Acquired Trichorrhexis Nodosa Secondary to Trichoteiromania: Prompt Diagnosis Using Trichoscopy.

Trichorrhexis nodosa (TN) is a common hair shaft defect that develops as a result of excessive physical or chemical trauma. Microscopy is considered the gold standard for its diagnosis. Outpatient diagnosis thus becomes difficult in the absence of availability of microscope. Trichoscopy is emerging as an excellent tool in outpatient diagnosis of hair shaft defects. Here, we report a young girl with localized TN secondary to trichoteiromania where trichoscopy clinched the diagnosis. Classical appearance of nodes in hair shaft and transverse hair shaft fractures producing "two brooms stuck in opposite direction" was evident. This case is being reported to emphasize the advantages of trichoscopy in quick diagnosis of hair shaft defects with review of published literature. Copyright:

INTRODUCTION

Trichorrhexis nodosa (TN) is a common hair shaft defect, which develops as a response to chemical or physical injury. It can be induced in normal hair with sufficient degree and frequency of trauma. However, in patients with preexisting developmental defects, namely, monilethrix, pseodomonilethrix, and ringed hair, even trivial trauma of combing and brushing can result in TN.[1] TN can be inherited or acquired. Acquired TN is more prevalent and occurs as a response to undue physical or chemical tension. Excessive combing and use of hair dryers/straighteners result in disruption of cuticle and splaying out of cortical fibers creating nodes.[2] Further, there are transverse fractures in the hair shaft which produces classical “two brooms stuck in opposite direction” appearance.[3] Localized TN is a subset of acquired TN ensuing in isolated patches of alopecia subsequent to a pruritic dermatoses or frictional alopecia that can appear in patients with trichoteiromania. Trichoteiromania is a compulsive hair disorder grouped with trichotillomania, trichotemnomania, trichophagia, and trichocryptomania. In Greek, it means, “I rub.”[4] the patient describes an irresistible desire to scratch an area of scalp.[5] Here, we report a case of a young girl with trichoteiromania, resulting in TN with review of literature. Until microscopy was considered the cornerstone of establishing the diagnosis but with advent of trichoscopy quick diagnosis is promising.

CASE REPORT

A 20-year-old girl with a history of anxiety presented with an area of hair loss over left sideburn for the last 20 days. She had noticed it suddenly, and though the hair appeared to be shaved off, she denied pulling or cutting the hair. On detailed enquiry, she acknowledged irresistible desire to scratch that area. Further, she also had the uncontrollable habit of rubbing and scratching the middle of both her ring fingers. Clinical examination showed a 3 cm × 3 cm area of short broken off hair over left sideburn associated with slight thickening of the underlying skin [Figure 1a]. Hair pull test was negative. Trichoscopy revealed multiple white nodes in the hair shafts at varying distance. At some of the nodes, the hair was bent at an angle, while at others, appearance of two brushes stuck in opposite direction was visible [Figure 2a]. The hair broken close to the scalp margin had splayed ends appearing as white nodes [Figure 2b]. Light microscopy of the hair showed nodular swellings of the hair shaft representing impending fractures and brush-like hair breakage [Figure 3a and b]. There were two lichenified plaques of 1 cm × 0.7 cm each over the middle phalanx of both ring fingers with the one over right having an area of hemorrhagic crust [Figure 1b]. A final diagnosis of acquired TN due to trichoteiromania was established. She was counseled regarding the role of scratching in producing hair loss and hair breakage. After consultation with psychiatrist, she was started on selective serotonin reuptake inhibitors and cognitive behavior therapy to control her anxiety and compulsive habit. After a month of treatment, there was slight improvement in the hair growth.

Figure 1

(a) Short broken off hair over left sideburn. (b) Lichenified plaques of 1 cm × 0.7 cm each over the middle phalanx of both ring fingers with the one over right having an area of hemorrhagic crust

Figure 2

(a) Multiple white nodes in hair shaft (red arrows) and two brooms stuck in opposite direction appearance (blue circle). (b) White nodes at the hair tips (orange square) (Dermlite DL2 hybrid, polarized mode, ×10)

Figure 3

Nodules (a) and two paintbrushes stuck in opposite appearance (b) in the hair shaft on light microscopy of hair (×40)

DISCUSSION

TN grouped under hair shaft defects can be either congenital or acquired [Table 1]. The congenital forms present early in life usually with generalized hair dystrophy presenting as dry, brittle, and lusterless hair that fail to achieve appreciable length. These are associated with mxetabolic syndromes such as biotinidase deficiency or argininosuccinic aciduria.[678] The acquired forms occur secondary to weathering. Young females are predisposed due to their habit of exposing hair to harmful chemical or physical insults.[910] Acquired TN is further of three subtypes. Distal TN, where the white nodes are seen at the ends of scattered hair, seen primarily in light skin phototypes and Asian due to cumulative physical and chemical trauma through the entire length of hair shaft. Proximal TN is seen in Afro-Caribbean women presenting with short and brittle hair because of their habitual application of lye and nonlye chemical hair relaxers that alters the basic hair shaft structure predisposing to loss of their strength.[1] Most rare of all forms is the localized TN, which appears to be underreported and is usually seen with an underlying pruritic dermatoses. However, frictional alopecia resulting from a compulsive desire to scratch a fixed area will also produce localized TN as in the presented case. The reported patient developed TN due to trichoteiromania that is a purely primary psychiatric disorder, resulting in self-induced hair damage. Compulsive scratching and rubbing of the hair makes them weak, resulting in transverse fractures in the hair shaft which breaks off at irregular intervals producing areas of short hair stubs. Fowler and Tosti reported TN as a result of frictional alopecia in a young girl subsequently diagnoses as trichoteiromania with improvement postcounseling.[11] Intense scratching or rubbing produces proximal TN, while weathering produces distal TN. The presented case could be labeled as proximal TN as well, however, as the changes were localized to a particular area, she has been labeled as localized TN. The categorization, however, seems irrelevant as compared to appropriate history extraction and remediation.

Table 1

Causes of trichorrhexis nodosa

Congenital trichorrhexis nodosa	Acquired trichorrhexis nodosa
Associated with metabolic diseases	Physical trauma
Arginiosuccinic aciduria	Excessive heat (blow dryers, hot curling rods, hair straighteners)
Citrullinemia	Frictional (trichoteiromania, pruritic dermatoses)
Menkes syndrome	Vigorous and frequent hair combing chemical trauma
Trichothiodystrophy	Chemical hair relaxers (lye and nonlye)
Multiple carboxylase deficiency	Frequent bleaching
Netherton syndrome	Iron deficiency anemia
Goltz syndrome	Hypothyroidism
Associated with ectodermal dysplasias	Malnutrition

Trichoscopy is emerging as an excellent tool for diagnosis of hair shaft defects. Being a small instrument it can be used as an outpatient device that helps in faster diagnosis obviating the need of bulky microscopes. The diagnostic utilities of trichoscopy are ever increasing and one should be proactive in using it as an ancillary aid to clinical diagnosis. It can help differentiate the common clinical differentials of TN including pediculosis, hair casts, seborrheic dermatitis, monilethrix, and trichorrhexis invaginata. Recent studies reporting various causes of TN have utilized trichoscopy with great diagnostic accuracy [Table 2]. Turra et al. recommend its use as a cost effective and easy tool for diagnosis of TN compared to optical microscopy and electron microscopy.[12] In the reported case, the nodes and transverse fractures of the hair shaft were clearly visualized with dermoscope and a corroborating history established the diagnosis. Clinical and trichoscopy findings of trichoteiromania reported in literature are white tips, brush-like splitting at ends, and transverse fractures. Furthermore, it serves as an important tool in educating the patient making them see the damaged hair.[20]

Table 2

Studies describing trichoscopy findings in acquired trichorrhexis nodosa

	Number of cases reported	Findings
Secondary to weathering
Kharkar et al., 2011[12]	1	Fraying of cortical fibersProximal and distal hair shaft breakage
Shah and Ankad, 2017[13]	1	White brown nodes on hair tipsThrust paint brush appearance
Pinheiro, 2016[14]	1	Breaks in hair shaft at irregular intervals
Kakitha and Sreedevi, 2018[15]	1	Hair shaft nodes
Turra et al., 2018[16]	1	Multiple white nodules in distal partTwo paint brushes thrust together
Secondary to friction
Freyschmidt-Paul et al., 2001[4]	1	Split, brush like ends
Reich and Trüeb, 2003[17]	4	White tips, splitting at the ends
Banky et al., 2004[18]	1	Brush-like splitting of ends
Diniz et al., 2018[19]	1	Longitudinal splitting of distal ends
Fowler and Tosti, 2019[11]	1	Short hairTransverse white bands and proximal nodes
Salas-Callo et al., 2019[20]	1	Fracture and loss of hair shafts

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

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Nil.

Conflicts of interest

There are no conflicts of interest.