Trichotillomania - Clinicals, Diagnosis, and Management

Impulse-Control Disorders

Clinicals - History

Fact Explanation
Pulling or plucking hair This is an impulse control disorder in which pulling or plucking his or her own hair is the characteristic feature. Patients experience tension when they try to refrain and resist the behavior, and they feel pleasure or relief when it is done. This is usually causing significant distress and impairment in social functions. Pulling or plucking hair
This is an impulse control disorder in which pulling or plucking his or her own hair is the characteristic feature. Patients experience tension when they try to refrain and resist the behavior, and they feel pleasure or relief when it is done. This is usually causing significant distress and impairment in social functions.
Patches of hair loss Patients may pluck their hair leading to patchy areas of hair loss. Patches of hair loss
Patients may pluck their hair leading to patchy areas of hair loss.
Skin irritation At the site of hair loss, skin irritation develops secondary to hair plucking and minor traumatic injuries caused by repetitive plucking of hair. Skin irritation
At the site of hair loss, skin irritation develops secondary to hair plucking and minor traumatic injuries caused by repetitive plucking of hair.
Symptoms due to trichobezoars Some patients swallow the plucked hair (trichophagia). The hair accumulates in the stomach and in intestine forming trichobezoars, which can present with anemia, abdominal pain, hematemesis and gastrointestinal bleeding, nausea and vomiting, bowel or gastric outlet obstruction, intestinal perforation (pressure effects of the trichobezoars cause ischemic necrosis of the bowel wall), pancreatitis, and obstructive jaundice. Symptoms due to trichobezoars
Some patients swallow the plucked hair (trichophagia). The hair accumulates in the stomach and in intestine forming trichobezoars, which can present with anemia, abdominal pain, hematemesis and gastrointestinal bleeding, nausea and vomiting, bowel or gastric outlet obstruction, intestinal perforation (pressure effects of the trichobezoars cause ischemic necrosis of the bowel wall), pancreatitis, and obstructive jaundice.
Presence of other comorbid disorders Trichotillomania is seen with anxiety disorders, mood disorders, substance use disorders, eating disorders and personality disorders. Presence of other comorbid disorders
Trichotillomania is seen with anxiety disorders, mood disorders, substance use disorders, eating disorders and personality disorders.

Clinicals - Examination

Fact Explanation
Alopecia There can be diffuse and non-scarring hair loss, patchy hair loss or in severe cases, baldness. Hair loss can be in eyebrows, eyelashes, axilla, limbs, torso pubic and perirectal areas, and face in some patients. Noticeable hair loss is one of the diagnostic criteria. Alopecia
There can be diffuse and non-scarring hair loss, patchy hair loss or in severe cases, baldness. Hair loss can be in eyebrows, eyelashes, axilla, limbs, torso pubic and perirectal areas, and face in some patients. Noticeable hair loss is one of the diagnostic criteria.
Friar tuck sign Friar tuck sign or the “tonsure pattern” is characteristic of trichotillomania. Friar tuck sign
Friar tuck sign or the “tonsure pattern” is characteristic of trichotillomania.
Trichoscopy Trichoscopy gives a magnified view of decreased hair density, broken hairs, varying lengths of hair shafts, black dots, and old minor hemorrhages are diagnostic of trichotillomania. Trichoscopy
Trichoscopy gives a magnified view of decreased hair density, broken hairs, varying lengths of hair shafts, black dots, and old minor hemorrhages are diagnostic of trichotillomania.

Management - Specific

Fact Explanation
Conservative management This might be effective in children. The skin lesions are managed conservatively while psychopharmacotherapy is in progress. Conservative management
This might be effective in children. The skin lesions are managed conservatively while psychopharmacotherapy is in progress.
Cognitive–behavioral interventions This is the main mode of treatment. Often treatment should be combined with pharmacological management. Habit Reversal Training and Stimulus Control is considered the most effective treatment modality and it is often combined with pharmacological treatment. Patients are educated about the disease. Patients should be self-monitoring throughout the treatment process. Patients are counseled to raise the awareness of the habit and to resist as an urge to pull hair is felt. The stress associated with urge suppression is dealt with relaxation techniques such as: deep breathing and progressive muscular relaxation. Cognitive–behavioral interventions
This is the main mode of treatment. Often treatment should be combined with pharmacological management. Habit Reversal Training and Stimulus Control is considered the most effective treatment modality and it is often combined with pharmacological treatment. Patients are educated about the disease. Patients should be self-monitoring throughout the treatment process. Patients are counseled to raise the awareness of the habit and to resist as an urge to pull hair is felt. The stress associated with urge suppression is dealt with relaxation techniques such as: deep breathing and progressive muscular relaxation.
Selective serotoninergic receptor reuptake inhibitors (SSRIs) SSRIs are considered as a first line treatment in trichotillomania. Selective serotoninergic receptor reuptake inhibitors (SSRIs)
SSRIs are considered as a first line treatment in trichotillomania.
Naltrexone An opioid antagonist used in the treatment of trichotillomania which gives promising results without any significant side effects. This is often combined with other treatment options for a better outcome. Naltrexone
An opioid antagonist used in the treatment of trichotillomania which gives promising results without any significant side effects. This is often combined with other treatment options for a better outcome.
N-acetylcysteine [NAC] NAC is a glutamate modulator effective in treating trichotillomania. This is really effective in treating trichotillomania in children. N-acetylcysteine [NAC]
NAC is a glutamate modulator effective in treating trichotillomania. This is really effective in treating trichotillomania in children.
Clomipramine This is a tricyclic antidepressant with serotonergic actions. It is considered a second line treatment option, because of its unfavorable side effects. Clomipramine
This is a tricyclic antidepressant with serotonergic actions. It is considered a second line treatment option, because of its unfavorable side effects.
Olanzapine Olanzapine is also used in treatment due to its neuroleptic effects. Olanzapine
Olanzapine is also used in treatment due to its neuroleptic effects.
Treatment of trichobezoars Surgical removal (laparoscopy or laparotomy) or endoscopic removal of the trichobezoars are practiced. Treatment of trichobezoars
Surgical removal (laparoscopy or laparotomy) or endoscopic removal of the trichobezoars are practiced.

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