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Trichotillomania is a behavior disorder seen in both pediatric and adult populations that involves the pulling out of one's own hair. It was described originally in 1889 by the French dermatologist Hallopeau. Many young children who pull their hair outgrow the habit without any major intervention and are not classified as having true trichotillomania. The Diagnostic and Statistical Manual of Mental Disorders-IV (DSM-IV) classifies trichotillomania as an impulse control disorder that is similar to kleptomania and pyromania, but there are some who argue that it is categorized more appropriately as an obsessive-compulsive disorder trichotillomania. To meet the DSM-IV diagnostic criteria, a patient must feel rising tension just prior to hair pulling or during attempts to resist pulling and must experience a sense of pleasure or relief during or after the behavior. Whether these criteria are always met in children is difficult to determine. Moreover, the strict definition may exclude patients who are in need of and may benefit from therapeutic intervention.
The prevalence of trichotillomania has been estimated variably in different studies, ranging from one report of a lifetime prevalence of 0.6% using the strict DSM-IV criteria to another estimate that 4% of the general population are hair pullers and 10% have had the habit at some point in their lives. Trichotillomania is more common among children than adults and occurs more frequently in females than males, although the gender difference is less evident at younger ages. The mean age of onset is 8 years for boys and 12 years for girls. The most frequent site of hair pulling is the scalp.
By the time the correct diagnosis is made, it is not uncommon for a patient to have been diagnosed with and treated already for other medical conditions, such as tinea capitis or alopecia areata. Tinea capitis is the most common cause of alopecia in childhood. Clinically, patients who have tinea present with small dark hairs broken off at the follicle and may have diffuse scaling. The usual culprit is the ringworm.
Parents of very young children should be reassured by the clinician explaining the usually benign nature and spontaneous resolution of early-onset hair pulling. In contrast, both the individual and the family may need to be treated when older children and adolescents are affected significantly. A variety of treatments have been proposed, with inconsistent reports of success in the literature. These include behavior modification, play therapy, hypnosis, psychotherapy, family therapy.
Due to the heterogeneity and enigmatic nature of the underlying pathology, referral to a child psychiatrist should be considered. If an underlying cause of trichotillomania can be identified, such as a stressful school or home environment, treatment should be directed at that problem and not at the symptom. When assessing children who have trichotillomania, it is important to recognize other parallel behaviors, such as thumb sucking. It has been reported that in such cases, stopping the other behavior may lead to resolution of the hair pulling.
Behavior modification is a mainstay of treatment. This includes self-monitoring, alternative therapy (teaching the patient to do something else whenever feeling the urge to pull hair), relaxation therapy.
It is important for the patient to recognize the hair pulling as a problem and to be motivated to participate in therapy or such management is not likely to be successful. Data on the effectiveness of drug treatment in children are very limited, but it may be considered in some cases. Mmedications are approved specifically for the treatment of trichotillomania, some antidepressants.
Comment: Tinea capitis, alopecia areata, and traction alopecia account for the majority of cases of alopecia. Trichotillomania usually begins before age 18 years, and as discussed previously, the patient and family may not acknowledge it as the cause of alopecia. Don't forget to consider possible stressful life events as precipitants for hair pulling or possible abuse, with other persons.