Extensive tonsure pattern trichotillomania-trichoscopy and histopathology aid to the diagnosis.

Trichotillomania manifests as a compulsive desire to pull out own hair. The clinical presentation of trichotillomania is usually characteristic, with varying length hair distributed within areas of alopecia on otherwise normal scalp. In severe forms, tonsure pattern of baldness results, involving the entire scalp sparing the hair at the margins. Extensive tonsure pattern trichotillomania is rare and difficult to differentiate from other nonscarring alopecias on clinical grounds alone. Trichoscopy and histopathology of scalp play a corroborative role in definitive diagnosis. We hereby report two cases of extensive tonsure pattern trichotillomania, with special reference to their trichoscopic and histopathological features.

INTRODUCTION

Trichotillomania is an impulse control disorder with irresistible urge to pull out own hair, accompanied by sense of relief after the hair has been plucked.[1] Scalp is the most common site for pulling hair although other hair bearing areas may be involved.[2] In less severe forms, patients may have only small areas of baldness, whereas in the more severe forms, tonsure pattern of baldness results, involving the entire scalp sparing the hair at the margins. We hereby report two cases of extensive tonsure pattern trichotillomania with special reference to their trichoscopic and histopathological features.

CASE REPORTS

Case 1

A 19-year-old female presented in dermatology outpatient department (OPD) with diffuse alopecia of scalp for 4 years. The alopecia started from frontal scalp 4-years back, which gradually extended to involve the entire scalp leaving behind the margins. On direct questioning, the mother gave history of repeated hair pulling behavior of the patient. She used to pull hair mostly during study hours at home. The patient was anxious and had a guilt feeling for her hair loss. There was no obvious stress in the family. The general and systemic examination revealed no abnormality except pallor. The cutaneous examination showed diffuse alopecia of scalp with varying length of remaining few hairs. The alopecia involved the entire scalp sparing only the occiput and margins of scalp resembling tonsure pattern [Figure 1a and b]. There were few follicular papules distributed sparsely on the scalp. There was no alopecia involving other body hair. The KOH mount for fungus was negative. The blood tests like complete blood count, liver function test, renal function test, and thyroid profile were within normal limits except for low hemoglobin. The trichoscopy showed broken hair of varying length, coiled hair, and black dots [Figure 1c]. The histopathological examination showed disrupted hair follicles and pigment casts without any inflammation [Figure 1d]. With the aid of trichoscopy and histopathology, the diagnosis of extensive tonsure pattern trichotillomania with pseudofolliculitis was made. The patient was referred to psychiatry OPD for further management.

Figure 1

(a and b) Extensive tonsure pattern trichotillomania in case 1; (c) Trichoscopy demonstrating broken hair of varying length, coiled hair, and black dots; (d) Histopathology of the affected scalp showing disrupted hair follicles and pigment casts without any inflammation (H and E, ×40). H and E = hematoxylin and eosin

Case 2

A 24-year-old para-2 postpartum female was referred to dermatology OPD for diffuse alopecia of scalp. The patient's mother gave history of hair pulling by the patient. The patient developed hair pulling behavior following an incident of molestation when she was 15-years old. Though the alopecia was patchy initially, there was aggravation during both pregnancies leading to extensive tonsure pattern alopecia. She used to pull her hair both with hands and tweezers especially during leisure time. She was married for 4 years and had two children. There was no history of familial disharmony or of any significant illness in the patient. The general and systemic examinations revealed no abnormality except for pallor. On cutaneous examination, there was diffuse nonscarring alopecia of the scalp with varying length of hair in some areas [Figure 2a and b]. There was sparing of hair on the scalp margin. The KOH mount for fungus was negative. The blood tests like complete blood count, liver function test, renal function test, and thyroid profile were normal except for low hemoglobin. Trichoscopy showed scanty hairs with varying length, few broken hair, trichoptilosis, coiled hair, and black dots [Figure 2c]. The histopathology showed empty hair follicles, disrupted follicles with pigment casts, and no inflammation, confirming the diagnosis of trichotillomania [Figure 2d]. The patient was referred to psychiatry OPD for further management.

Figure 2

(a and b) Extensive tonsure pattern trichotillomania in case 2; (c) Trichoscopy demonstrating scanty hair with varying length, few broken hair, trichoptilosis, coiled hair, and black dots; (d) Histopathology of the affected scalp showing empty hair follicles, disrupted follicles with pigment casts, and no inflammation (H and E, ×40). H and E = hematoxylin and eosin

DISCUSSION

Extensive tonsure pattern trichotillomania is rare and difficult to differentiate from other nonscarring alopecia on clinical grounds alone. Trichoscopy (hair and scalp dermoscopy) helps for differential diagnosis of various hair and scalp diseases.[3] Trichotillomania most commonly results in patchy alopecia with irregular length of hair. However, in severe cases, hair loss in vertex area creates characteristic “tonsure trichotillomania.”[4] The common trichoscopic features of trichotillomania are decreased hair density, hairs broken at different lengths, short hair with trichoptilosis ("split ends"), irregular coiled hairs, upright regrowing hairs, and black dots.[56] In a recent study, some novel trichoscopic features characteristic of trichotillomania were described like flame hair, v-sign, tulip hair, and hair powder.[7] In our patients, we noticed hair broken at different lengths, coiled hair, black dots, and v-sign. Coiled hair results due to hair shaft fracture, following pulling, and coiling of the remaining proximal part, which is fixed to the scalp. In alopecia areata, the common trichoscopic findings are yellow dots, uniform black dots, broken hair, trichoptilosis, upright regrowing hair, and vellus hair.[78] As some of the trichoscopic features are overlapping in trichotillomania and alopecia areata, histopathology plays a corroborative role in definitive diagnosis. The histopathological features of trichotillomania include empty follicles, incomplete disrupted follicular anatomy, trichomalacia, and pigment casts without significant inflammation.

The pathogenesis of trichotillomania is multifactorial and complex.[910] The pulling behavior serves as a coping mechanism for anxiety, stress, and other difficult emotions. Both positive and negative influence of pregnancy in trichotillomania is noted.[10] In our second patient, pregnancy has aggravated trichotillomania in two successive pregnancies. Hormonal changes during pregnancy may cause mood changes leading to aggravation of the problem.

To conclude, trichoscopy is a noninvasive tool in the armamentarium of dermatologist for diagnosis of hair and scalp disorders. However, it has to be emphasized that, in every case, the final diagnosis has to be based on all available data, including clinical features, laboratory investigations, trichoscopy, and histopathology.