Update on the Treatment of Trichotillomania

Summary

Trichotillomania (TTM) is an obsessive-compulsive disorder in which affected individuals repeatedly pull out hair from any part of the body, causing hair loss or alopecia. The treatment of TTM presents a therapeutic challenge for dermatologists, and involves a combined approach of pharmacological and non-pharmacological alternatives. Cognitive behavioral therapy has been successfully used in the treatment of TTM, but not all patients are willing or able to comply with this treatment strategy. Unconventional supportive tools, such as electronic devices, internet therapies, and microneedling, are being proposed. The efficacy of N-acetylcysteine and memantine has been described as appropriate first-line treatment alternatives due to their favorable safety profile, with low risk of adverse effects and significant benefits. The use of other drugs, including fluoxetine, clomipramine, olanzapine, and naltrexone, has limited evidence of variable efficacy. This review presents current treatment modalities in the management of TTM.

Definition

TTM is defined in the Diagnostic and Statistical Manual of Mental Disorders, 5th edition, Text Revised (DSM-5-TR), as an obsessive-compulsive disorder (OCD) or related disorder in which individuals repeatedly pull hair from any part of the body, resulting in hair loss that may not be perceptible in diffuse patterns1,2.

Etiopathogenesis

The etiology of TTM is still to be fully understood. Multiple independent or interrelated factors may contribute to its development, including genetic, psychological, social, and neurobiological factors3. TTM has been classified into two types: automatic, where the action is unconscious, and focused, which occurs consciously in response to emotional stress, sadness, anger, or anxiety2. It has been proposed that pulling hair produces a "counter-irritation" phenomenon that reduces the brain's perception of stress3.

Clinical Presentation

Clinically, TTM can present with a diffuse pattern of scalp involvement, non-scarring alopecia in irregular patches, or with 1 or 2 plaques (figs. 1 and 2)2. The scalp is the most commonly affected anatomical location, but eyebrows, eyelashes, extremities, pubis, armpits, and chest hair can also be involved. The alopecia pattern is often localized or diffuse with angular or irregular borders. Patients with TTM present hairs of different lengths, which creates a rough sensation when touching the scalp2,3.

Its prevalence is between 0.5-2% of the population, with a female predominance of 4:12.

Trichoscopy

Trichoscopy reveals anomalies resulting from the stretching and breaking of hair shafts. Common trichoscopic signs include decreased hair density, black dots, broken hair shafts at different lengths, and yellow dots (figs. 3 and 4). Other trichoscopic signs, all representing broken hair shafts, have been described1,2,4.

Authors: L. Nina Dominguez, A. Imbernón-Moya, D. Saceda-Corralo, S. Vano-Galván

a Dermatology Service, Dominican Dermatological Institute and Skin Surgery "Dr. Huberto Bogaert Díaz," Santo Domingo, Dominican Republic

 b Dermatology Service, Severo Ochoa University Hospital, Madrid, Spain

 c Trichology Unit, Pedro Jaén Dermatology Group, Madrid, Spain

 d Dermatology Service, Ramón y Cajal University Hospital, Department of Systems Biology, Faculty of Medicine, University of Alcalá, IRYCIS, Madrid, Spain

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