Correspondence Address:
Suresh Kumar Jain
Department of Skin AND VD, Government Medical College, Kota, Rajasthan
India

Full Text



Sir,

A 5-year-old girl was brought to the dermatology outpatient department by her mother with a complaint of a patch of hair loss from the scalp of 3–4 months' duration. She was apparently well until the age of 4 years when her mother noticed her pulling hair from the right side of the parietotemporal area during thumb sucking [Figure 1]a. There was no history of hair pulling from other parts of the body and no history of eating the pulled hair. The child had attained all the milestones for her age normally. There was no such history in her family members.{Figure 1}

Cutaneous examination revealed a bizarre-shaped patch of incomplete hair loss on the right parietotemporal area. The hairs on the patch were broken, short, and of uneven length [Figure 1]b. The hairs on the rest of the scalp were normal. Hair pull test was negative. Examination of the skin, mucous membranes, and nails was normal.

A 10% potassium hydroxide examination of the hair under a microscope and fungal culture of the hair were negative.

The child was diagnosed with early-onset trichotillomania (TTM) and referred to the psychiatry department where she is being managed with behavioral therapy.

Trichoscopy of the alopecia patch revealed decreased hair density, uneven length with black dots, tulip hair (short hairs with darker and tulip flower-shaped ends), V-hair (split ends), burnt matchstick sign, and flame hairs. There were no exclamation mark hairs [Figure 2].^[1] Trichoscopic images were obtained at 10× magnification using a DermLite 3 dermoscope.{Figure 2}

TTM is a disorder characterized with recurrent pulling out of one's hair from any part of his/her body and significant distress or functional impairment. In DSM-IV, TTM was classified as an impulse control disorder, whereas with DSM-5, it is classified under the category of “obsessive compulsive and related disorders.” The term TTM was first used by the French dermatologist Francois Hallopeau in 1889 from the Greek words thrix (hair) tillein (pulling) mania (madness).^[2] TTM has the bimodal age of presentation, early onset and late onset.

Early-onset TTM begins at 2–10 years of age, is more common in boys (62%), and has a benign self-limiting course.^[3] Early-onset TTM is associated with other habit disorders such as nail biting, thumb sucking, and skin picking. It is likely that early-onset TTM represents a stressful life event, rather than serious psychopathology.^[4] Late-onset TTM begin during adolescence is more common in girls, with frequency of up to 3.5:1 and has a poorer outcome with progression into adulthood.

Clinically, TTM is characterized by a bizarre-shaped area of incomplete nonscarring hair loss with hairs of uneven length. The scalp is the most common site, although any site can be affected, including the eyebrows and eyelashes. On the scalp, the side of their dominant hand is most commonly affected due to easy accessibility; hence, the common sites affected are the corresponding frontotemporal areas and the vertex.

Trichoscopy is a useful procedure to aid the diagnosis of TTM. It is a useful tool in differentiating TTM from alopecia areata. The most common finding in TTM is fractured hairs of uneven length. Other findings include trichoptilosis (hair with fraying ends), black dots, yellow dots with central black dots, and perifollicular hemorrhages.^[5] Habit disorder is a broad spectrum of disorders with varied manifestations and associations. In every case of young-onset nonscarring alopecia, TTM and other related disorders should be ruled out to avoid inadvertent wrong therapy and development of other behavioral disorders.

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Conflicts of interest

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