N-acetylcysteine in the Treatment of Trichotillomania.

Trichotillomania is as medical condition caused by the patient himself by pulling out of is own hair, resulting in a perceptible hair loss pattern that frequently is associated with other psychiatric processes. Generally has a chronic course in most patients, and a challenging therapeutical management. There are several available options for is treatment, but the clinical response is not satisfactory in many patients. Recently, N-acetylcisteine, a glutamate modulator, has shown efficacy in the treatment of trichotillomania and other compulsive behaviors, and is considered a new alternative in the management of this condition. We describe two patients with trichotillomania successfully treated with N-acetylcysteine. Nevertheless, further studies need to be conducted to establish the appropriate treatment regimen and to evaluate it long-term efficacy in improving this chronic condition.

INTRODUCTION

Trichotillomania consists of the recurrent compulsive habit of pulling out of one's own hair, resulting in a perceptible hair loss pattern that frequently is associated with other psychiatric processes, and social or functional impairment. It can be a self-limiting symptom but in most cases is a chronic disorder with frequent remissions and relapses. Therapeutical management is difficult and behavioral therapy, psychotherapy, hypnosis, or pharmacological treatment has been used without satisfactory results. Recently, N-acetylcysteine has been proposed as an effective alternative in the treatment of this disorder.[1] We describe 2 patients with trichotillomania successfully treated with N-acetylcysteine.

CASE REPORT

The first patient was a 23-year-old woman that attended at our outpatient Dermatology Department with partial alopecia of her eyebrows, eyelashes, and frontal hairline of the scalp. The disorder was related with the death of her mother during childhood. On physical examination, patchy alopecia in eyebrows, eyelashes and in the frontal area was noted, with somewhat artificial appearance and presence of hairs with different length [Figure 1a]. In the past she had received treatment with fluoxetine and psychotherapy but it was ineffective. N-acetylcysteine 1,200 mg/day was started and complete regrowth occurred in the frontal area within the first two months of treatment, which maintained until the 6-month follow-up period [Figure 1b]. No response was observed in eyelashes and eyebrows. The second patient was a 19-year-old woman with an irresistible urge to pull out of her hair since the age of 9. Once the diagnosis of trichotillomania was made she tried different treatments without satisfactory response. She presented diffuse hair loss affecting the entire scalp with broken hairs and hairs with different lengths on dermatoscopic examination [Figure 2a]. Eyelashes and eyebrows were preserved. Complete regrowth was observed after introducing N-acetylcisteine 1,200 mg/day during 3 months [Figure 2b]. No adverse events with the medication were reported in both patients.

Figure 1

(a) Patchy alopecia in frontal area with presence of hairs with different length; (b) Complete regrowth in the frontal area after two month treatment with N-acetylcysteine

Figure 2

Dermoscopic examination before (a) and after (b) three month treatment with N-acetylcysteine 1,200 mg/day

DISCUSSION

Trichotillomania is a traumatic alopecia caused by the patient himself by pulling out of the hair with the aim of tearing it off. The incidence it's not known with exactitude, but it is estimated that affects between 0.6-1% of the population.[2] It can appear in any hair-bearing area, but the most frequent locations are the scalp and eyebrows, while the eyelashes are exceptionally affected. The alopecia presents with an artificial pattern, with circular or lineal forms, and fractured hairs at different lengths.[3] The disorder can be associated with trichofagia, onichofagia and other self-inflicted cutaneous mutilations, as well as trichobezoar.

Trichotillomania management is often challenging. It depends on the beginning-age of the disorder and of the possible associated co-morbidities. In any case is important to establish a good doctor-patient relationship, to inform and advice about the nature of the disorder and recommend a psychiatric evaluation. Between the available pharmacological treatments for trichotillomania, tricyclic antidepressant clomipramine has shown to be effective, but often the patient adherence is poor and the results are modest. Also, selective serotoninergic receptor reuptake inhibitors (SSRIs) have been considered as a first line treatment for this disorder but there is no evidence that supports its benefits.[4] Furthermore, some agents, such as naltrexone or neuroleptics, like pimozide, have been used in combination with other alternatives.[56] Habit reversal training is the most effective behavioral therapy, and should be associated with pharmacological treatment.

Recently several reports have indicated that N-acetylcysteine, a glutamate modulator, could be effective in reducing symptoms of trichotillomania. It acts by restoring the extracellular glutamate concentration in the nucleus accumbens, decreasing its levels, which seem responsible for the pathogenesis of compulsive behaviors, and therefore, trichotillomania.[7]

Grant et al. conducted an aleatorized double-blind clinical trial, comparing N-acetylcysteine with placebo, with doses ranging between 1200 and 2400 mg per day and have observed that it was more effective and safe than placebo, and that also produced better results than other pharmacological alternatives, with no reported adverse events.[1]

Nevertheless, the promising results N-acetylcysteine is showing further studies need to be conducted to establish the appropriate treatment regimen and to evaluate it long-term efficacy in improving this chronic condition.