Focus on Sciences
Case Report
Aug 2017, Volume 3, Issue 3
Trichotilomania and Request for Hair
Transplantation
Reza Bidaki 1, 2, Sogol Alesaeidi 3, Seyed-Ali Mostafavi 4, Narges
Ghanei Yakhdani 5 , *, Aida Farsham 6, Mojtaba Babaei Zarch 7
1
Department of Psychiatry, Research Center of Addiction and Behavioral Sciences,
Shahid Sadoughi University of Medical Sciences, Yazd, Iran
2
Diabetes Research Center, Shahid Sadoughi University of Medical Sciences, Yazd,
Iran
3
International University of Medical Science, Yazd, Iran
4
Psychiatry Research Center, Roozbeh Hospital, Tehran University of Medical
Sciences, Tehran, IR Iran
5
Department of Dermatology, Shahid Sadoughi University of Medical Sciences,
Yazd, Iran
6
MS in Clinical psychology, Alzahra University, Tehran, Iran
7
Student Research Committee, Shahid Sadoughi University of Medical Sciences, Yazd,
Iran
DOI: 10.21859/focsci-03031413
Submitted: 03.14.2017
Accepted: 05.23.2017
Keywords:
Trichotillomania
Hair Transplantation
Psychodermatology
© 2017. Focus on Sciences
* Corresponding author: Narges Ghanei Yakhdani, Department of Dermatology,
Shahid Sadoughi University of Medical Sciences, Yazd, Iran. Tel: +98-3532632004;
Fax: +98-3532623555; E-mail: Nargesgh73@yahoo.com.
Abstract
Introduction: Trichotillomania (TTM) is a type of impulse control disorder with
chronic hair pulling. It effects on behavior, feelings, thoughts and quality of life.
Case Presentation: The patient is a 28 year-old single woman that was referred to
hair transplantation. She was worried about her appearance, cosmetic problems and
marriage. The physician noticed that she is a patient with trichotilomania type of impulse
control disorder. After confirming the diagnosis of trichotillomonia by a psychiatrist,
pharmacotherapy begun with Rispridone 1 mg at night, Fluvoxamine 50 mg/daily and
Clomipramine 5 mg at night. Over nine months of treatment there were significant
reductions in hair pulling. She was followed up and finally, the response was acceptable.
Conclusions: TTM is a poorly understood disorder that requires more studies. Despite
what we know about TTM, those with the disorder report not receiving enough
information for diagnose and treatment. However, the information presented in this
paper can help us to prevent this disorder, reduceing the prevalence and selecting the
appropriate treatment.
INTRODUCTION
Trichotillomania (TTM) is an impulse control chronic behavioral disorder [1], characterized by the recurrent compulsive
hair pulling from different parts of the body which can cause
tension relief during the act [2] and it may be associated with
major functional impairments and psychiatric comorbidities
as well as infections or skin diseases in the hair pulling areas
[3]. Some patients eat the hair after pulling, which can cause
masses, called trichobezoar [4, 5]. Its prevalence is below
1% [6]. Trichotillomania is diagnosed in all age and gender
groups; with a notable onset peak at 12–13 [7]. Generally, it
is a female dominant disorder. The exact etiology is unknown,
but it is likely that multiple genes confer to trichotillomania,
because it may be more likely happens in twins and the members of the families with a past history of trichotillomania [8].
It may be difficult to treat and its treatment usually consists of
both pharmacotherapy and psychotherapy [9].
CASE PRESENTATION
The patient is a 28 year-old single woman that was referred
the hair transplantation clinic because of the long term, treatment resistant, scalp alopecia (Fig 1), But At the time the
physician noticed that she is a patient with trichotilomania
type of impulse control disorder, and referred her to psychologist but although She denied her behavioral problem the
dermatologist started Clomipramine 10 mg at bedtime and
Fluoxetine 20 mg /daily and referred her to us.
When she attended in our clinic she covered her head by a hat,
without that, the patient’s appearance was notable for total alopecia and the lack of both eyebrows. She was depressed with
Bidaki, et al.
motor tic in the form of eye blinking and worried about her
appearance, cosmetic problems and decision for marriage. She
reported a 4 year history of compulsive hair pulling, restricted to
the scalp and eyebrows. She had the history of whole life anxiety
disorder too. The Symptoms first begun 4 years ago when she
had severe stresses about her future life, marriage and the fear
of remaining alone, and after that, symptoms flared times and
times by increasing life stressors for example during educational
period. When the first symptoms begun, she was ashamed of
that, so she referred to a dermatologist and denied that her hair
loss was due to such behavior. She got different local and oral
drugs but because of the treatment failure she was referred to
hair transplantation clinic. During this time she had lower life
stressors so after a short time of local treatment she exhibited
hairs of differing lengths; some were broken hairs with blunt
ends, some new growth with tapered ends, and some broken
mid-shaft [10]. She denied any other medical problems. She
was from a low socioeconomic family and there was a history
of obsessive compulsive disorder in her first degree family. After
establishing the diagnosis of trichotillomonia, pharmacotherapy
begun with Rispridone 1 mg at night, Fluvoxamine 50 mg/daily
and Clomipramine 5 mg at night. Over nine months of treatment there were significant reductions in hair pulling (Fig 2).
Figure 1: The Patient with Trichotilomania. Extensive Tonsure Pattern, Severe form Involving the Entire Scalp Sparing the Hair at the
Marginal Zone and Eyebrows (Before Treatment)
DISCUSSION
Good clinical practice begins with accurate assessment for
reaching true diagnoses, then planning for treatment and finally assessing changes in severity of symptoms [11]. Assessment of TTM needs gathering some information from different sources by a well-established interview performed by a
psychiatrist. Our psychiatrist similarly tried to assess patient’s
symptoms and its severity, functional impairments, comorbiditis and differential diagnosis all based on DSM-5 criteria.
Then we tried to tailor a treatment for her and assessed the
patient’s symptoms after psychopharmacotherapy. A 28 year
old woman was referred to our outpatient clinic of psychology in Yazd medical university, reporting a 4 year history of
compulsive hair pulling, restricted to the scalp and eyebrows.
She had the history of whole life anxiety disorder and depression too. Instead of referring to psychiatrist, she was referred
to dermatologist since
She was ashamed of declaring her behavioral problem. As
she denied her problem her dermatologist just used skip
local and oral skin drugs to treat her and at last because of
the treatment resistance referred her to the hair transplantation clinic. This patient is diagnosed with trichotillomonia,
because of the vast hair pulling area consist of the total region of scalp and both eyebrows and, 4 years of attempts to
deny her behavioral problem and going to the dermatologist
to seek treatment instead of the psychologist. In this case
after Psychopharmacotherapy the patient was re-assessed.
One objective and practical method of assessing the severity
of trichotillomonia over the time is the use of photographs
[11]. We snapped shot the patients’ primary pulling sites, before psychopharmacotherapy and repeated again nine month
after the treatment, providing an objective way of assessing
the treatment success. While such patients should usually
attend psychological clinics in the first step,but sometimes
these patients will refuse a psychiatric referral because either
they think, there is societal stigma associated with psychiatric illness or they do not believe in their psychiatric nature
of disorder [12]. Therefore, it is essential for dermatologists
to understand the common reasons of psychodermatological
cases for example depression, anxiety, delusions, and obsessive-compulsive disorder [12]. And refer these patients to
psychiatrists or other mental health care professionals.
The most common approach includes combination of pharmacotherapy and psychotherapy. Choice of the drugs in
adults are SSRIs [13]. Clomipramine, has shown moderate effectiveness over placebo, N-acetylcysteine (NAC) has strongest empirical support in adults with TTM [12]. Psychotherapy in adults, adolescents and children consist of A wide
variety of methods, including cognitive and behavioral therapies, supportive counseling, support groups, and hypnosis
[14]. This paper is reported a patient with trichotillomonia,
because of the vast hair pulling area consist of the total region
of scalp and both eyebrows and, 4 years of her attempts to
deny her behavioral problem and going to the dermatologist
to seek treatment instead of the psychologist.
CONCLUSIONS
Figure 2: The Patient with Trichotilomania. (After Psychopharmacotherapy)
2
A case with trichotilomania may refer for hair transplantation
so dermatologists should always be ready for referring them for
psychotherapy. Whenever it is diagnosed, consultation with a
psychiatrist about treatment of trichotilomania is necessary.
Bidaki, et al.
ACKNOwLEDGMENTS
There is no acknowledgment for the present study.
5.
6.
CONFLICTS OF INTEREST
There is no conflicts of interest to declare.
7.
FUNDING
Not applicable.
AUTHORS’ CONTRIBUTION
This work was carried out in collaboration between all authors.
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