Trichotillomania is chronic obsessive compulsive disease with a diagnostic hair loss patterns

Abstract

Background: Trichotillomania (TTM) is a common cause of childhood alopecia. It’s a traumatic alopecia and is defined as the irresistible urge to pull out the hair, accompanied by a sense of relief after the hair has been plucked. The condition maybe episodic and the chronic type is difficult to treat. There seem to be an increase in the prevalence of the condition probably due to the changing life style into a more stressful one. Objective: To do full evaluation of this disease and description of hair loss patterns. Patients and methods: In this descriptive study, we collected patients with trichotillomania who had attended department of dermatology, college of medicine, university of Baghdad, Baghdad teaching hospital during the period from 2011 through 2019 where 114 cases of TTM were seen. The diagnosis was established on clinical basis after exclusion of other dermatological diseases and medical problems.Full history was taken from each patient including demographic data, presence of stressful life event as a triggering factor. Psycholgical assessment was carried out for each patient by experienced dermatologist as psychiatric referral was refused by all patients and their families.Full description of patterns of hair loss was carried out after exclusion of other causes of hair loss especially alopecia areata. Results: A total of 114 patients diagnosed with TTM were enrolled in this study,88 (77.19%) patients were females and 26 (22.8%) males with female to male ratio: 3.38:1 . Age of patients ranged from 6 – 65 years with a median age of 16 years with the commonest age range between 10-19 years in 64(56.14%) patients.While the duration of the condition ranged from 3 months to 4 years. Family history was positive in 6 (5.3%) patients, all of them were first degree relatives. Psychological evaluation showed obsessive compulsive neurosis in all patients and all patients or parents denied their action. Patients usually presented with areas of different hair lengths. Some hairs may be broken mid-shaft or appeared as uneven, whereas others had small black dots at the surface of the scalp, these features simulating fire in field but no exclamation mark hair were seen. There is usually no scaling on the scalp and the hair does not pull out easily. The affected area often had a strange shape, which had a useful diagnostic clue. The hair loss in TTM can take many shapes; morphological forms or patterns and as follow: crest like in 2 patients (1.75%) both of them were females in the 2nd decade of life, there was loss of hair at the sides of the scalp leaving the frontovertical and occipital area not affected,the second pattern so called cap like were found in 39 patients (34.21%), most patients were in the second decade of life, there was a hair loss at the top of the scalp mainly frontovertical area and leaving the sides of the scalp,the third pattern alopecia areata- like, where multiple patches of hair loss were seen in 20 (17.5%) patients,the forth pattern frontal baldness like seen in 19 patients (16.66%), where the patients presented with complete hair loss of the frontal hair only. While the fifth pattern was the generalized (TTM totalis) type were seen in 19 (16.66%) patients all of them were females. Involvement of the eyebrows and eyelashes alone were seen in 6 (5.26%) patients, most of them were females, all but one in the first and second decade of their lives. Mixed patterns were seen in 8 (7.01%) patients all of them were females in their second decade and as follow: frontal plus eyebrows involvement was the most common in5 patients, followed by frontal plus patchy patterns in 2 patients, then totalis plus eyebrow in one patient. Only one patient was presented with beard involvement. Conclusion: TTM is disease of young female children with obsessive compulsive neurosis that presented with different patterns of hair loss that run chronic course . It is a debilitating disorder to the patients with emotional struggle as have to endure the embarrassment and shame of hair loss. A better understanding and awareness of the disorder is certainly the first step toward recognizing this disorder and management of these patients