Trichotillomania

Trichotillomania is more common than is generally appreciated, especially in children. At the Mayo Clinic, we saw 145 patients in a ten-year period (1968-1977), and we have observed approximately 15 to 20 such patients per year since that time. Trichotillomania can be a mild or major cosmetic impairment and can be a minor neurotic trait or a sign of serious psychiatric disorder. Although the clinical presentation is characteristic, it can be confused with many different types of alopecia but particularly alopecia areata. Punch biopsy of the affected scalp may be very useful in confirming the clinical diagnosis of trichotillomania, particularly if catagen hairs, melanin casts, and signs of follicular tear or avulsion are present. Trichophagy and trichobezoars are rare associated disorders that should be sought. A common sense approach with a kind and honest explanation to the patient or the parents may be sufficient to terminate the hair-pulling. It is the responsibility of the physician to determine whether psychiatric consultation is desirable in the assessment and treatment of associated psychiatric disorders. Patients in whom the trichotillomania is resistant to simple reinforcement and explanation should have psychiatric consultation. Intensive psychotherapy may be worthwhile in selected patients.