7.2.1 Trichotillomania

Grading & Level of Importance: C




Hair pulling disorder; compulsive hair pulling.


Usually seen in adolescence; F>M 3-10:1. It is present in <1:1000 of the general population.


Compulsive self-manipulation of hairs through pulling, twisting and plucking (or other mechanisms), leading to localised areas of alopecia.

Aetiology & Pathogenesis

The aetiology is psychological and the condition may be considered part of the impulse-control disorder spectrum. Individuals with this disease feel compelled to manipulate the hair to an excessive degree. There may be underlying psychological disease such as body dysmorphic disorder, anxiety, depression or psychosis.

Signs & Symptoms

The patient is usually distressed by the hair loss and has some insight into the fact that they are causing the manifestations of the disease. Clinically, solitary (rarely multiple) circumscribed areas of incomplete hair loss with short hairs of varying lengths are seen. Only those hairs reaching 3mm in length can be removed. The hair shafts often show distal splits and a frayed appearance, especially marked on microscopy. Broken-off hairs may appear as dark dots on the scalp.


The most common site is the centro-parietal scalp, because the pain tolerance is higher there. This is known as a tonsure trichotillomania, due to the resemblance with a monastic tonsure.


An imperfect classification is based on the age of the patient.


The infantile form often results from frustration. The adolescent form may reflect obsessive-compulsive disorder.

Laboratory & other workups

This is only required to exclude other conditions. Other tests may confirm the diagnosis. Trichoscopy may show broken hairs, trichoptilosis (split ends), irregular coiled hairs, empty follicular orifices etc. A trichogram would show an absence of telogen hairs and dystrophic anagen hairs. 


Not usually required but would show disrupted follicular anatomy without inflammation. In early lesions erythrocytes are found in and around the follicle.


Trichotillomania in young children often resolves spontaneously. In adults, the problem tends to persist.


Rarely, if the manipulated hair is ingested (a phenomenon known as trichophagia), a trichobezoar (hairball in stomach or intestine) may form. There is a danger of ileus (Rapunzel syndrome) in this situation.


DSM-5 diagnostic criteria of the American Psychiatric Association for the diagnosis of trichotillomania:


  1. Recurrent pulling out of one’s hair resulting in noticeable hair loss. 
  2. An increasing sense of tension immediately before pulling out the hair or when attempting to resist the behaviour. 
  3. Pleasure, gratification, or relief when pulling out the hair. 
  4. The disturbance is not better accounted for by another mental disorder and is not due to a general medical condition.
  5. The disturbance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning.


Generally, the clinical findings (including trichoscopy) are sufficient for a confident diagnosis, but tests such as a trichogram or biopsy may be required to exclude other conditions. A psychological evaluation is mandatory.

Differential diagnosis

Alopecia areata, tinea capitis, androgenetic alopecia, adverse effect of medications, post-traumatic.

Prevention & Therapy

Best coordinated by a clinical psychologist or psychiatrist (habit reversal therapy and treatment of any underlying psychological disease). It is unclear whether pharmacological treatment is truly helpful or not.



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