Trichotillomania contrasting clinical connotation in a child and adult women.

Sir,

A 10-year-old boy who was studying 5th standard in the public sector school reported with progressive thinning of the hair from the right scalp, eyebrows and eyelashes. Child was introverted and backbencher. Little attention was given to the child. He was found to be engaged in pulling out and twisting the hair from the right scalp, eyebrows and eyelashes, resulting in an explicit rarefaction [Figure 1]. The process was irresistible and continuing for the past 2 years.

Figure 1

Thinning/rarefaction of the hair of the right scalp, eyebrows and eyelashes

Interestingly, during the sojourn, an elderly 65-year-old woman reported with a well-demarcated, localized progressive loss of hair in the midst of thick, white hair for the past 3 months. The stumps of the hair could be seen embarrassing the underling skin [Figure 2]. She has been alone and was being looked after by her grand-daughter. She seldom had an opportunity of interaction with either her own family members or others. She seemed to have been a victim of isolation in a far flung small village in South India.

Figure 2

Localized, non-scarring loss of hair on the scalp

Trichotillomania/hair-pulling madness is an intriguing compulsive disorder, resulting in alopecia from repetitive hair manipulations, comprising pull out or twists until it breaks off.[12] The process results in an instant release of tension, a sense of relief and security. Non-scaring alopecia is its clinical presentation, both in children and adults. The hair may be eaten, the trichobezoar resulting in gastrointestinal disturbances, such as intestinal obstruction, perforation, pancreatitis and obstructive jaundice, The Rapunzel syndrome may occur when gastrointestinal obstruction is produced by a rare manifestation of a trichobezoar with a long tail that extends to or beyond the ileocecal valve.[3]

The diagnosis is made after taking a thorough history, noting the clinical features and evaluating a hair-root examination, where telogen hair is (almost) completely lacking, which distinguish trichotillomania from other hair disorders. In addition, co-axial tomography scan[4] of whole abdomen is imperative to perform in order to evaluate it gastrointestinal undertones.

Treatment modalities vary in childhood and adult varieties. Apart from psychotherapy, the drug treatment involves several agents including selective serotonin reuptake inhibitors and clomipramine. Trichobezoar/Rapunzel syndrome requires surgical intervention.[5]