Chapter 188. Traction Alopecia and Trichotillomania

A 38-year-old woman was found to have hair thinning on the anterior scalp. She had long thick heavy hair that she always styled in a bun on the top of her head. She was concerned about the slow, steady loss of hair that she was experiencing. Figure 188-1 shows the appearance of the thinned hair as a result of chronic traction. A 4-mm punch biopsy was performed to confirm the clinical impression and the histology was supportive of this diagnosis.

Traction alopecia is hair loss caused by damage to the dermal papilla and hair follicle by constant pulling or tension over a long period. It often occurs in persons who wear tight braids, especially “cornrows” that lead to high tension, pulling, and breakage of hair. Trichotillomania (Greek for “hair-pulling madness”) is a traction alopecia related to a compulsive disorder caused when patients pull on and pluck hairs, often creating bizarre patterns of hair loss.

• The prevalence of traction alopecia (Figures 188-1 and 188-2) is unknown and varies by cultural hairstyle practices. It is most commonly seen in females and children.1
• The prevalence of trichotillomania (Figures 188-3, 188-4, 188-5, and 188-6) is also difficult to determine, but is estimated to be approximately 1.5% of males and 3.4% of females in the United States. The mean age of onset of trichotillomania is 8 years in boys and 12 years in girls, and it is the most common cause of childhood alopecia.2

• Traction alopecia is seen in individuals who place chronic tension on the hair shafts with tight braids, heavy natural hair, use of hair prostheses, or chronic pulling (Figures 188-1 and 188-2).1 It also occurs commonly in female athletes who pull their hair into tight ponytails.
• Chronic tension on the hair shaft seems to create inflammation within the hair follicle that eventually leads to cessation of hair growth. Because hair loss from traction alopecia may become permanent, prevention and early treatment are important.
• It is seen most frequently in black women who tightly braid or pull the hair into a hairstyle during youth and on into adulthood. May also be seen in individuals who wear hair prostheses or extensions for a prolonged period of time. It is also seen in Sikh men of India and Japanese women whose traditional hairstyles may pull and damage hair.
• Trichotillomania is a subtype of traction alopecia manifested by chronic hair pulling (Figures 188-3, 188-4, 188-5, and 188-6) and sometimes hair eating (trichophagy), which can lead to a trichobezoar. It is classified as a psychiatric impulse-control disorder.3
• Trichotillomania may be a manifestation of the inability to cope with stress rather than more severe mental disorders.
• Children who exhibit trichotillomania may discontinue the hair pulling with parental support and maturity. Adults who exhibit trichotillomania, even though they are aware of the problem, may require psychiatric intervention to limit the behavior. The hair loss is initially reversible but may become permanent if the habits persist.

Clinical Features

In patients with traction alopecia, there are decreased follicular ostia in the affected area coupled with decreased hair density. The hair loss usually occurs in the frontal and temporal areas but depends on the precipitating hairstyle (Figures 188-1 and 188-2). No scalp inflammation or scaling is typically visible. No pain or other discomfort is associated with the condition. Patients with trichotillomania often demonstrate short, broken hairs (Figure 188-6) without the presence of inflammation or skin scale early in the disease. The affected areas are not bald, but rather possess hairs of varying length. There may be telltale stubble of hairs too short to pull. The hair loss often follows bizarre patterns with incomplete areas of clearing. The scalp may appear normal or have areas of erythema and pustule formation. With chronic pulling, the hair loss becomes permanent (Figure 188-4). The patient may be observed pulling or twisting the hair by friends or family members.

Typical Distribution

Trichotillomania most commonly occurs on the scalp and can involve any area of the body that can be reached by the patient.1 Traction alopecia can occur anywhere on the scalp, but is most commonly seen at the anterior hairline. This is the site where the hair is pulled back from the face into braids or a bun.

Laboratory Studies

Laboratory tests are not needed to make the diagnosis. A hand lens can be used to examine the affected scalp for decreased follicular ostia, if desired. A scalp biopsy (4-mm punch biopsy) may be necessary to make the diagnosis and rule out other etiologies, especially in trichotillomania, because patients may not acknowledge the habit.

Hypothyroidism or hyperthyroidism may be associated with telogen effluvium or alopecia areata. It may be worth ordering a thyroid-stimulating hormone (TSH) if the history and physical exam are not completely convincing for self-induced hair loss.

• Alopecia areata is characterized by the total absence of hair in an area and the presence of exclamation point hairs. These hairs are thinner in diameter closer to the scalp and thicker in diameter away from the scalp, creating the appearance of an exclamation point. Hairs are often white when they start to regrow (see Chapter 187, Alopecia Areata).1
• Tinea capitis exhibits hairs broken off at the skin surface and the presence of scale and/or inflammation. Some varieties fluoresce when examined with a Wood light (UV light). Microscopy of a KOH preparation may detect the dermatophyte. Sometimes it is necessary to culture some hairs and scale to make this diagnosis (see Chapter 137, Tinea Capitis).
• Scarring alopecia (lichen planopilaris, folliculitis decalvans) is observed as loss of the follicular ostia and the absence of hairs. The scalp may appear scarred with changes in pigmentation (see Chapter 189, Scarring Alopecia).
• Telogen effluvium (postpregnancy hair loss) is associated with hair loss during the postpartum period and can happen after other stressful events such as surgery or severe illness (see Chapter 74, Skin Findings in Pregnancy). The hair loss is evenly distributed across the head and the hair is thinned all over rather than in patches as in traction alopecia.
• Androgenetic alopecia produces central thinning in women and temple and crown thinning in males. It should be considered in women with symptoms of hormonal abnormalities such as hirsutism, amenorrhea, or infertility.

Nonpharmacologic

• Stop hairstyling practices that led to the traction alopecia. No tight braiding or buns should be worn.1 SOR C
• For trichotillomania, open discussions with the patient, and the family, if appropriate, are important to understand the reason for the behavior. Many times there are secondary social or emotional issues that must be resolved before the trichotillomania ceases.
  • Cognitive behavioral treatment is the most effective treatment for trichotillomania.1,3 SOR B
  • Cognitive-behavioral therapy usually is successful if the patient is recalcitrant to simple education.5 SOR C

Medications

• Topical corticosteroids can be used to decrease scalp inflammation if erythema or itching is present. SOR C
• Topical minoxidil is sometimes used to speed hair regrowth in the area. SOR C
• Fluoxetine hydrochloride (Prozac) 20 to 40 mg/day in adults or clomipramine (Anafranil) 25 to 250 mg/day in adults or a maximum of 3 mg/kg per day in children has had some success for alleviating compulsive hair pulling.4-6 SOR B

Olanzapine (Zyprexa) has been studied for the treatment of trichotillomania in a 12-week, randomized, double-blind, placebo-controlled trial. A dose of 10 mg/day showed a significant decrease in the CGI-Severity of Illness scale in 85% of subjects.7 SOR B

Methylphenidate also has showed limited efficacy in trichotillomania patients with comorbid attention deficit hyperactivity disorder (ADHD) in a 12-week study.8 SOR B

Explain that in traction alopecia, current grooming practices are responsible for the hair loss and a new hairstyle must be selected. It is important to tell the patient that some of the hair loss may be permanent and no guarantee can be given regarding the amount of expected hair regrowth. Similar hair grooming practices should be avoided in the patient's children to prevent traction alopecia from occurring. Prevention is definitely the best treatment.

Explain that trichotillomania is a self-induced disease that can often resolve if the hair pulling or twisting is discontinued. Patients may exhibit hair pulling or twisting unconsciously when stressed or use it as a calming activity when relaxing or going to sleep. The underlying reasons for the behavior should be explored and discussed. Sometimes trichotillomania can be substituted with another behavior, such as playing with beads or rubbing a stone.

Specific follow-up is not required for traction alopecia but psychiatric/behavioral counseling follow-up is indicated for trichotillomania.

Patient Resources

• Trichotillomania Support and Therapy Site. Emphasis on Growth—http://www.trichotillomania.co.uk/.
• WebMD. Mental Health and Trichotillomania—http://www.webmd.com/anxiety-panic/guide/trichotillomania.
• Traction Alopecia: Causes and Treatment Options—http://www.traction-alopecia.com/.
• National Organization for Rare Disorders, Inc. Trichotillomania—http://www.kumed.com/healthwise/healthwise.aspx?DOCHWID=nord768.
• MedlinePlus. Trichotillomania—http://www.nlm.nih.gov/medlineplus/ency/article/001517.htm.
• Mental Health America. Trichotillomania—http://www.nmha.org/go/information/get-info/trichotillomania.

Provider Resources

• Trichotillomania—http://emedicine.medscape.com/article/1071854-overview.
• Traction Alopecia—http://www.emedicine.com/derm/topic895.htm.