Trichotillomania (hair pulling disorder): Clinical characteristics, psychosocial aspects, treatment approaches, and ethical considerations

Trichotillomania: A perspective from bibliometric analysis

Aim: Trichotillomania, an obsessive-compulsive-related disorder, is defined by the recurrent act of pulling out one's own hair from different areas of the body. Despite the considerable body of research dedicated to the subject of trichotillomania, the overarching trends that unify these studies remain obscure. The purpose of the present bibliometric analysis was to ascertain these trends.Method: To achieve this objective, we conducted a thorough search of publications in the Web of Science database and subsequently evaluated the acquired data using VOSviewer software.Results: The most cited article on trichotillomania was written by Simonoff et al. The most prolific writer on trichotillomania is Grant JE. The most publications on the subject of trichotillomania were published in the "Journal of Obsessive Compulsive and Related Disorders" and the most frequently repeated keyword is trichotillomania. Trichotillomania studies have focused on treatment, clinical features, and other accompanying psychiatric conditions.Conclusion: Potential areas of research could include treatment methods in addition to the psychiatric and physical comorbidities of trichotillomania, and efforts to enhance international collaborations in this domain should be intensified.

Exploring pharmacological treatment for trichotillomania: do we need better education?

BACKGROUND

Trichotillomania, also known as hair-pulling disorder, is a chronic psychiatric condition with a fluctuating course in which an individual pulls out their hair, leading to visible hair loss and psychosocial sequelae. Due to the unknown pathogenesis, the treatment of this disorder is complex and remains a challenge for dermatologists and psychiatrists. Since guidelines for treating trichotillomania are lacking and, consequently, no common treatment strategy exists, we decided to perform a large-scale, global retrospective cohort study to assess the characterized real-world prescription patterns in treating trichotillomania.

METHODS

The research used the TrinetX database for patients with trichotillomania (ICD 10 - F63.3) within the European and the United States Collaborative Network (EC and UC, respectively). After consulting with a psychodermatology expert, a list of 25 medications was investigated.

RESULTS

Data on the prescription drugs of 1,275 patients from the EC and 109,741 patients from the UC were collected. In both the EC and UC cohorts, benzodiazepine derivatives, particularly lorazepam and midazolam, were the most commonly prescribed sedatives/hypnotics. Antipsychotic prescriptions, primarily haloperidol, followed benzodiazepines. After the trichotillomania diagnosis, notable changes in drug prescriptions for the EC cohort, including an increased likelihood of receiving acetylcysteine, haloperidol, quetiapine, sertraline, olanzapine, and risperidone were observed. The UC cohort showed minimal changes. Overall, both cohorts leaned toward benzodiazepine prescriptions (37% UC, 21% EC) and had limited antidepressant usage. Haloperidol (19.3%) and quetiapine (15.1%) were commonly prescribed in both cohorts.

CONCLUSIONS

The results of our study indicate that the real-world prescription patterns for trichotillomania differ significantly from the expert-proposed therapeutic approach and point toward the necessity of creating standards of pharmacological care and better education.

Trichotillomania Treatment Update

Trichotillomania (TTM) is an obsessive-compulsive disorder in which affected individuals recurrently pull-out hair from any region of the body, causing hair loss or alopecia. The management of TTM is a therapeutic challenge for dermatologists and consists of a combination of pharmacological and non-pharmacological alternatives. Cognitive-behavioral therapy has successfully been used to treat TTM. However, not all patients are willing to follow this treatment strategy. Unconventional support tools are proposed, such as electronic devices, internet therapies and microneedling. N-acetylcysteine and memantine are considered suitable first-line therapies thanks to their favorable safety and efficacy profile, low risk of adverse effects, and significant benefits. The use of other drugs, including fluoxetine, clomipramine, olanzapine, and naltrexone has limited evidence of variable efficacy. The present review illustrates the current treatment modalities for the management of TTM.

Impulsivity in adolescent girls diagnosed with trichotillomania: an evaluation of clinical and neuropsychological characteristics

The aim of this study is to compare the clinical and neuropsychological features of impulsivity in adolescent girls with trichotillomania (TTM) and healthy controls, and to assess the relationships between the severity of TTM and the impulsivity/concomitant symptoms of anxiety and depression. The study sample consisted of 43 adolescent girls who were 12 to 18 years old. The Kiddie-Schedule for Affective Disorders and Schizophrenia for School Age Children-Present and Lifetime Version DSM-5 (K-SADS-PL) was administered to the adolescents and their parents. All of the participants completed a sociodemographic data form, the Revised Children's Anxiety and Depression Scale-Child Version (RCADS-CV), the Barratt Impulsiveness Scale-Brief (BIS-Brief), and the Massachusetts General Hospital Hairpulling Scale (MGH-HPS). The Eriksen Flanker task, the Stop Signal Reaction Time (SSRT) task, the Go/No-Go task, and the Balloon Analog Risk Task (BART) were used to assess behavioral impulsivity. The adolescents with TTM reported higher levels of impulsivity and anxiety/depression symptoms than the healthy controls, and they also performed worse on the behavioral tasks. While there were no relationships between clinical and behavioral impulsivity and TTM severity, social anxiety symptoms were the most important predictor of the severity of TTM. It seems important to better understand the role of impulsivity in the onset and persistence of TTM symptoms in adolescents.

Trichotillomania: a perspective synthesised from neuroscience and lived experience

Trichotillomania, or hair-pulling disorder, is one of a family of disorders called body-focused repetitive behaviours (BFRBs), which also include disordered skin-picking (dermotillomania) and nail-biting (onychophagia). The disorders affect 1%-2% of the population, cause high levels of distress and have high levels of comorbidity with other psychiatric diagnoses. The key facts and figures are briefly reviewed and some important points are further explored: (1) BFRBs are associated with psychological distress, but are distinct from other diagnoses, (2) The pathological behaviours mirror excessive self-grooming behaviours in other species, and may relate to immune-system mediated feedback loops, and (3) The resulting behaviours are stigmatised and cause intense shame and isolation for those who suffer, which might in itself maintain the feedback loop. These observations lead to the hypothesis that the core disorder is one of pathological grooming, which may have a basis in an immune response, with shame being both a consequence and a maintainer of the disorder. The major barrier to testing the hypotheses and potential interventions remains the stigma that keeps these disorders, and those who suffer from them, in the shadows.

A review of psychocutaneous disorders from a psychotherapeutic perspective—Toolkit for the dermatologist

Introduction

The study of psychocutaneous disorders requires a multidisciplinary approach. It is of paramount importance that dermatologists understand the psychiatric premise for these disorders. Mental health professionals can also benefit from a better understanding of the dermatologic manifestations of psychiatric disorders they may encounter in their practice.

Aim

The aim of this study is to elevate the level of understanding regarding psychotherapeutic treatment of psychocutaneous disorders.

Methods

We performed a literature review using the major databases. Four researchers reviewed English, full text, peer-reviewed articles that were published after 2000 using our specific search terms and inclusion/exclusion criteria.

Results

The majority of psychocutaneous disorders seem to be clustered among three DSM-5 disorders: depressive disorders, anxiety disorders, and obsessive-compulsive related disorders.

Conclusions

Better recognition of the underlying psychiatric comorbidities may lead to improved patient outcomes.

Sociodemographic variables, clinical characteristics, and treatments in children with trichotillomania in terms of age and gender: a multicenter study

OBJECTIVE

Although trichotillomania (TTM) is a common, typically pediatric-onset disorder, data on the phenomenology of TTM in children, accompanying comorbid psychiatric disorders, and treatment options are extremely limited. In our study, it was aimed to investigate these variables and related factors in patients undergoing psychiatric evaluation and follow-up.

METHOD

The study included 79 children and adolescents between the ages of 4 and 17 who were diagnosed with TTM and followed up in four different Child and Adolescent Psychiatry outpatient clinics between 2015 and 2020. The sociodemographic characteristics of these patients, clinical features of the disease, comorbid psychiatric disorders, and treatment approaches have been studied.

RESULTS

Our results showed that TTM was more common in girls, hair and eyebrow plucking was the most common, and symptoms and features accompanying TTM changed with age, but not with gender. Again, 79.7% of these children had at least one psychiatric comorbid disorder (most common being anxiety disorders and Attention Deficit/Hyperactivity Disorder), comorbidity was closely related to TTM severity, 93.7% used at least one pharmacotherapeutic agent, and positive response rates to treatment were found to be low. Moreover, TTM severity was found to increase with age and disease duration.

CONCLUSION

Study findings support that clinical presentation, disease severity and comorbidity rates may change with age in children and adolescents with TTM, and early intervention is important to prevent clinical progression/worsening and mental health sequela.

Obsessive-compulsive and related disorder symptoms in the perinatal period: prevalence and associations with postpartum functioning

Obsessive-compulsive disorder (OCD) symptoms are more likely to develop or be exacerbated during pregnancy and the postpartum period, which can cause significant distress and impairment. However, the disorders grouped with OCD in the DSM-5, obsessive-compulsive and related disorders (OCRD; e.g., hoarding disorder (HD), body dysmorphic disorder (BDD), trichotillomania (TTM), excoriation disorder (ED)), have rarely been examined in the perinatal period. This study aimed to explore (1) the prevalence of all clinically significant OCRD symptoms in pregnancy and the postpartum period and (2) the correlations between OCRD psychopathology and postpartum functioning. Participants were recruited during their second trimester of pregnancy from a Midwestern medical center. Participants completed an online questionnaire and a semi-structured clinical interview during pregnancy (28-32 weeks' gestation, N = 276) and the postpartum period (6-8 weeks, N = 221). BDD and OCD symptoms were the most prevalent. In pregnancy, 14.9% (N = 41) of participants endorsed clinically significant BDD symptoms and 6.2% (N = 17) endorsed clinically significant OCD symptoms. In the postpartum period, 11.8% (N = 26) endorsed clinically significant BDD symptoms and 14% (N = 31) endorsed clinically significant OCD symptoms. Poorer postpartum functioning was associated with elevated OCRD symptoms in pregnancy and postpartum. OCRD symptoms occur during pregnancy and the postpartum period at rates similar or higher than other life periods. Elevated OCRD symptoms are associated with poorer postpartum functioning across domains. Future research should explore how all OCRD symptoms may affect functioning in the perinatal period, not only OCD symptoms.

Pharmacotherapy for trichotillomania

BACKGROUND

Trichotillomania (TTM; hair-pulling disorder) is a prevalent and disabling disorder characterised by recurrent hair-pulling. Here we update a previous Cochrane Review on the effects of medication for TTM.

OBJECTIVES

To assess the effects of medication for trichotillomania (TTM) in adults, children and adolescents compared with placebo or other medication.

SEARCH METHODS

We searched CENTRAL, MEDLINE, Embase, PsycINFO, eleven other bibliographic databases, trial registries and grey literature sources (to 26 November 2020). We checked reference lists and contacted subject experts.

SELECTION CRITERIA

We selected randomised controlled trials of medication versus placebo or other medication for TTM in adults, children and adolescents.

DATA COLLECTION AND ANALYSIS

We used standard methodological procedures expected by Cochrane.

MAIN RESULTS

Twelve studies were included. We identified 10 studies in adults (286 participants) with a mean sample size of 29 participants per trial; one study in children and adolescents (39 participants); and, one study in adults and adolescents (22 participants: 18 adults and 4 adolescents). All studies were single-centre, outpatient trials. Eleven studies compared medication and placebo (334 participants); one study compared two medications (13 participants). Studies were 5 to 13 weeks duration. We undertook meta-analysis only for opioid antagonists as other comparisons contained a single study, or reported insufficient data. Antioxidants versus placebo in adults There was little to no difference in treatment response between antioxidant (35.7%) and placebo groups (28.6%) after six weeks, based on a single trial of silymarin (risk ratio (RR) 2.25, 95% confidence interval (CI) 0.84 to 5.99; 36 participants; low-certainty evidence). We could not calculate differences in number of dropouts as there were no events in either group (18 participants; low-certainty evidence). Antioxidants versus placebo in adolescents There was little to no difference in treatment response between antioxidant (50%) and placebo groups (25%) after six weeks, based on a single trial of silymarin (RR 2.00, 95% CI 0.28 to 14.20; 8 participants; low-certainty evidence). We could not calculate differences in number of dropouts as there were no events in either group (8 participants; low-certainty evidence). Antipsychotics versus placebo in adults There may be greater treatment response in the antipsychotic group (85%) compared to the placebo group (17%) after 12 weeks, based on a single trial of olanzapine (RR 5.08, 95% CI 1.4 to 18.37; 25 participants; low-certainty evidence). We could not calculate differences in number of dropouts as there were no events in either group (25 participants; low-certainty evidence). Cell signal transducers versus placebo in adults There was little to no difference in treatment response between cell signal transducer (42.1%) and placebo groups (31.6%) after 10 weeks, based on a single trial of inositol (RR 1.33, 95% CI 0.57 to 3.11; 38 participants; low-certainty evidence). We could not calculate differences in number of dropouts as there were no events in either group (38 participants; low-certainty evidence). Glutamate modulators versus placebo in adults There is probably greater treatment response in the glutamate modulator group (56%) compared to the placebo group (16%) after 12 weeks, based on a single trial of N-acetylcysteine (RR 3.5, 95% CI 1.34 to 9.17; 50 participants; moderate-certainty evidence). We could not calculate differences in number of dropouts as there were no events in either group (50 participants; low-certainty evidence). Glutamate modulators versus placebo in children and adolescents There was little to no difference in treatment response between the glutamate modulator (25%) and placebo groups (21.1%) in children and adolescents, based on a single trial of N-acetylcysteine (RR 1.19, 95% CI 0.37 to 3.77; 39 participants; low-certainty evidence). There was little to no difference in dropouts due to adverse events between glutamate modulator (5%) and placebo (0%) groups, based on a single trial (RR 2.86, 95% CI 0.12 to 66.11; 39 participants; low-certainty evidence). Opioid antagonists versus placebo in adults There may be little to no difference in treatment response between opioid antagonist (37.5%) and placebo groups (25%) after six to eight weeks, based on two studies of naltrexone, but the evidence is very uncertain (RR 2.14, 95% CI 0.25 to 18.17; 2 studies, 68 participants; very low-certainty evidence). No data were available regarding dropouts due to adverse events. Selective serotonin reuptake inhibitors (SSRIs) versus placebo in adults There were no data available for treatment response to SSRIs. There was little to no difference in dropouts due to adverse events in the SSRI group (5.1%) compared to the placebo group (0%) after 6 to 12 weeks, based on two trials of fluoxetine (RR 3.00, 95% CI 0.33 to 27.62; 2 studies, 78 participants; low-certainty evidence). Tricyclic antidepressants (TCAs) with predominantly serotonin reuptake inhibitor (SRI) actions versus placebo in adults There may be greater treatment response in the TCAs with predominantly SRI actions group (40%) compared to the placebo group (0%) after nine weeks, but the evidence is very uncertain, based on a single trial of clomipramine (RR 5.73, 95% CI 0.36 to 90.83; 16 participants; very low-certainty evidence). There may be increased dropouts due to adverse events in the TCAs with predominantly SRI actions group (30%) compared to the placebo group (0%), but the evidence is very uncertain (RR 4.45, 95% CI 0.27 to 73.81; 16 participants; very low-certainty evidence). TCAs with predominantly SRI actions versus other TCAs in adults There may be greater treatment response in the TCAs with predominantly SRI actions group compared to the other TCAs group after five weeks, based on a single trial comparing clomipramine to desipramine (mean difference (MD) -4.00, 95% CI -6.13 to -1.87; 26 participants; low-certainty evidence). We could not calculate differences in number of dropouts as there were no events in either group (26 participants; low-certainty evidence).

AUTHORS' CONCLUSIONS

There was insufficient evidence from meta-analysis to confirm or refute the efficacy of any agent or class of medication for the treatment of TTM in adults, children or adolescents. Preliminary evidence suggests there may be beneficial treatment effects for N-acetylcysteine, clomipramine and olanzapine in adults based on four trials, albeit with relatively small sample sizes.

[Kerion Celsi due to Microsporum canis infection]

Tinea capitis is seen world-wide among children up to 12 years. The most severe type is Kerion Celsi with painful abscesses and lymphadenopathy. We report on an 11-year-old boy with Kerion Celsi, who was initially treated using antibiotics under the common misdiagnosis of a bacterial infection. Mycological investigations could identify Microsporum canis. The patient was treated orally with griseofulvin, which resulted in complete mycological remission after 8 weeks. Cicatrical alopecia, however, could not be prevented. Purulent infections of the scalp should lead to early mycological diagnostics in children.

Trichotillomania Incognito: Two Case Reports and Literature Review

Trichotillomania is a compulsive disorder characterized by repetitive hairpulling. It is an important cause of patchy alopecia, especially in children between 9 and 13 years of age. The aim of this paper is to report 2 pediatric cases presenting with trichotillomania without patches. This condition may be extremely distressful, impacting psychosocial development of children. In these case reports, we reinforce the relevance of trichoscopy in hair disorder evaluation, which allowed early recognition to better advise and conduct these unique pediatric cases.

Recent advances in the treatment of trichotillomania (hair-pulling disorder)

Trichotillomania (TTM) is a condition in which affected individuals pull out their hair resulting in hair loss. This disorder affects roughly 0.5% to 2.0% of the population and can have significant psychological morbidity. Behavioral therapy has been used with success in the treatment of TTM, but not all patients are willing or able to comply with this treatment strategy. There is a need for effective pharmacological treatment options. Historically, pharmacotherapy for TTM has been inadequate in most cases, but recent advances have been made in this regard. Fluoxetine, clomipramine, olanzapine, and naltrexone have all been used in the treatment of TTM, but evidence of benefit has varied, and side effect profiles can limit practical utility. Recent advances in the understanding of the pathophysiology of TTM, as well as evidence of benefit seen with some glutamate-modulating agents such as N-acetylcysteine and dronabinol, have provided newer potential pharmacotherapy options.

Trichoscopy features of trichotillomania

Trichotillomania is a form of traction alopecia resulting from repetitive and compulsive hair pulling and plucking. Trichotillomania and patchy alopecia areata may have similar clinical and dermoscopic features in some cases. On trichoscopic examination, the presence of black dots, coiled or hook hair, shafts of varying lengths with fraying or split ends (trichoptilosis), and an absence of exclamation mark hairs and yellow dots are suggestive of trichotillomania.