A childhood case of trichotillomania associated with body dysmorphic disorder and stigmatization due to outstanding red hair.

Sir,

Body dysmorphic disorder (BDD) is a distressing preoccupation with an imagined or slight defect in appearance of a body part.[1] Trichotillomania (TTM), the phenomenon of hair pulling, is usually considered an impulse-control disorder.[2] Here, we describe a girl with TTM and BDD, caused by stigmatization due to her hair color.

A 12-year-old girl with bright red hair was referred for parietotemporal hair loss of 4-months duration, unresponsive to oral terbinafin and itraconazole. Examination showed ill-defined, noncicatricial alopecic patches [Figure 1a–c]. Hair pull test was negative. Native preparation with 15% KOH and culture on Saburaud agar yielded no fungi. Scalp dermoscopy revealed black dots, coiled fractured short hairs besides broken hairs of different lengths. There were many dystrophic hairs, some with frayed ends, sparse yellow dots, but no exclamation-mark hairs [Figure 2a–c]. All these findings led to a diagnosis of TTM. During an interview conducted by a psychologist, the patient admitted that she hated her hair color. School and play mates were calling her as “carrot head.” Her parents then declared that they noticed increased hair loss after she was alone in bathroom or toilette. Though they did not directly observe hair pulling, they were convinced about the diagnosis of TTM.

Figure 1

(a-c) Patchy hair loss and unevenly broken hair shafts

Figure 2

(a-c) Dermoscopy reveals broken hair, black dots, hair with frayed ends, sparse yellow dots

In childhood hair disorders such as tinea capitis or alopecia areata are also common, posing diagnostic difficulties for TTM. Misdiagnosis as tinea capitis might have promoted our patient to keep on hair pulling. As patients with TTM usually deny the pulling habit, diagnosis is based on clinical, dermoscopic, and histopathologic findings. Clinical diagnosis of TTM with unevenly broken hair is straightforward. Dermoscopy of the scalp and hair in TTM improves diagnostic accuracy especially in equivocal cases for alopecia areata. The presence of black dots, coiled hair, shafts of varying lengths with fraying or split ends, and absence of exclamation mark hairs are suggestive of TTM.[34] In our case, dermoscopic features were consistent with TTM, and supported our clinical diagnosis, avoiding scalp biopsy which is a traumatic procedure.

Children with TTM tend to have perfectionistic personality qualities, and among such patients BDD is especially prevalant. One of the most common areas of concern for adolescents with BDD is hair, most often excessive hair and thinning.[1] These patients often have a low self-esteem and feelings of unattractiveness, which may also be caused by stigmatization. Stigmas are attributes that spoil an individual's identity due to a perceived or actual trait. They always carry negative evaluations, therefore stigmatized individuals develop coping strategies to protect themselves.[5] Stigmatization in our patient was caused by the red hair color which is quite rare in Turkish population. This case suggests that TTM and BDD with stigmatization may overlap and hair color may contribute to all these psychopathologies.