TRICHOTILLOMANIA

1. Introduction

Trichotillomania is a traumatic, non-scarring alopecia, an obsessive-compulsive disorder or stereotyped motor disorder (OCDs) . The disease is characterized by hair pulling in any position, repeated leading to hair loss but due to the patient’s own actions.

2. Epidemiology

• Usually starts in the teenage, adults who has less activity.
• Incidence up to 3.5%.
• Female/male ratio = 9/1.

3 . CLINICAL

– The area of asymmetrical hair loss , polymorphism and unevenness

– T -minded fractures in different lengths, average hair density FREQUENTLY ng, hair pull test is negative.

(Hair pulling test is used to assess the progression of hair loss: grasp about 50-60 hairs jerk from the root to the tip. Positive test when there are 6 hair loss, indicating that the process of hair loss is progressing However, if 3 strands of hair are shed in different areas of the scalp, this test is also considered to be positive)

– The location of hair loss can be on the scalp (usually the top and forehead), eyebrows, eyelashes, pubic hair and often more than one location.

– Often accompanied by some other motor activities such as sucking or biting nails . In some cases, chewing and eating hair lead to bowel obstruction caused by a tufts of hair (trichobezoar).

8 year old female patient with the hair loss area cause by trichotillomania.

Images of hair loss with varying degrees of length, position of forehead and top of head
(Source: Internet)

Investigation

– Trichoscopy : 2 quite specific signs in the disease :

+  Broken hair with lots of different lengths

+  Flame hair sign with head fractures fuzzy hair like the shape of the flame

• It is a very specific sign for hair pulling and not seen in other diseases
• It is the result of restoring the rest of a healthy hair after being subjected to strong traction and is less likely to occur in fragile and brittle hair.

+ In addition, you can see signs of black dot, twisted hair, V-shaped …

Different short hairs and flames (red arrows), Bleeding around hair follicles (black arrow) and split hair (red arrow)

5 . DIAGNOSE

– Diagnosis of hair pulling :  DSM-IV criteria are:

1. Recurrent pulling out of one’s hair resulting in noticeable hair loss.
2. An increasing sense of tension immediately before pulling out the hair or when attempting to resist the behavior.
3. Pleasure, gratification, or relief when pulling out the hair.
4. The disturbance is not better accounted for by another mental disorder and is not due to a general medical condition (e.g., a dermatological condition).
5. The disturbance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning.

– Severe diagnosis: based on Massachusetts General Hospital Hairpulling Scale.

6 . DIFFIRENT DIAGNOSTIC

– Alopecia anterior due to other causes .

– Fungal scalp.

Pigment in hair follicles

7 . TREATMENT

7.1. Specific treatment

– No use of drugs is the first option, including : educating patients, psychotherapy , hypnosis .

– Using drugs : There are currently 3 drugs that prove effective in hair pulling.

+ Olanzapin: antipsychotic drug. In Van’s study, 25 patients with hair loss were randomly divided into 2 groups receiving olanzapine once a day, starting as low as 10mg, then increasing the daily dose depending on clinical response and placebo for 12 weeks. Results 85% (11/13) of patients in the drug group improved compared to 17% of patients in the control group. The average dose of 10.8 ± 5.5 mg / day. Note side effects such as drowsiness, weight gain (about 10% of patients).

+ Fluoxetine : reuptake inhibitor receptors of serotonin (SSRIs), the dose used 60 mg / day , the effect on the individual case.

+ N-acetylcysteine .

7.2. About N-acetylcysteine

– Dosage of 1200 mg / day for the first 2 weeks, then 1200mg / day x 2 times / day for 3-4 months. For adults who have proven effective, children who are effective are uncertain.

– Grant tested 50 patients with adult hair pulling in two randomly divided groups: group 1 received N-acetylcysteine ​​1200mg twice daily, group 2 took placebo for 12 weeks. Results: 56% of the placebo group had a good and very good effect compared to 16% in the placebo group, after 9 weeks of treatment, there was a difference in effectiveness between the 2 groups, no side effects were noted. However, in Bloch’s study, using the same regimen in 39 children aged 8-17 years saw 25% in the responsive group compared with 21% in the control group, the difference was not statistically significant. In this study, the author concluded that N-acetylcysteine ​​has no effect on hair pulling in children.

REFERENCES

1. Pereyra A.D. và Saadabadi A. (2019). Trichotillomania. StatPearls. StatPearls Publishing, Treasure Island (FL).
2. Johnson J. và El-Alfy A.T. (2016). Review of available studies of the neurobiology and pharmacotherapeutic management of trichotillomania. Journal of Advanced Research, 7(2), 169–184.
3. Grant J.E., Odlaug B.L., và Kim S.W. (2009). N-acetylcysteine, a glutamate modulator, in the treatment of trichotillomania: a double-blind, placebo-controlled study. Arch Gen Psychiatry, 66(7), 756–763Grant JE, Odlaug BL, Kim SW. N-acetylcysteine, a glutamate modulator, in the treatment of trichotillomania: A double-blind, placebo-controlled study. Arch Gen Psychiatry. 2009; 66:756–63.
4. Bloch MH, Panza KE, Grant JE, Pittenger C, Leckman JF. N-acetylcysteine in the treatment of pediatric trichotillomania: A randomized, double-blind, placebo-controlled add-on trial. J Am Acad Child Adolesc Psychiatry. 2013;52:231–40.
5. Van Ameringen M, Mancini C, Patterson B, Bennett M, Oakman J. A randomized, double-blind, placebo-controlled trial of olanzapine in the treatment of trichotillomania. J Clin Psychiatry. 2010;71:1336–43.

Author:  Nguyễn Doãn Tuấn

Publisher: Social Work Department