Trichotillomania associated with the "Friar Tuck sign" and nail-biting

Trichotillomania is a form of traction alopecia resulting from compulsive repetitive removal of one's own hair. This entity can mimic the clinical appearance of many other forms of hair loss including alopecia areata, androgenetic alopecia, and tinea capitis. It is important to differentiate trichotillomania from other forms of alopecia because its treatment is quite different. We present three cases of trichotillomania demonstrating the "tonsure pattern" or "Friar Tuck sign" and onychophagia (nail-biting), which we describe as clinical identifying features of this syndrome.     

Trichotillomania and trichophagia leading to trichobezoar

A 14-year-old female presented with the complaints of loss of hair, scalp pruritus, and pain in the abdomen. On careful work-up, she was found to have trichotillomania as well as trichophagia. Investigations also revealed a trichobezoar which completely filled the stomach. Hemogram showed moderate hypochromic anemia. Her detailed psychiatric profile showed a few additional features like obsessive hand washing, knuckle cracking, nose picking and body rocking. Her trichobezoar was removed surgically, and she had an uneventful post-operative recovery. She is being maintained on fluoxetine and is doing well. The role of a multi-disciplinary approach to trichotillomania patients is highlighted.     

Alopecia areata: Clinical presentation, diagnosis, and unusual cases

Alopecia areata (AA) is a nonscarring hair loss disorder with a 2% lifetime risk. Most patients are below 30 years old. Clinical types include patchy AA, AA reticularis, diffuse AA, AA ophiasis, AA sisiapho, and perinevoid AA. Besides scalp and body hair, the eyebrows, eyelashes, and nails can be affected. The disorder may be circumscribed, total (scalp hair loss), and universal (loss of all hairs). Atopy, autoimmune thyroid disease, and vitiligo are more commonly associated. The course of the disease is unpredictable. However, early, long‐lasting, and severe cases have a less favorable prognosis. The clinical diagnosis is made by the aspect of hairless patches with a normal skin and preserved follicular ostia. Exclamations mark hairs and a positive pull test signal activity. Dermoscopy may reveal yellow dots. White hairs may be spared; initial regrowth may also be nonpigmented. The differential diagnosis includes trichotillomania, scarring alopecia, and other nonscarring hair loss disorders such as tinea capitis and syphilis.     

Trichoteiromanie

Background: The physical influences leading to traumatic hair injury may be the result of cosmetic treatments, may be accidental or self‐inflicted. The most frequent cause of self‐inflected hair loss is trichotillomania, in which the hair is plucked, while trichotemnomania, in which the hair is deliberately cut, is less frequent. Freyschmidt‐Paul et al. proposed the term trichoteiromania for yet another type of artificial hair loss, which results from perpetual rubbing of the scalp with fracturing of the hair shafts. Patients and methods: Four patients with trichoteiromania are further characterized on the basis of clinical, morphological and psychopathological criteria. Results: In contrast to trichotillomania, trichoteiromania has no diagnostic histopathological features and has a normal trichogram. Traumatic changes to the hair shaft are more conspicuous, with splitting at the ends of the hairs, giving the impression of white tips. The underlying mental disorder varis among the patients, though scalp dysaesthesia, not explained through any specific dermatological disorder, is a common denominator in all cases. Conclusions: While trichotillomania is considered to be an obsessive‐compulsive disorder, the underlying mental disorder in trichoteiromania represents a more heterogeneous group. Cooperation with the psychiatrist is indicated, as much as the management and prognosis of trichoteiromania will depend on recognition of the underlying mental disorder and its specific psychotherapeutic and pharmacological treatment.     

拔毛癖的临床表现、组织病理及皮肤镜特征

目的:分析拔毛癖患者的临床表现、皮肤镜影像及组织病理特征。方法:收集46例拔毛癖患者临床资料,对其中36例患者毛发进行皮肤镜观察并与62例斑秃患者进行比较;对其中5例皮损进行病理活检。结果:46例拔毛癖患者中男女比例为1:1.88,平均年龄为11.74岁,最常见脱发部位为头顶部。拔毛癖皮肤镜下最常见表现为黑点征(94.44%)和断发(94.44%)。拔毛癖患者病理组织主要表现为退行期毛囊增多、色素管型、毛囊周围出血、毛软化,炎症轻微。结论:皮肤镜是诊断、鉴别诊断拔毛癖的有力工具,组织病理检查则有助于确诊。     

Loose anagen syndrome as a severity factor for trichotillomania

Loose anagen syndrome (LAS) is a condition of childhood where anagen hairs are easily and painlessly extracted. The condition is due to poor adhesion between the cuticle of the hair shaft and the inner root sheath. A 4-year-old girl presented with patches of hair loss and a clinical diagnosis of trichotillomania was made. A hair pull test extracted multiple hairs easily and painlessly. Light microscopic examination was consistent with LAS. A biopsy was performed, which showed features of trichotillomania. However, on request the child did not display sufficient dexterity to pull out her own hair. It was subsequently determined that her hair loss was likely to be due to a third person plucking out her hair. It appears that in this case the LAS was not the cause of her hair loss, but rather acted as a severity factor for trichotillomania by proxy in that the lack of pain on plucking the hairs removed the principle deterrent.     

Trichoscopy features of trichotillomania

Trichotillomania is a form of traction alopecia resulting from repetitive and compulsive hair pulling and plucking. Trichotillomania and patchy alopecia areata may have similar clinical and dermoscopic features in some cases. On trichoscopic examination, the presence of black dots, coiled or hook hair, shafts of varying lengths with fraying or split ends (trichoptilosis), and an absence of exclamation mark hairs and yellow dots are suggestive of trichotillomania.     

Trichotillomania

ABSTRACT:  Patients with trichotillomania often first present to dermatologists, as patients may be unaware of or deny hair pulling and seek an etiology for their hair loss. It therefore becomes the job of the dermatologist to correctly diagnose trichotillomania as well as offer treatment options. There appear to be three groups characterized by age of onset: preschool-age children, preadolescents to young adults, and adults. Young children often have a self-limited course of hair pulling. Adults frequently have psychiatric conditions associated with their trichotillomania. Preadolescents to young adults may benefit the most from active intervention, such as increasing awareness of hair pulling behaviors and behavior modification training. The approach of a patient by age of onset is helpful in guiding a dermatologist towards effective treatment options.     

Diagnosis: alopecia areata or not?

Alopecia areata is a common cause of hair loss in children and adults. In most cases, the diagnosis is straight forward and is easily made based on the patient's history and clinical presentation. However, in two specific scenarios, the diagnosis can be difficult and may require a scalp biopsy. We present four cases that illustrate these two problematic differentials: alopecia areata versus trichotillomania in adolescent females; and diffuse alopecia areata versus telogen effluvium versus androgenetic alopecia in adult women. Tables compare and contrast the clinical and histopathologic features of these nonscarring localized and diffuse alopecias.     

Trichotillomania (hair pulling disorder): Clinical characteristics,psychosocial aspects,treatment approaches,and ethical considerations

Trichotillomania (hair pulling disorder) is a fairly common but underreported disorder characterized by recurrent episodes of pulling hair from different parts of the body. Currently classified in Diagnostic and Statistical Manual of Psychiatric Disorders (DSM‐5) under the heading of the “Obsessive–compulsive spectrum and related disorders.” The estimated prevalence data suggest that 0.5–2% of the general population suffers from this disorder. Stress and anxiety are directly correlated to the production of trichotillomania symptoms. The psychosocial aspects of trichotillomania are greatly underestimated, but recent literature suggests an increased interest in this neglected area. Although no FDA approved medications are available for the treatment of trichotillomania, a variety of medications including N‐acetylcysteine have shown benefit in case reports. Combined liaison clinics, with an interdisciplinary approach, are highly advisable in the treatment of these cases.     

Postoperative pressure-induced alopecia: report of a case and discussion of the role of apoptosis in non-scarring alopecia

We report a case of postoperative pressure induced alopecia in a 21-year-old black female after multiple intraoperative procedures. The histopathology is distinctive and demonstrated features in common with trichotillomania and alopecia areata, including the presence of pigment casts, catagen follicles, melanophages and apoptotic bodies. External hair manipulation is considered the primary event in the etiology of pigment casts, however, our present case demonstrated numerous pigment casts despite a complete lack of evidence of external hair manipulation. We performed pattern analysis and in situ end-labeling in 19 cases of non-scarring alopecia. Pigment casts were seen in postoperative alopecia (1 case), alopecia areata (1 case) and trichotillomania (5 cases). These forms of alopecia have in common the sudden termination of the anagen phase of the hair cycle. When the anagen portion of the hair cycle is prematurely disrupted hairs enter into catagen. Pigment casts may represent a non-specific reaction pattern of follicles that are suddenly transformed from anagen to catagen. We therefore propose that hair manipulation is not uniquely responsible for the formation of pigment casts. The primary pathophysiology resulting in the formation of pigment casts more correctly reflects the sudden termination of the anagen phase of the hair cycle.     

Obsessive‐compulsive disorder in dermatology

Patients with obsessive‐compulsive (OCD) and related disorders – primarily trichotillomania, body dysmorphic disorder, and skin picking disorder – frequently present to dermatologists due to associated hair and skin symptoms. It is therefore crucial that dermatologists be familiar with these disorders. In this review article, we provide an update on clinical features, neurobiology factors, and treatment options for OCD spectrum disorders. Employing PubMed and Cochrane Library databases, a selective literature search was conducted using keywords related to dermatological disorders within the OCD spectrum. OCD and its related disorders share several phenomenological as well as pathophysiological similarities, thus warranting their classification within a separate nosological category of psychiatric disorders. Another similarity of OCD spectrum disorders is the frequent concurrence of hair and skin diseases. Besides symptomatic dermatological treatment, the combination of psychotherapy (behavioral therapy) and psychopharmacotherapy (SSRIs) may be helpful. Although recent insights into OCD have contributed to a better understanding and treatment thereof, more research is required, especially with respect to OCD spectrum disorders, for which large controlled treatment studies are still lacking.     

TONSURE TRICHOTILLOMNIA

Summary— We describe 8 cases of trichotillomania in women in which the scalp exhibits a cropped appearance over the crown, extending to the frontal margin in some cases, but sparing the nape of the neck and lateral margins. The condition has persisted with no improvement for periods up to 17 years in one case.
The hair on the affected area is mostly less than 3 cm. long and of normal texture. Many of the short hairs have a tapered hypopigmented tip and when groups of hairs are plucked only anagen roots are found. There is no microscopical abnormality of the hair shaft and no exclamation mark hairs have been extracted. The only explanation for the persistence of newly growing short anagen hairs is the continual plucking of all those exceeding 3 cm. length.
All the patients but one repeatedly denied interfering with their hair, even after the significance of the changes in hair growth had been explained to them. In all the cases except one, psychiatric assessment showed a provocative social situation and personality traits likely to result in a disorder such as trichotillomania.
The disorder has many features in common with idiopathic trichoclasia as described by Sabouraud and other French writers. It could be mistaken for a congenital hair dystrophy and we believe other cases have been shown as "diffuse alopecia areata".
The tonsural pattern may be determined by a higher threshold for pain in the centre of the scalp than at the margins.     

103例学龄期儿童拔毛癖皮肤镜表现

目的:总结学龄期儿童拔毛癖患者皮肤镜表现.方法:回顾性研究2017年6月至2021年6月于我院诊治的103例拔毛癖患者临床资料.结果:103例患者中,男51例,女52例,平均年龄(10.20±2.75)岁.拔发部位位于头顶部(48.5％),单侧颞部(28.2％),双侧颞部(15.5％),额部(20.4％),枕部(5.8...     

Hair‐pulling disorder (Trichotillomania): Etiopathogenesis,diagnosis and treatment in a nutshell

Hair‐pulling disorder (Trichotillomania) is a disabling mental disorder. Patient's behavior is characterized by the recurrent pulling of own hair with hair loss and a marked dysfunction in various areas of daily life. Trichotillomania is a relatively common disorder with pediatric onset, often associated with significant morbidity, comorbidity, and functional decline. Surprisingly, children or adolescents have been little studied in the research studies on the pathophysiology and psychopathology of trichotillomania. Furthermore, more evidences regarding the effective and evidence‐based pharmacological interventions for the treatment of this condition are encouraged. This narrative review will report on the etiopathogenesis and clinical manifestations of trichotillomania including criteria for diagnosis and treatment issues of this complex mental disorder.     

Splitting hairs: the 'hamburger sign' in trichotillomania

Background: A 43‐year‐old male presented with the clinical findings of patchy alopecia that contained persistent hair and re‐growth of hairs of various lengths, consistent with trichotillomania. A biopsy was performed to confirm the diagnosis.. Results: Histologic evaluation revealed findings consistent with trichotillomania, including trichomalacia. Several hair shafts also showed a vertically oriented split, which contained proteinaceous material and erythrocytes. Morphologically, these were reminiscent of a hamburger within a bun. Conclusions: The unusual finding reported in this case has not been previously reported. The “hamburger bun sign” provides an additional clue to traumatic injury in the evaluation of biopsies for trichotillomania.     

Trichotillomania in early childhood--a report of two cases with a peculiar habit

Trichotillomania in early childhood is considered a benign habit disorder in contrary to older children and adults where trichotillomania is associated with greater psychopathology. We present two cases of trichotillomania in young children, both using a pacifier to pull out their hair.     

Splitting hairs: the 'hamburger sign' in trichotillomania

Background:  A 43-year-old male presented with the clinical findings of patchy alopecia that contained persistent hair and re-growth of hairs of various lengths, consistent with trichotillomania. A biopsy was performed to confirm the diagnosis..
Results:  Histologic evaluation revealed findings consistent with trichotillomania, including trichomalacia. Several hair shafts also showed a vertically oriented split, which contained proteinaceous material and erythrocytes. Morphologically, these were reminiscent of a hamburger within a bun.
Conclusions:  The unusual finding reported in this case has not been previously reported. The "hamburger bun sign" provides an additional clue to traumatic injury in the evaluation of biopsies for trichotillomania.     

Traumatic Alopecia in Trichotillomania: a Pathogenic Interpretation of Histologic Lesions in the Pilosebaceous Unit*

Ten patients with traumatic alopecia (trichotillomania) were being investigated histologically and. in five of them, hairs from the affected scalp area were plucked out for direct microscopic examination. Some histologic features appear to be specific markers for traumatic alopecia: empty hair ducts, plucked out hair bulbs, clefts in hair matrix, catagen involution of empty outer root sheaths, Miescher's trichomalacia in the deep dermis and torn-off sebaceous glands. Other signs are unspecific, such as presence of catagen and anagen VI hairs, infundibular plugging, melanin in keratin plugs and in the dermal papilla. The relative frequency of the different histopathologic features was evaluated. When little clinical information is available, a diagnosis of traumatic alopecia can he supported by skin biopsy. The histologic picture of trichotillomania is always incomplete, depending upon factors such as intensity of pulling or/and time of biopsy after plucking.     

Erworbene Alopezien im Kindesalter

Hair loss and alopecia occur frequently in children. The prevalence of the underlying causes and conditions, treatment options and prognosis differ in part significantly from adulthood. This article focuses on frequent forms of acquired alopecia which are not associated with inflammation or scarring of the scalp. Special attention is given to alopecia areata as the most important entity and to trichotillomania as its most difficult differential diagnosis. Significant forms of diffuse hair loss include anagen-dystrophic and telogen effluvium, androgenetic alopecia and loose anagen hair.