What is Trichotillomania?

Trichotillomania was first identified in 1889 by French dermatologist François Henri Hallopeau. Since then, numerous medical reports have been published from both dermatologists and psychologists regarding the condition.

As the name suggests, trichotillomania is based on an obsession with hair. People with trichotillomania tug and pluck their hair making bald patches or sometimes areas of diffuse hair loss. The hair for plucking is selected from other hair based on it being different in some way, perhaps feeling rough to the touch or more curly than other fibers. Once a bald area has been made it becomes even more enticing to pull at the hair around it making the alopecia patch larger. Sometimes the hair plucking is more generalized and looks like a diffuse alopecia.

This is generally a non-scarring non-inflammatory form of hair loss although long term repeated plucking over several years may result in a mild immune cell infiltrate and irreversible scarring damage to some hair follicles (Olsen, 1993)

Trichotillomania in Numbers

Trichotillomania affects 2-3% of all people with hair loss, making it a fairly common condition. Trichotillomania can affect both children and adults although the mean age of first onset is 13 years. Both boys and girls are affected in childhood but the adult version of trichotillomania almost always affects women (Jaspers, 1996).

Studies have identified the scalp as being the most commonly affected area. Approximately 70% of cases involve scalp hair loss, 50% involve eyebrows and or eyelashes, 30% include pubic hair, 20% body hair, and about 10% involve facial hair. As well as plucking the hair, affected individuals may then chew or eat the hair.

Hair eating is known as trichophagia, while hair chewing may result in hair balls (trichobezoars). About 40% of cases involve hair chewing while 10% of affected individuals eat their hair. Eating hair is rather unwise as it is very irritating to the stomach and may lead to digestion problems and ulcers.

The Psychology Behind Trichotillomania

Trichotillomania is a neuro-biological condition and may develop in people with anxiety disorders or mood problems. This form of hair loss is seen in many species, not just humans. In mice the condition is called barbering and mice housed together under stressful conditions may pull each other’s hair out. Certain mouse species are much more prone to barbering than others which suggests genetics play a part in this condition. Parrots are a well known example where a distressed parrot separated from its owner will start to pluck its own feathers.

The affected individual is most often unaware of what they are doing and arrive at the dermatology clinic complaining of hair loss from an unknown cause. Dermatologists have been known to resort to making a video of the individual to prove to them that they are unconsciously plucking their hair.

Treatment for Trichotillomania 

There are two treatment approaches for Trichotillomania: one from a psychiatric perspective and one from dermatological perspective. There is a degree a friction between the two groups as psychiatrists regard hair pulling as a disorder and dermatologists regard it as an alopecia and subsequently, their “domain”.

  • Psychiatrists will naturally focus on psychology and exploring why the child might have developed this habit. Treatment may involve therapy and in adults can involve drugs.
  • Dermatologists take a more direct approach. Children with trichotillomania may be made to wear gloves. The gloves stop the sensation of touch and this makes it impossible for the person to identify suitable hairs for plucking. Sometimes a child’s hair may be covered with Vaseline which makes it difficult to get hold of and unpleasant to the touch. In extreme cases the scalp may be bandaged so the child can’t get at the bald area.

The prognosis for children is generally good — with treatment they usually grow out of it. There is some importance in obtaining successful treatment as repeated plucking of hair will gradually destroy hair follicles to the degree that they will not grow properly and may not even grow at all. However, to reach this stage would take several years of continuous hair pulling. At this stage the condition becomes traumatic/traction alopecia and involves scar tissue development in the hair follicle. Adults who develop trichotillomania have a poor prognosis and are much less likely to respond to treatment.