Trichotillomania

Trichotillomania is a disorder characterized by the repetitive and irresistible impulse to pull out one's own hair or the hair from different parts of the body. It is currently classified within the disorders related to obsessive-compulsive disorder and other related disorders, according to the main international classification systems.

It is not a primary skin problem, but a behavioral disorder that has an important repercussion on the hair and skin. It is a relatively frequent disease, especially in adolescents and young women, although it can appear at any age and also affects men.

It is important to understand that the person does not pull out their hair because they want to be left without hair, but because they experience an impulse that is difficult to control. With an early diagnosis and an adequate treatment, many people manage to improve significantly.

The exact cause is unknown. It is believed that several factors are involved: genetic predisposition, psychological factors, alterations in the brain circuits related to impulse control and environmental factors.

In some people the act of pulling out the hair produces a transitory sensation of relief or a decrease in anxiety. In others, the behavior appears automatically while they read, study, work, watch television or use their mobile phone.

Stress is not the cause, but it can act as a trigger or favor the episodes. The symptoms can worsen during periods of anxiety, work or academic stress, personal conflicts, boredom or tiredness.

The most frequent locations are the scalp, the eyebrows, the eyelashes, the beard, the pubis, the arms and the legs. Some people pull out the hair from a single area and others from several locations.

Patients usually present areas with irregular hair loss, hairs of different lengths, broken hairs, decreased density and repeated episodes of pulling.

Many people try to hide the lesions through changes of hairstyle, caps, hats or eyebrow makeup. Some patients are fully aware of the behavior, while others perform it in an almost automatic way.

Yes. The main complications are permanent hair loss when the damage is very prolonged, skin irritation, infrequent local infections, psychological impact, decreased self-esteem and social isolation.

In a small percentage of patients there is also trichophagia, that is, the habit of ingesting the pulled-out hair. In these cases a trichobezoar (accumulation of hair in the stomach) can form, an infrequent but potentially serious complication that may require surgical treatment.

The diagnosis is based on the clinical history, the physical examination and trichoscopy. Trichoscopy usually shows hairs broken at different heights, black dots, flame hairs, coiled hairs and different signs characteristic of repeated pulling.

It may sometimes be necessary to differentiate trichotillomania from alopecia areata, scalp ringworm, traction alopecia and scarring alopecias.

Treatment is usually multidisciplinary.

Psychological therapy. Cognitive-behavioral therapy, especially Habit Reversal Training, constitutes the first-choice treatment. It helps to identify the triggers, to recognize the impulse before pulling out the hair and to replace the behavior with alternative responses.

Psychiatric treatment. When there is anxiety, depression, obsessive-compulsive disorder or other associated disorders, an evaluation by a psychiatrist may be necessary. In some patients specific medications can be used.

Medical treatment of the hair and skin. The doctor monitors the evolution of the hair and treats the possible skin complications. In some cases minoxidil and other treatments can be added to favor the regrowth of the hair when the pulling is controlled.

In most cases, yes. If the follicle has not suffered permanent damage, the hair usually grows back once the pulling disappears. When the behavior is maintained for many years, an irreversible destruction of some follicles and a localized scarring alopecia can occur.

Learn to identify the situations that trigger the impulse, keep your nails short, use the strategies recommended by your therapist, do not blame yourself or feel ashamed of the disease, seek family support when possible and attend the medical and psychological check-ups regularly.

You should consult if you observe irregular areas without hair, if you cannot control the impulse to pull out your hair, if the disease affects your daily life, if you present significant anxiety or sadness, if you ingest the pulled-out hair or if signs of infection appear on the skin. An early intervention significantly improves the prognosis.

• Myth: Trichotillomania is a simple mania. Fact: No. It is a recognized disorder that requires understanding and treatment.
• Myth: The person can stop pulling out their hair if they really want to. Fact: The impulse is usually very difficult to control without specialized help.
• Myth: It is a contagious disease. Fact: No. It cannot be transmitted between people.
• Myth: It is always caused by serious psychological problems. Fact: Not necessarily. Each patient presents different circumstances.
• Myth: The hair will never grow back. Fact: In most cases the growth recovers when the pulling ceases and the follicle remains intact.

• Trichotillomania is an impulse-control disorder that causes the repeated pulling of the hair.
• It is not a contagious disease nor a simple habit.
• The diagnosis is based on the clinical history, the examination and trichoscopy.
• Cognitive-behavioral therapy is the first-choice treatment.
• In most cases the hair grows back when the pulling is controlled.
• A joint approach between skin medicine, psychology and psychiatry offers the best results.