Case
A 20-year-old female presented with a 7 year history of progressive asymptomatic hair loss that developed initially on her eyebrows then progressively to her scalp. There was no relevant past medical or family history and no regular medications. Multiple previous dermatologists had diagnosed either alopecia areata or female pattern hair loss, however the pattern of the hair loss was bizarre. The areas of hair loss changed slowly over weeks to months with some areas extending and others improving. Examination showed multiple broken hairs of variable length with no actual baldness. There was no inflammation, hair miniaturisation or exclamation mark hairs.
On further questioning, the patient reported fiddling with her hair and her mother commented that she regularly observed her daughter touching and twirling her hair and constantly told her daughter not to fiddle with her hair. With this new information, the patient was asked to pluck a single hair from her scalp, which she performed expertly. Features visible on trichoscopy were consistent with a diagnosis of trichotillomania.
Discussion
Trichotillomania is characterised by frequent, repeated and irresistible urge to pull one’s own hair resulting in hair loss, with the scalp being the most commonly described area. The hair presentation test is a good tool to aid clinicians with this diagnosis. This test is positive when the patient is able to expertly pull a single hair and present it to the doctor when asked to do so, suggesting years of practice.
Approximately 10%-20% of patients with trichotillomania eat their hair after pulling it, termed as trichophagia, which leads to trichobezoar. The potential life threatening complication of trichotillomania, occurs when the trichobezoar causes intestinal obstruction. The management of trichotillomania involves psychotherapies and pharmacotherapies. A consultation with a trichologist may be helpful for advice relating to leave-on conditioners and other camouflage aids.