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Clinical Presentation

Trichotillomania (TTM) is a type of obsessive-compulsive disorder characterized by repeated thoughts and activities of hair pulling (1). A French dermatologist 1st named the condition in 1889 (1). Hair can be pulled from anywhere on the body and results in non-scarring hair loss. People engaged in TTM are usually sedentary and in a “trance” like state (2). TTM is most commonly located scalp (“friar truck” appearance), eyelashes and eyebrows. It presents with geometric areas of hair loss with hair of differing lengths and various stages of regrowth (1, 2). It can be associated with a trichobezoar (abdominal pain, nausea, vomiting, constipation, or bowel obstruction from swallowing pulled hairs)


TTM typically affects women (9:1- female:male ratio) (1). The mean age of onset of hair pulling is between 9 and 13 (2). The prevalence of subclinical hair pulling is estimated to be around 11% of the general population (2, 3)


The exact cause is not well understood. However, TTM is thought to be associated with genetic predisposition, and neurotransmitter (serotonin, dopamine, norepinephrine) and structural brain abnormalities (1, 2). Stress, trauma, and boredom have also been shown to be triggers for the condition (1, 2).  


TTM is diagnosed via careful history (DSM-V - 4), clinical scalp and hair exam, and dermoscopic evaluation.  Scalp biopsies may be performed to help confirm the diagnosis. 

Clinical Imitators (Differential Diagnosis)

Traction alopecia, pattern baldness, pressure alopecia, alopecia areata, tinea capitis, secondary syphilis

Treatment Options (1, 2)

  • Cognitive Behavioral therapy: Habit reversal therapy

  • Medications

    • Selective Serotonin Reuptake Inhibitors: Poor efficacy (2)

    • Tricyclic antidepressants: Clomipramine

    • Antipsychotics: Olanzapine, Aripiprazole, and Quetiapine

    • Other: N-acetylcysteine (5)