair loss, (2) an increasing sense of tension immediately before pulling out the hair or when attempting to resist the behavior, and (3) pleasure, gratification, or relief when the hair is pulled.1
The prevalence of trichotillomania is estimated to be 0.6% when evaluated on the basis of these strict criteria and up to 3.4% when the criteria are relaxed to include all hair-pulling resulting in noticeable hair loss.2 The mean age of onset is 11 years.3 There is a female predominance, with one study showing that 76% of affected individuals are women, but the prevalence among boys and girls is equal until age6.4
Hair-pulling presenting in young children is frequently a comfort technique, like thumb-sucking or nail-biting, and does not usually indicate psychopathology. Accordingly, studies suggest that trichotillomania presenting before age 6 is less likely to continue into adulthood and more likely to represent a milder disorder.5 These young children are also less likely to pull hair from nonscalp areas. Patients and their families may deny hair-pulling, which often takes place when the child is going to sleep and may not be witnessed by others.
Patients with trichotillomania usually present with poorly defined, irregularly shaped, or linear patches of partial alopecia, frequently on the scalp. The crown and occipital and parietal areas are frequently involved, particularly the contralateral region of the dominant hand. Uninvolved areas appear completely normal. Hair may also be pulled from nonscalp areas. One study showed that 82% of subjects pulled hair from the scalp, 54% from the eyelashes, 51% from the eyebrows, and 33% from the pubic hair.3 Close examination of the affected areas reveals short, broken hairs in addition to some normal-appearing hairs. Pruritus, scarring, erythema, scaling, and atrophy are characteristically absent, but excoriations and lichenification may develop.6
The most common causes of hair loss in children are telogen effluvium, tinea capitis, alopecia areata, trichotillomania, and traction alopecia. Telogen effluvium affects hairs throughout the scalp, causing diffuse hair thinning without patches of alopecia. Tinea capitis often presents with multiple hairs broken off at the scalp level (or a few millimeters above) and scale, papules, or pustules. Clinically, alopecia areata differs from trichotillomania because alopecia areata usually presents with a well-defined smooth area of total alopecia with exclamation point hairs surrounding the periphery. Traction alopecia is the result of tight ponytails or braids.
The diagnosis of trichotillomania is best confirmed by a biopsy extending into the subcutaneous tissue. Biopsies taken from recently affected areas (hair loss within the past 8 weeks) have been shown to yield most characteristic features.4 Traumatized hair bulbs, frequently with a hemorrhagic or exudative reaction of the bulbar tissue, are diagnostic of trichotillomania. However, a study reviewing 66 scalp biopsies of patients diagnosed with trichotillomania observed this finding in only 21% of the specimens.4 Supported by earlier research,6 the same study confirmed an increased number of catagen hairs (found in 74% of the biopsies) and the presence of pigment casts (found in 61% of the biopsies) as diagnostic findings in trichotillomania. The catagen phase of hair growth is the phase of acute regression immediately following the anagen (growth) phase. In a normal scalp, approximately 1% to 3% of hairs are in the 2- to 3-week catagen phase at any time. The formation of pigment casts represents a heavily pigmented keratinous material accumulated in the empty follicles after the hair is pulled.4 Pertinent negative findings include the lack of inflammation of the hair bulb in trichotillomania, as this is a diagnostic finding in alopecia areata. Atrophic anagen hairs are another finding in alopecia areata not seen in trichotillomania.4 Folliculitis is not diagnostic and represents a nonspecific response to severe follicular damage.
Because trichotillomania in children usually represents a habit, the mainstays of treatment are psychotherapy aimed at habit reversal and the establishment of a support network. Treatment regimens that combine increased physical contact with parents, positive reinforcement, punishment, making the child sit quietly for a time (taking a "time out"), and direct preventive measures have shown some success in case reports.7,8 When trichotillomania and thumb-sucking co-occur, hair-pulling has resolved with the treatment of thumb-sucking.7
1. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 4th ed. Washington, DC: American Psychiatric Association; 2000:674-677.
2. Christenson GA, Pyle RL, Mitchell JE. Estimated lifetime prevalence of trichotillomania in college students. J Clin Psychiatry. 1991;52:415-417.
3. Cohen LJ, Stein DI, Simeon D, et al. Clinical profile, comorbidity, and treatment history in 123 hair pullers: a survey study. I Clin Psychiatry. 1995;56:319326.
4. Muller SA. Trichotillomania: a histopathologic study in sixty-six patients. j Am Acad Dermatol. 1990;23:56-62.
5. Christenson GA, Mackenzie TB, Mitchell lE. Characteristics of 50 adult hairpullers. Am I Psychiatry. 1991;148:365-370.
6. Mehregan AH. Trichotillomania: a clinicopathologic study. Arch Dermatol. 1970;102:129-133.
7. Blum NJ, Barone VI, Friman PC. A simplified behavioral treatment for trichotillomania: report of two cases. Pediatrics. 1993;75:993-995.
8. Chand SP. Case of the month. Eur] Pediatr. 1996;155:141-142.
Stephanie E. Zone, BA; Cheryl M. Coffin, MD; Sheryl L. Vanderhooft, MD
Accepted for publication August 13, 2002.
From the Department of Dermatology, University of Utah School of Medicine (Ms Zone and Dr Vanderhooft), and the Department of Pathology, University of Utah School of Medicine, Primary Children's Medical Center (Dr Coffin), Salt Lake City.
Corresponding author: Sheryll L. Vanderhooft, MD, Department of Dermatology, University of Utah School of Medicine, Room 48454, 30 N 1900 E, Salt Lake City, UT 84132 (e-mail: email@example.com). Reprints not available from the author.
Copyright College of American Pathologists May 2003
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