By Gary M. White, MD
Trichotillomania is an obsessive-compulstive disorder in which patients repeatedly pull or manipulate their hair resulting in hair loss.
Patchy loss of hair with the hairs of non-uniform lengths is seen. The scalp is normal. The main differential diagnosis is alopecia areata (look for exclamation point hairs). Often, a peripheral collar of normal hair is seen along the hair line--the so called Friar Tuck sign.
A tactful, but open discussion with both child and parent about the need to not pull, twist or twirl the hair is in order. In fact, behavioral therapy (BT) seems to be more effective treatment than medication--especially in children.
Children and teens can reap benefits from BT. For mild disease, strategies that make hair pulling harder may be employed (e.g. placing bandages on fingers, wearing gloves, and putting on a hat). Parents may also praise the child when he/she avoids pulling the hair.
For more moderate disease, habit reversal therapy may be tried. Initially, the child is taught to perceive and understand the triggers (e.g. situations, stress, location) of their hair pulling. Then, the child is taught competing behaviors, e.g. making a fist, sitting on hands, playing with a stress ball. They may be instructed to do this for a minute in order to let the urge to pull pass.
Some studies have shown a benefit in using N-Acetylcysteine (1200 mg/day) especially in adults [Arch Gen Psychiatry. 2009 Jul;66(7):756-63] while others have not, especially in children [J Am Acad Child Adolesc Psychiatry. 2013 Mar;52(3):231-40].
If these are not sufficient, oral medication, e.g. clomipramine may be tried.
A teenage girl with short hairs of varying lengths across the top but the hair on the edges is spared.
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