UCLA Department of Medicine Clinical Insights

Case report

A 31-year-old female patient came to our clinic with a complaint of a bald spot on her head for more than a year. She denied any history of trauma to that area of her head. The patient mentioned that she had been under a lot of stress over the past year due to conflicts with her husband. Initially, she felt embarrassed to see a doctor and tried to cover the bald spot, which significantly decreased her self-confidence. However, she eventually decided to seek treatment.

She denied any family history of hair loss. The patient did not smoke or consume alcohol and had no other medical history. There was a family history of hypertension in her father.

On examination, a bald spot was noted at the top center of her head, with broken hair of varying lengths. The rest of the examination was normal. After further questioning, the patient admitted that when she gets stressed, she pulls her hair, which gives her a sense of relief. She was referred to a dermatologist, who confirmed the diagnosis of trichotillomania.
 

The patient was then referred to a psychologist, where they began cognitive-behavioral therapy (CBT) focused on identifying triggers for hair-pulling and teaching coping strategies. After several sessions, the patient reported a decrease in her hair-pulling habits, and gradually her hair began to regrow in that area, leading to an increase in her self-confidence.

Discussion

Trichotillomania is a disorder where an individual compulsively pulls out their hair. This can occur on the scalp or other areas of the body, but pulling hair from the scalp is the most common. Typically, a thorough history and examination are sufficient for diagnosis, and a biopsy is not necessary unless there is doubt about the diagnosis or similarity to another type of hair loss known as alopecia areata, in which case a biopsy may be performed. The bald spots in trichotillomania show broken hair of varying lengths, while alopecia areata presents with very smooth bald patches. The etiology of the disorder is unclear, but a twin study suggest that genetic factors may play a role.(1)

The most common age of onset is between 9 and 13 years, but it can occur at any age. Most patients suffer from anxiety and obsessive-compulsive disorder (OCD). In one study of 131 individuals, 87% had OCD, 64% had mood disorders, 52% had generalized anxiety, and 44% had skin-picking disorder. (2)

Some patients also exhibit behaviors such as hair biting and hair ingestion, known as trichophagy.

Alongside physical treatment for hair loss provided by dermatologists, these patients often require psychiatric referral. cognitive-behavioral psychotherapy is usually more beneficial than medication.

Habit Reversal Training (HRT) is part of this treatment approach. HRT provides patients with practical tools to manage their urges. By increasing awareness of their hair-pulling behavior and replacing it with alternative actions, patients learn to regain control over their impulses. Our patient experienced an increase in self-esteem after treatment, and her relationship with her husband also improved. This highlights how effective treatment not only benefits the individual but also positively influences their interpersonal relationships.

 
This case serves as a reminder to approach disorders like trichotillomania with a broader, multidisciplinary perspective and to ensure patients are connected with appropriate treatment that supports recovery. It also highlights the need for greater awareness and understanding of trichotillomania to avoid unnecessary testing and delays in diagnosis. Lastly,  it reminds clinicians the importance of patient education to reduce stigma and encourage engagement in care.
 

References

1.  Novak CE, Keuthen NJ, Stewart SE, Pauls DL. A twin concordance study of trichotillomania. Am J Med Genet B Neuropsychiatr Genet 2009; 150B:944.

2.    Gerstenblith TA, Jaramillo-Huff A, Ruutiainen T, et al. Trichotillomania comorbidity in a sample enriched for familial obsessive-compulsive disorder. Compr Psychiatry 2019; 94:152123.