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A 12-year-old female with hair loss
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A 12-year-old female presents to a pediatric dermatology clinic for evaluation of a bald patch on the left side of her scalp. The patient notes this lesion has been present for at least 5 months. She denies pruritus and pain in the area. She denies any history of a rash on her feet or body. The patient does not wear her hair in tight braids or a tight ponytail. She is not taking any medication and denies any history of diffuse hair thinning or hair loss. The patient’s mother said she is unaware of any family history of thyroid disease or type I diabetes.
Shehla Admani
Andrew C. Krakowski
On physical exam, the patient is noted to have a somewhat polygonally shaped patch of alopecia on her left temporo-occipital scalp with fine regrowth of hairs of various lengths noted in the center. Pull test is negative. Her eyebrows and eyelashes are within normal limits. She does not have any pitting of her fingernails. There is no appreciable lymphadenopathy, and her thyroid is normal.
What is the next best step in this patient’s management?
A. Perform a fungal culture.
B. Discuss any potential stressors in the patient’s life.
C. Start topical corticosteroids to cure the underlying inflammation.
D. Further explore any mechanical causes of hair loss (twirling of the hair, picking at the scalp).
E. Consider a punch biopsy.
F. B, D and E.
Can you spot the rash?
Trichotillomania
Upon further discussion, the patient notes she often finds herself “twirling” her hair. As she is left-handed, her natural tendency is to grab the hair on the left side of her scalp while she is sitting in class or while she is at home watching television. Although she does not note a history of directly pulling out her hair, when asked to demonstrate her hair twirling, it is found to be in the exact area of alopecia.
Trichotillomania is a form of traumatic alopecia and is a self-induced hair loss, resulting from repetitive pulling of one’s own hair. Cases of trichotillomania “by proxy” have also been described in which the parent plucks the child’s hair. Pediatric cases of trichotillomania show a female predominance and most commonly occur in children aged 9 to 13 years.
The scalp is the most common area of involvement; however, eyebrows, eyelashes and pubic hair can be involved as well. Hair breakage can be the result of plucking, twirling or rubbing of the hair-bearing areas.
The diagnosis is typically based on clinical history and physical exam showing irregularly shaped patches of short broken hairs of varying lengths. To confirm the diagnosis, the patch of interest can be shaved, which will prevent further manipulation of the area and all of the hair should grow back uniformly.
Left temporo-occiptal scalp with irregularly shaped patch of alopecia with fine regrowth of hairs of various lengths in the center.
Source: Krakowski AC
Trichoscopy (hair and scalp dermoscopy) can be used to further evaluate areas of hair loss and in cases of trichotillomania will most likely show irregularly broken hairs; however, this is non-specific and can also be seen in other forms of hair loss. Results from a recent study have shown additional trichoscopic findings that are more specific to trichotillomania and include flame hairs, v-sign, hook hairs, hair powder and tulip hairs. If further diagnostic evidence is needed, a biopsy can be performed that may show pigmented casts with twisted, linear (zip), and “button”-like pigment aggregation.
Treatment can be difficult because most patients are unaware of their hair pulling or will not openly admit to it. Behavioral interventions such as habit reversal training (HRT) can be beneficial. HRT consists of awareness training and self-monitoring, stimulus control and competing response procedures (such as squeezing a stress ball). This allows patients to take control of their hair pulling and reduce its interference in their daily lives.
Mild shampoos and mild topical corticosteroids can also be used to provide the patient with a distraction and allow them to take control of the treatment process without direct accusation that this is a self-inflicted condition. In severe or persistent cases, psychiatric intervention may be considered.
References:
Beattie KC. J Can Acad Child Adolesc Psychiatry. 2009;18:51-52.
Hautmann G. J Am Acad Dermatol. 2002;46:807-821; quiz 822-826.
Miteva M. Am J Dermatopathol. 2013; [published online ahead of print July 2].
Paller AS, Mancini AJ, Hurwitz S. Disorders of hair and nails. In: Paller AS, Mancini AJ, eds. Hurwitz Clinical Pediatric Dermatology: A Textbook of Skin Disorders of Childhood and Adolescence, Fourth Edition. Philadelphia, Pa: Elsevier; 2011:152-154.
Rakowska A. Acta Derm Venereol. 2013;doi:10.2340/00015555-1674.
Sah DE. Dermatol Ther. 2008;21:13-21.
Sarah HM. Expert Rev Neurother. 2013;13:1069-1077.
For more information:
Shehla Admani, MD, is a Clinical Research Fellow in Pediatric Dermatology at Rady Children’s Hospital, San Diego. Andrew C. Krakowski, MD, is an attending physician at Rady Children’s Hospital, San Diego.
Disclosure: Admani and Krakowski report no relevant financial disclosures.