A case of trichotillomania with recently defined trichoscopic findings.

Trichotillomania (TTM) is an impulse control disorder characterized by repetitive behavior of hair pulling resulting in secondary alopecia. It is among the psychocutaneous diseases known to be associated with psychiatric comorbidity, social, and functional impairment. Although most of the time, an experienced dermatologist easily recognizes the key features of TTM, a history and physical examination alone might not be enough to make a definitive diagnosis. As an effective noninvasive technique for the evaluation of scalp and hair diseases, trichoscopy also has proven to be a valuable tool in the diagnosis of TTM. Currently, new trichoscopic findings of TTM have been described. Here, we report a case of TTM with recently defined trichoscopic features.

INTRODUCTION

Trichotillomania (TTM) is a behavioral disorder characterized by recurrent and overwhelming urges to pull out body hair, accompanied by a sense of pleasure and relief after the hair has been plucked.[12] Although the exact incidence of TTM is not known, it is estimated to affect as high as 4% of the population.[3] TTM appears to be common in children and adolescents.[3] Despite the adult cases who generally develop a chronic course and exhibit an accompanying psychopathology, in children TTM is usually a self-limited benign condition often considered to be a simple habit disorder.[2] Here, we report a case of TTM in a 7-year-old girl with typical clinical features and recently defined trichoscopic findings.

CASE REPORT

A 7-year-old girl came to our outpatient clinic with a several-months' history of hair loss on the forelock, midscalp and crown. Dermatological examination revealed a patch of incomplete alopecia containing hairs with variable diameter and length encircled with a rim of normal-appearing hair at the periphery [Figure 1]. No inflammation or scale was present, and the hair pull test was negative along the edges of the alopecia. Trichoscopy images of the affected area, which were obtained with videodermoscopy at 30-fold magnification (MoleMax, Derma Instruments, Vienna, Austria), demonstrated decreased hair density, vellus hairs, broken hairs, hair with trichoptilosis, coiled hairs, flame hairs, tulip hairs, V-sign, black dots, and broom fibers [Figures 2–4]. Based on clinical and trichoscopic findings a diagnosis of TTM was made and the patient was referred to a child psychiatrist.

Figure 1

Tonsure pattern of alopecia with sparring at the temporoparietal region and the occiput

Figure 2

Tulip hairs

Figure 4

Black dots (yellow arrow), tulip hairs (pink arrow), flame hairs (red arrow), vellus hairs (light green arrow)

Broken hairs (turquoise arrow), V-sign (violet arrow), coiled hairs (yellow arrow), trichoptilosis (orange arrow), broom fibers (dark green arrow)

DISCUSSION

Trichotillomania has been defined as an impulse control disorder in Diagnostics and Statistic Manual of Mental Disorders, 4th edition.[124] The diagnostic criteria include irresistible urge to pull out the body hair resulting in evident alopecia accompanying with pleasure and relief as well as social, functional, and occupational impairment.[4] Sufferers periodically engage in rituals of hair plucking from the areas that are easy to manipulate, particularly the forehead and the vertex.[24] Bizarre shaped, sharply demarcated patches of incomplete alopecia containing short, broken-off hairs with variable lengths are highly suggestive for TTM.[4] Hair pulling in or beyond vertex creates typical tonsure pattern which is also known as the Friar Tuck sign. This type of alopecia specifies the distribution which remarkably involves the crown surrounded by a rim of unaffected hair at the periphery, that is obviously resembles to tonsures of Christian monks.[12456]

Trichoscopy is a sensitive noninvasive technique that provides rapid detection of scalp and hair disorders.[789] In addition, trichoscopy has been shown to improve diagnostic accuracy and decrease the number of unnecessary biopsies.[81011] The well-known trichoscopic findings of TTM includes decreased hair density, broken hairs, short vellus hairs, coiled hairs, trichoptilosis, yellow dots, black dots, and exclamation mark hairs.[568911121314] Rakowska et al. recently defined new trichoscopic features of TTM including V-sign, tulip hairs, flame hairs, hook hairs, and hair powder.[15] Our case not only demonstrated typical trichoscopic features of TTM such as broken hairs, vellus hairs, black dots, coiled hairs, and trichoptilosis, she also displayed newly defined findings like tulip hairs, flame hairs and V-sign. V-sign is created when two or more hairs that originate from one follicular unit broken at the equal level. V-sign is highly characteristic for TTM, Rakowska et al. have reported that V-sign was observed in 57% of TTM cases.[15] Although it may also be seen in alopecia areata, another characteristic finding for TTM is tulip hairs.[91415] Believed to be the result from diagonal hair shaft fractures, these hairs have tulip flower shaped distal hyperpigmentation. Recently defined pathognomonic finding for TTM is flame hairs. Generally noticed in active TTM, flame hairs are observed after severe mechanical trauma. These are wavy hair residues seen 25% of TTM patients.[1415] Rarely observed in other alopecias, coiled hairs are a common finding in TTM.[14] Hair pulling leads proximal part of the hair to coil at the site of fracture and creates coiled hairs with varied trichoscopic appearances. Hook hairs are partially coiled hairs which are also a highly characteristic finding for TTM.[91415] Hair powder is another newly defined trichoscopic feature of TTM. Rakowska et al. have proposed that this shattered appearance may be seen if the hair shafts are totally damaged.[15] Our case also demonstrated trichoptilosis and broom fibers. Although trichoptilosis is not pathognomonic for any type of alopecia, it is notably evocative for TTM. Trichoptilosis is also known as split ends and observed as longitudinal splitting of the distal end of the hair shaft as a result of mechanical trauma.[9121415] Broom fibers refer to the appearance of multiple thin, short hairs emerging from one follicular unit. On the other hand broom fibers are not specific for TTM, they may be observed in both cicatricial and noncicatricial alopecias.[14]

Here we present a case of TTM with characteristic Friar Tuck sign, typical and recently defined trichoscopic features. The findings were so conclusive that we did not perform a lesional skin biopsy. We think that as the clinicians gain more experience on dermoscopy, the diagnostic accuracy will increase, and the number of unnecessary biopsies will decline.