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

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

Khalifa E. Sharquie1, Fatema A. Al-Jaralla2

1Department of Dermatology, College of Medicine, University of Baghdad. Iraqi and Arab Board for Dermatology & Venereology, Baghdad Teaching Hospital, Medical City, Baghdad, Iraq.
2Department of Dermatology, College of Medicine, University of Baghdad , Baghdad, Iraq.

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

Keywords: Trichotillomania, hair pulling disorder,obsessive compulsive neurosis,hair loss patterns.

Free Full-text PDF

How to cite this article:
Khalifa E. Sharquie, Fatema A. Al-Jaralla. Trichotillomania is chronic obsessive compulsive disease with a diagnostic hair loss patterns. American Journal of Dermatological Research and Reviews, 2020, 3:17. DOI: 10.28933/ajodrr-2019-12-1505


1. Johnson J, El-Alfy AT. Review of available studies of the neurobiology and pharmacotherapeutic management of trichotillomania. J Adv Res. 2016;7(2):169–184.
2. American Psychiatric Association. Diagnostic and statistical manual of mental disorders. 5th ed. Washington, DC; 2013.
3. Christenson GA, Pyle RL, Mitchell JE: Estimated lifetime prevalence of trichotillomania in college students. J Clin Psychiatry 1991; 52:415–417
4. O’Sullivan RL, Keuthen NJ, Christenson GA, Mansueto CS, Stein DJ, Swedo SE. Trichotillomania: behavioral symptom or clinical syndrome? Am J Psychiatry. 1997;154(10):1442–1449
5. Cohen LJ, Stein DJ, Simeon D, et al. Clinical profile, comorbidity, and treatment history in 123 hair pullers: a survey study. J Clin Psychiatry. 1995;56:319–326.
6. Siddappa K. Trichotillomania. Indian journal of Dermatology, venereology and Leprology. 2003;96:2: 63-68
7. Golubchik P, Sever J, Weizman A, et al. Methylphenidate treatment in pediatric patients with attention-deficit/hyperactivity disorder and comorbid trichotillomania: a preliminary report. Clin Neuropharmacol. 2011;34:108–110.
8. Nuss MA Carlisle D Hall M Yerneni SC Kovach R . Trichotillomania: A Review and Case Report. Cutis. 2003 ;72(3):191-196
9. Franklin ME, Zagrabbe K, Benavides KL. Trichotillomania and its treatment: a review and recommendations. Expert Rev Neurother. 2011;11(8):1165–1174.
10. Sharquie KA, Noaimi AA, Younis MS, Al-Sultani BS. The Major Psychocutaneous Disorders in Iraqi Patients. Journal of Cosmetics, Dermatological Sciences and Applications 2015; 5: 53-61.
11. Mahmoud L.H., Aldoori S.K. The Effect Of Rapport On primary Psychocutaneous Patients’ Referral To Psychiatry Department A dissertation is submitted in partial fulfillment for certification by the Arab Board of Health Specializations in dermatology and venereology 2019
12. Chen Y, Lyga J. Brain-skin connection: Stress, inflammation and skin-aging. Inflamm Allergy Drug Targets 2014; 13: 177–90.
13. Grant JE, Chamberlain SR. Trichotillomania. Am J Psychiatry. 2016;173(9):868–874.
14. Al-Hemiary J.N., AlHasnawi M.S., Al-Diwan K.J. Obsessive Compulsive Disorder in Karbala, Iraq: a preliminary Report. Kerbala Journal of Medicine, 2014; 7(2): 2014-2017.
15. Flessner CA, Lochner C, Stein DJ, Woods DW, Franklin ME, Keuthen NJ. Age of onset of trichotillomania symptoms: investigating clinical correlates. J Nerv Ment Dis. 2010 Dec. 198(12):896-900.
16. Keren M, Ron-Miara A, Feldman R, Tyano S. Some reflections on infancy-onset trichotillomania. Psychoanal Study Child. 2006. 61:254-72

Terms of Use/Privacy Policy/ Disclaimer/ Other Policies:
You agree that by using our site, you have read, understood, and agreed to be bound by all of our terms of use/privacy policy/ disclaimer/ other policies (click here for details).

This work and its PDF file(s) are licensed under a Creative Commons Attribution-NonCommercial 4.0 International License.