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  • Trichotillomania is an obsessive-compulsive or related disorder in which patients recurrently pull out hair from any region of their body.

  • Trichotillomania affects mainly female patients. This disease usually presents with a bizarre pattern non-scarring patchy alopecia.

  • Cognitive-behavioral therapy has been used with success in the treatment of trichotillomania, but not all patients are willing or able to comply with this treatment strategy.

  • Glutamate modulating agents such as N-acetylcysteine are potential pharmacotherapy options, with significant benefits and low risk of side effects.


  • Think of this diagnosis in front of a bizarre pattern of alopecia with short hair and a negative pull test.

  • Patient often denies the habit.

  • Trichoscopy can reveal the abnormalities resulting from the stretching and fracture of hair shafts.

  • Biopsy can be necessary if patient or parents have difficulties in accepting the diagnosis.


  • Trichotillomania requires a comprehensive treatment plan with interdisciplinary approach. Physicians should always have a non-judgmental, empathic, and inviting attitude.

  • Cognitive-behavioral therapy is often used as a first-line non-pharmacologic treatment.

  • Pharmacotherapy can be necessary, especially in adolescents and adult patients. Options include tricyclic antidepressants, selective serotonin reuptake inhibitors, and glutamate modulating agents.


  • To explain that in the long-term pulling/plucking can cause permanent scarring.

  • To consider that trichophagia can be associated with possible severe complications.

  • To emphasize that the role of psychiatry–dermatology liaison.


  • Trichotillomania incognito is a variant of trichotillomania without patches, as the patient plucks isolated hair strands diffusely.

  • Trichotillomania might be difficult to distinguish from alopecia areata at trichoscopy, as broken hairs and black dots are common in both conditions.


  • Suspect trichotillomania in the case of alopecia limited to upper eyelashes.

  • Suspect trichotillomania in patchy alopecia with a negative pull test.

  • Suspect trichotillomania when patches have a rough feel to the touch.


  • In pediatric cases, explain to parents to avoid punishing and other negative feedback as they may worsen the condition.

  • Social support is a significant pillar to successful habit reversal training; therefore,

  • physicians must convey the importance of familial support to achieving remission.


The Diagnostic and Statistical Manual of Mental Disorders (DSM-V) defines trichotillomania, also called hair-pulling disorder, as an obsessive-compulsive or related disorder in which patients repeatedly pull out hair from any area of the body, resulting in hair loss.1–3 Although psychosocial aspects of trichotillomania are underestimated, recent studies suggest an increased interest in this topic.2


Available data indicate trichotillomania affects 0.5%–2% of the general population.2 However, since people with trichotillomania often feel ashamed of their habit, real prevalence is probably higher.3

Lifetime prevalence in children is estimated to be around 1%–3%. Most common sites of involvement are the scalp, the eyebrows, the eyelashes, and ...

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