Definition And Pathogenesis
- Classified within obsessive-compulsive and related disorders category.
- Represents acute reactional process related to emotional stress or habitual behavior in young children.
- Manifests as severe psychiatric disorder primarily in adolescents.
Diagnostic Criteria
- Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition outlines specific criteria.
- Visible hair loss directly attributable to pulling.
- Mounting tension preceding or during hair pulling.
- Gratification or tension release following hair pulling.
- Absence of hallucinations, delusions, or inflammatory skin conditions explaining behavior.
Clinical Manifestations
- Compulsive pulling, twisting, and breaking produces irregular areas of incomplete hair loss.
- Favors crown, occipital, and parietal scalp regions.
- Eyebrows, eyelashes, and body hair occasionally traumatized.
- Behavior typically begins during inactivity (watching television, going to bed) and remains unobserved by parents.
- Remaining hairs exhibit variable lengths and blunt tips secondary to breakage.
- Scalp generally appears normal; however, hemorrhage, crusting, and chronic folliculitis occasionally occur.
- Long-term repetitive trauma provokes irreversible follicular damage and permanent alopecia.
- Trichophagy complication frequently produces trichobezoars.
Differential Diagnosis And Clinical Clues
| Diagnostic Feature | Trichotillomania | Alopecia Areata | Tinea Capitis |
|---|
| Pattern | Irregular pattern with mixed length and stubbly hairs. | Circular or oval patches. | Broken hairs at scalp surface (black-dot). |
| Specific Hair Clues | Blunt-tipped broken hairs. | Exclamation-point hairs. | None. |
| Scalp Surface | Normal; occasional hemorrhage or crusting. | Normal. | Scaling, pustules, or kerion. |
| Hair-Pull Test | Consistently negative. | Usually negative. | Negative. |
| Associated Conditions | Anxiety or obsessive-compulsive tendencies. | Nail pitting or grooves. | Not applicable. |
Management Protocol
- Therapy directly targets underlying obsessive-compulsive disorder.
- Pharmacologic options include clomipramine 50 to 150 mg/day.
- Selective serotonin reuptake inhibitors including fluoxetine provide therapeutic benefit.
- Efficacy maximized when combining pharmacotherapy with behavioral interventions.
- N-Acetylcysteine demonstrates potential adjunctive utility.
