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Year : 2016  |  Volume : 17  |  Issue : 1  |  Page : 65-67

Early-onset trichotillomania: A case report with dermoscopic findings

1 Department of Dermatology, Venereology and Leprosy, Pondicherry Institute of Medical Sciences, Puducherry, India
2 Department of Psychiatry, Pondicherry Institute of Medical Sciences, Puducherry, India

Date of Web Publication4-Jan-2016

Correspondence Address:
Nisha V Parmar
Department of Dermatology, Venereology and Leprosy, Pondicherry Institute of Medical Sciences, Puducherry - 605 014
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/2319-7250.172463

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Early-onset trichotillomania (TTM) can be a challenging diagnosis as other common causes of childhood patchy alopecias such as alopecia areata and tinea capitis have to be excluded. We report a 3-year-old boy with TTM and dermoscopic findings.

Keywords: Childhood trichotillomania, trichoscopy, trichotillomania

How to cite this article:
Parmar NV, Kuruvila S, Thilakan P. Early-onset trichotillomania: A case report with dermoscopic findings. Indian J Paediatr Dermatol 2016;17:65-7

How to cite this URL:
Parmar NV, Kuruvila S, Thilakan P. Early-onset trichotillomania: A case report with dermoscopic findings. Indian J Paediatr Dermatol [serial online] 2016 [cited 2021 Oct 16];17:65-7. Available from: https://www.ijpd.in/text.asp?2016/17/1/65/172463

  Introduction Top

Trichotillomania (TTM) is a form of traumatic alopecia caused by an irresistible compulsion to pull one's own hair. Early-onset TTM is when the age of onset is between 2 and 10 years. This form is commoner in boys and tends to remit spontaneously with age. Other forms of nonscarring alopecias in this age group may pose a challenge in its diagnosis. These include common conditions such as alopecia areata and tinea capitis. Dermoscopy is a useful noninvasive procedure to aid the diagnosis of TTM and help to differentiate it from these conditions. We describe a 3-year-old boy with TTM with characteristic dermoscopic findings.

  Case Report Top

A 3-year-old boy was brought to the Dermatology Outpatient Department by his mother with complaints of a patch of hair loss from his scalp of 1-year duration. He was apparently well until the age of 2 years when his mother noticed him pulling hair from the right side of his scalp while watching television, while lying down on the bed before sleeping and occasionally when his demands were not met. The child was right handed. There was no history of hair pulling from other parts of the body. The child would pull his mother's scalp hair or his father's chest hair if they tried to cover his head with a cap. There was no history of eating the pulled hair or of any abdominal symptoms. He had no habits of thumb sucking or nail biting. The child was born to nonconsanguineous parents and had attained all the milestones for his age normally. There was no similar history in his family members. He was taken care of by his grandmother while his parents were at work throughout the day.

Cutaneous examination revealed a bizarre shaped patch of incomplete hair loss on the right frontotemporal area. The hairs on the patch were short, broken, and of uneven length [Figure 1]. The hairs on the rest of the scalp were normal. A 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. Trichoscopy of the alopecic patch revealed broken hairs of uneven length, black dots, few yellow dots containing black dots, coiled hairs, and hair powder [Figure 2]. There were no exclamation mark hairs. The child was diagnosed with early-onset TTM and referred to the Psychiatry Department where he is being managed with behavioral therapy.
Figure 1: Bizarre shaped patch of incomplete hair loss on the right frontotemporal region

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Figure 2: Dermoscopic findings: (a) Decreased hair density with hairs of uneven length and empty hair follicles (blue arrow) (b) short broken hair (black arrow), hair powder (white arrow), black dot within a yellow dot (green arrow) (c) hook hair (red arrow) and short re-growing vellus hair (yellow arrow)

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  Discussion Top

The term TTM was first composed by the French dermatologist Francois Henri Hallopeau in 1889 from the Greek words thrix (hair) tillein (pulling) mania (madness).[1] The fourth edition of Diagnosis and Statistical Manual of Mental Disorder (DSM-IV) classifies TTM as an impulse control disorder and provides criteria for its diagnosis [Table 1].[2] However, these criteria may not be applicable to children.[3]
Table 1: DSM-IV diagnostic criteria for TTM[2]

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Based on the bimodal age of onset, TTM is classified into two groups: early-onset and late-onset. Early-onset TTM begins at 2–10 years of age, is commoner in boys (62%), and has a benign self-limiting course.[4] In this group, 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.[5] Late-onset TTM begins during adolescence, is commoner in girls, with ratios of up to 3.5:1 and has a poorer outcome with progression into adulthood. The psychopathology may be attributed to difficult parent-adolescent relationships, bullying in school, pubertal body image changes as well as physical and sexual abuse.[6]

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

Other common causes of nonscarring hair loss in children include noninflammatory tinea capitis and alopecia areata. Tinea capitis can be differentiated by the presence of scaling and a positive hair microscopy using a potassium hydroxide mount as well as a fungal culture. Alopecia areata is characterized by one or more smooth bald patches commonly on the scalp. A hair pull test is positive at the margins of these patches. Habitual hair pulling of infancy and childhood is a benign self-limiting condition which is not accompanied by visible hair loss. It represents normal tactile environmental exploration and is not associated with any stress or impulse control.[7]

Dermoscopy has now become an easily-available, simple, and noninvasive outpatient procedure for the diagnosis of various dermatological conditions including hair disorders. It is a useful tool in differentiating TTM from alopecia areata. The most consistent 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, perifollicular hemorrhages.[8] Various novel findings of TTM have been recently described [Table 2].[9]
Table 2: New trichoscopic findings in TTM[9]

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Treatment of TTM differs in the two groups. Late-onset TTM is managed with cognitive behavioral therapy alone or in combination with drugs such as tricyclic antidepressants or selective serotonin reuptake inhibitors.[3],[4] Since the cognitive development of children is not complete, behavioral therapy guided towards exposure and risk factor prevention, is considered first line in the management of early-onset TTM.[10]

Declaration of Patient Consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

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Conflicts of Interest

There are no conflicts of interest.

  References Top

Hallopeau H. Alopecie par grattage (trichomanie ou trichotillomanie). Ann Dermatol Syphiligr (Paris)1889;10:440-1.  Back to cited text no. 1
American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders: DSMIV-TR. Washington, DC: American Psychiatric Association; 2000.  Back to cited text no. 2
Franklin ME, Flessner CA, Woods DW, Keuthen NJ, Piacentini JC, Moore P, et al. The child and adolescent trichotillomania impact project: Descriptive psycho-pathology, comorbidity, functional impairment, and treatment utilization. J Dev Behav Pediatr 2008;29:493-500.  Back to cited text no. 3
Bruce TO, Barwick LW, Wright HH. Diagnosis and management of trichotillomania in children and adolescents. Paediatr Drugs 2005;7:365-76.  Back to cited text no. 4
Oranje AP, Peereboom-Wynia JD, De Raeymaecker DM. Trichotillomania in childhood. J Am Acad Dermatol 1986;15 (4 Pt 1):614-9.  Back to cited text no. 5
Lochner C, Seedat S, du Toit PL, Nel DG, Niehaus DJ, Sandler R, et al. Obsessive-compulsive disorder and trichotillomania: A phenomenological comparison. BMC Psychiatry 2005;5:2.  Back to cited text no. 6
King RA, Scahill L, Vitulano LA, Schwab-Stone M, Tercyak KP Jr, Riddle MA. Childhood trichotillomania: Clinical phenomenology, comorbidity, and family genetics. J Am Acad Child Adolesc Psychiatry 1995;34:1451-9.  Back to cited text no. 7
Lencastre A, Tosti A. Role of trichoscopy in children's scalp and hair disorders. Pediatr Dermatol 2013;30:674-82.  Back to cited text no. 8
Rakowska A, Slowinska M, Olszewska M, Rudnicka L. New trichoscopy findings in trichotillomania: Flame hairs, V-sign, hook hairs, hair powder, tulip hairs. Acta Derm Venereol 2014;94:303-6.  Back to cited text no. 9
Tay YK, Levy ML, Metry DW. Trichotillomania in childhood: Case series and review. Pediatrics 2004;113:e494-8.  Back to cited text no. 10


  [Figure 1], [Figure 2]

  [Table 1], [Table 2]

This article has been cited by
1 An atypical case of early-onset trichotillomania Management implications
Sai Spoorthy Mamidipalli,Lokesh Kumar Singh
Asian Journal of Psychiatry. 2019; : 101914
[Pubmed] | [DOI]


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