From the Departments of Dermatology and Venereology & *Psychiatry, Government Medical College & Hospital, Sector 32, Chandigarh 160 047, India.

Correspondence to: Dr. Rashmi Sarkar, C/o. Mrs. C. Sarkar, Teachers’ Flats No. 9, Sector 12, P.G.I. Campus, Chandigarh 160 012, India.  Email: [email protected] 

Manuscript Received: October 31, 2001;
Initial review completed: November 28, 2001;
Revision Accepted: September 27, 2002,

Key words: Children, trichotillomania.

Trichotillomania is a disorder of compulsive hair pulling that results in alopecia(1,2). While in dermatology, trichotillomania is classified as a self-inflicted dermatosis, in psychiatry, it is classified as an impulse-control disorder(3) along with conditions such as compulsive gambling and kleptomania. Trichotillomania in children is commonly associated with nail biting, thumb sucking, anxiety and learning disability while adult patients show more diverse psychopathology with depression, anxiety, obsessive-compulsive disorder and panic attacks. Hair pulling and plucking is commonest from the frontoparietal and temporal regions of the scalp, often on the non-dominant side of the scalp although occasionally the eyelash, eyebrow, pubic and hair on other body sites may be involved(2). We describe three girls with trichotillomania who presented with loss of hair over scalp and other parts of the body; one of the patients had co-existing alopecia areata.

Case 1: A 4-year-old girl presented with loss of hair over the scalp of 6 months duration, since the time she had started going to school. Examination revealed an irregular, coarse patch of hair loss over the left frontal region of the scalp (Fig. 1). Short, broken hairs of variable length were present, palpable as a stubble. There was no evidence of scaling or inflammation, the hair at the margin were not easily pluckable and the hair over the rest of scalp was normal in texture and strength. There was no history of loss of appetite, abdominal pain, diarrhea or constipation. Examination of the mucous membranes, nails, oral cavity and abdomen was normal. On questioning, the mother revealed that this child was constantly fighting with her brother, was obstinate and quick to take offense. Child was the youngest of three siblings and pampered a lot by the grandparents. The mother used to hit her often on undesirable behavior e.g. hair pulling with her fingers when sitting idle and fighting. This would often result in the child becoming angry and pulling out more hair.

Fig.1. A coarse patch of loss of hair over left frontal area scalp with short broken hairs.

Case 2: A 4-year-old girl presented with loss of hair over the vertex of the scalp of 1-year duration. She had developed a small, bald patch over the vertex of the scalp, which gradually increased in size. There was no scaling but short exclamation mark hairs were present which were confirmed on light microscopy of the hair; the hair over the rest of the scalp was normal in texture and strength. The rest of the cutaneous and systemic examination was normal. Potassium hydroxide (KOH) examination of the hair was negative. She was diagnosed as alopecia areata and was initially treated with topical steroids for 4 weeks and later oral steroids (prednisolone 10 mg OD) were given for 8 weeks. There was some improvement in the form of hair regrowth but after a while the baldness started extending on one side. On examination, coarse irregular patches of hair loss with few short broken hair of varying lengths palpable as a stubble were present on the left temporal region of the scalp. No exclamation mark hair were seen. The parents, on questioning, revealed that they had noticed the child pulling out her hair from the sides of the scalp which was not related to any activity. She was willful, frequently threw temper tantrums, had the habit of thumb sucking and was the only child of her parents.

Case 3: A 6-year-old girl presented with loss of hair over the scalp of 4 years duration. The mother gave the history that the child initially used to pluck out hair from the left parietal region of the scalp, but since the last 6 months the child had started pulling hair from the right parietal and temporal areas. Six months back, the school of the child had been changed. She had the habit of thumb sucking. The rest of the history, cutaneous and systemic examination were similar as in case 1.

A potassium hydroxide examination and light microscopic examination of the hair was done in all cases which did not reveal any abnormalities. A diagnosis of trichotillomania was considered in all three cases though the second patient also had co-existing alopecia areata. The parents were advised to shave the affected area and watch for hair regrowth. The children were referred to the child guidance clinic for behavior therapy where they were seen by a psychiatrist, who also ruled out other psychiatric ailments. All three girls had normal IQ. Parental counseling was dne for nature of illness, to stop using physical punishment and to bring consistency in discipline. The patients received several sessions of play therapy, which were aimed at conflict identification, and suggestion. Distraction was taught, to be used by parents. Differential reinforcement was used where good behavior was rewarded and rewards were withdrawn whenever there was undesirable behavior. Along with these the first and the second child were asked to make star charts and were rewarded with play sessions. The first two patients benefited from therapy and their hair showed re-growth on the shaved area and they stopped pulling out the hair. The re-growing hair was of fairly uniform length though thinner; and light microscopy revealed the hair ends to be fractured. In the case of the third patient, after the counselling and two sessions with the psychiatrist, the mother reported that the child had stopped pulling hair from the scalp but had started doing the same from the legs, as a consequence of which, patches of hair loss were present over the legs. So, she was referred once again to the child guidance clinic. However, subsequently the child was lost to follow-up.

Trichotillomania is a term coined by Hallopeau, a French dermatologist, in 1889(4). It literally means a morbid craving to pull out hair. It may have a multifaceted etiology, including alteration in brain metabolism, a positive family history, a disturbed social setting and possibly maternal deprivation(5). It occurs worldwide including in Indian setup, and may prove to be a serious condition, if accompanied by trichophagy and trichobezoar(6,7). Trichotillomania occurs more than twice as frequently in females as in males in the adult age groups, but below the age of 6 years boys outnumber girls by 3:2 ratio, although others have found the male to female ratio in children to be 1:1(5). In clinical setting, the disorder predominantly affects females(3), as also observed in the present cases.

In psychiatry, trichotillomania is classified under impulse control disorders(3). Features of trichotillomania that fit this description include the inability to resist urges to pull one’s hair which was present in these cases and mounting tension before pulling and feeling of relief afterwards which may not always be forthcoming especially in a small child(8). However, in the present cases, the parents had noticed the children pulling out the hair unconsciously or deliberately. Moreover, the disturbance could not be accounted for by another mental disorder or any dermatological condition and the condition caused significant clinical distress, both of which were other features, which supported the diagnosis. The child develops the habit of twisting hair around his fingers and pulling it, which is only partially conscious and may replace the habit of thumb sucking(9) as observed in two patients. Other associated clinical features include nail biting and temper tantrums. Hair pulling and twirling is a normal aspect of behavior in children and young adults and assumes clinical importance only when significant alopecia develops(9).

It is usual for trichotillomania to occur in a rather disturbed social setting. Young girls may utilize this condition to avoid being sent to school and to induce the parents to give in to their demands(9) as noted in two of our patients. In early childhood, the factors contributing to the emotional strain, which leads to trichotillomania, are almost always found in a conflicting mother-child relationship whereas, at the school-going age, it usually results from the pressure on a child to achieve more or sibling rivalry, which could be the case in the first patient. From the psychodynamic point of view, hair may be regarded as a ‘transitional object’, which acts as a comforter to the child who is distanced by the mother from the breast(9).

Alopecia areata and trichotillomania present the most frequent causes of circumscribed hair loss in children and can occur together in childhood(10), as observed in the second patient. The connection between the two is not very clear but it has been proposed that trichotillomania may result from scratching at the site of alopecia areata that is symptomatic with pruritus, initiating a habit-forming behavior, or patients with a mental predisoposition may artificially prolong the disfigurement as the hair on the bald patches of alopecia areata regrows(10). Skin biopsy is useful for documenting the two conditions (but was refused by the parents), although these can be diagnosed easily by the dermatologist.

Early onset trichotillomania, beginning before the age of six years is usually self-limiting and responds to simple interventions involving suggestion, reassurance and simple behavioral treatment approaches(11), as was done in the present cases as well. In children, the drug therapy which includes selective serotonin reuptake inhibitors, tricyclic antidepressants, neuroleptics and lithium carbonate is rarely used(5). Trichotillomania may be uncommon but must be thought of in cases where there is ambiguous loss of hair in childhood with no apparent underlying cause and where the scalp is normal or where almost no hair is lost by combing or gentle pulling. Trichotillomania is best overcome by an interdisciplinary approach to treatment and a liaison between the dermatologists, psychiatrist and the parents is needed for the effective management of this condition.

Contributors: MB worked up the patients clinically, reviewed the literature and drafted the manuscript. RS was the consultant-in-charge, provided the concept, co-drafted the manuscript and revised it critically. PA was the psychiatrist who treated the patients, co-drafted the manuscript and revised it critically. AJK has overall critically revised and approved of the manuscript in its final version. RS shall act as the guarantor.

Funding: None.

Competing interests: None stated.

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