Children with trichotillomania in COVID-19 outbreak.

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ETHICS STATEMENT

Verbal and signed consent was obtained from the legal representatives of the patients for the use of the photographs.

Dear Editor,

Skin and oral mucosal findings of viral infections are significant both in diagnosis and follow‐up. There have been many reports of direct skin findings in COVID‐19, a severe viral infection. The cutaneous findings of COVID‐19 were classified as macular eruption, vesicular eruption, pernio‐like lesions, urticaria, livedoid, and necrotic lesions. Also, Ertugrul and Aktas drew attention to one of the indirect skin signs related to COVID‐19, stria rubra cases whose frequency increases significantly in the young population due to sedentary life and obesity.

We would also like to draw attention to another indirect skin finding in the young population. In our country, schools were closed within the scope of pandemic measures, and face‐to‐face formal education was suspended for about a year. Curfews were very common for individuals under the age of 20. In the last month, three girls, aged 12, 13, and 14, were admitted to our clinic due to extensive hair loss. The first patient had alopecic plaques with different lengths of broken hair in the frontal region and the other two in the vertex (Figures 1 and 2). Trichoscopic examination revealed hair broken at different levels, black spots, coiled hairs, hooked hairs, and vellus hairs (Figures 1 and 2). When we obtained the anamnesis of the patients with a diagnosis of trichotillomania, they stated that they were now very bored because of not going to school for the last few months, and therefore, they were pulling out their hair. Treatment of the patients was arranged, children who were called for clinical follow‐up were also offered a child psychiatry visit.

FIGURE 1

12‐year‐old female with an alopecic plaque in the frontal region

FIGURE 2

14‐ year‐old female with an alopecic plaque in the vertex

Trichotillomania is characterized by repetitive hair removal resulting in significant hair loss, and the age of onset is usually between 10 and 13 years. Trichoscopic findings include hair broken at different levels, black dots, black powder, vellus hair, i hair, hook hair, flame hair, and V sign. The reasons playing a role in the etiology are not clear yet, but biological, psychological, and social factors are thought to be caused. The common problem expressed in all three of our patients was that they were very bored at home because the schools were closed. The inability of children to attend face‐to‐face education due to the outbreak decreases their learning level and negatively affects their mental health as it causes them to stay away from their friends and social environments.

Four hundred sixty patients with body‐focused repetitive behaviors were examined in a study and 70% of the patients had repetitive hair pulling. A 1.6‐point increase was detected on the Massachusetts General Hospital Hairpulling Scale of the patients, and as a result, the authors reported that hair‐pulling symptoms of these patients increased in the COVID‐19 pandemic. Ocampo‐Garza et al. reported that telogen effluvium, a common cause of non‐cicatricial alopecia, also increased due to the negative psychological effects of the COVID‐19 pandemic. In addition, we would like to state that the number of patients with hair‐pulling disorder may increase in the outbreak. In the following days, due to the prolongation of the outbreak and the longer children stay away from school, besides physical findings, we may be more likely to encounter various indirect skin findings of COVID‐19 such as trichotillomania and other psychiatric skin diseases.