When I was in my family nurse practitioner training, women presenting with #trichotillomania was not an uncommon finding. I can't say that I ever remember being introduced to this diagnosis previously, but Dawe's & Fretzen Dermatology allowed me opportunity to grow my clinical expertise in dermatology a few years ago, and certainly within their practice, trichotillomania was a staple consult.
Trichotillomania is an impulse-control disorder that seems to first present at about thirteen years of age. These individuals pull, twist, or twirl their hair, either consciously or unconsciously, causing hair loss. Within the dermatology clinic I mentioned above, we met with a younger man whose partner would pull his chest hair out, leisurely, while watching a movie on the couch because it felt necessary, and comforting, for him. The dermatologist diagnosed this as tricotillomania as well. Whoopi Goldberg shared recently that she regularly shaves off her eyebrows as well. I am not sure this qualifies, but interesting none-the-less.
Trichotillomania is reported to affect as much as 4 percent of the population, with the highest incidence in childhood and adolescence (Phillips, Slomiany, & Allison, 2017). This one can be hard to diagnose though, because individuals don't think about it as a condition to report. They know they do it and know they probably shouldn't, but don't really recognize that potentially their healthcare provider could help them resolve this habit. Some are embarrassed as well, so aren't as forthcoming.
Hair loss in these individuals though are more typically around the front and sides of the head, where they find pulling most convenient, and often, more so in my experience, includes the eyebrows and eyelashes. My good friend in high school would pull her eyebrows and eyelashes out when she was anxious, and she was one of our salutatorians. Interestingly, looking back on that, she was super smart and was always focused on her school work and being the best piano player, flute player, even marching band drum major, but I would never have thought she was anxious or had impulse control. In my clinical practice though, when I treat little ones with ADHD, this habit resolves with therapy.
Trichotillomania may lead to problems with self-esteem and social avoidance. They may experience infection, skin damage, and permanent scarring. There really isn't a lot of guidance for clinicians on treatment. Psychiatric referrals are really the mainstay here, but again, as an impulse-control disorder, this is how we've approached it in our practice and we really have had pretty good success.
Cognitive behavioral therapy and anti-depressants have not really demonstrated to be super helpful in the literature. Acetylcysteine, Zyprexia, and Anafranil has some support. Maybe combining medications with cognitive therapy is more helpful? Either way, this issue originates in the brain so brain inflammation or chemical neurology is the approach in my mind. What does the brain need or what might be causing it inflammation? This is where we start and it seems to work.
Phillips, T. G., Slomiany, W. P., & Allison, R. (2017). Hair loss: Common causes and treatment. American Family Physician, 96(6), 371-378.