Comment on a Multicenter Retrospective Descriptive and Analytical Study of 129 Cases of Trichoteiromania

We have read Ramos Costa et al.'s publication "Trichoteiromania: A multicentre retrospective descriptive and analytical study of 129 cases" in the Journal of the European Academy of Dermatology, and comment on some critical issues related to the nosology, nomenclature, and methodology. The term trichoteiromania was originally coined for the rubbing of the hair due to an underlying psychiatric disorder without further specifications. Based on case observations of patients with trichoteiromania, it was later reported that in contrast to trichotillomania that represents an obsessive-compulsive disorder, the underlying disorder in trichoteiromania varies among patients. Histopathological features are unspecific, while the traumatic changes to the hair shaft are more conspicuous, and 15 min of rubbing the hair is sufficient for hair breakage. Therefore, a clear distinction must be made between trichotillomania, trichoteiromania, neurotic excoriations, factitious dermatitis, lichen simplex chronicus, and nodular prurigo of the scalp, while the dermoscopic findings provided by Ramos Costa et al. showed the mechanics of hair damage without a deeper insight into its etiology. Trichoscopy has gained disproportionate popularity for the differential diagnosis of the hair and scalp disorders since its introduction into dermatologic practice, and as a self-reliant examination technique, it can even be misleading. As a diagnostic procedure, trichoscopy is to be understood as representing an integral part of a more comprehensive dermatological learning, to include a stringent nosological classification and nomenclature of diseases, based on a pathogenic understanding. Specifically, in trichoteiromania studies with a more detailed assessment of the psychopathological status will be of more value to determine disease management strategies, specifically approaches to psychotherapeutic, behavioral, and pharmacological interventions aimed at reducing or eliminating the hair-rubbing behavior. Regrettably, the majority of recent publications on trichoteiromania have been based on trichoscopy without any disease-relevant insights, and obviously, the editors and reviewers of the respective publishing journals have so far failed to acknowledge this major shortcoming.