Trichoteiromania

ARTICLE

Hair loss does not only occur due to diseases of the hair and scalp, but may also be self-inflicted by a patient in the form of a factitious disorder. The most frequent forms of such self-inflicted hair loss are trichotillomania [1] and trichotemnomania [2]. However, in daily clinical practice another type of artificially induced hair loss that cannot be categorized as trichotillomania or trichotemnomania is sometimes observed. We report such a case and suggest a new name for this disorder.

Case report

A 61-year-old woman presented with scalp areas, where the hairs broke off and were no longer than 2 cm. Such areas were present for several years, sometimes changing their location on the scalp. The patient complained about severe itching and burning of the involved scalp areas, which compelled her to rub the scalp. She reported her feeling that "something from inside was happening in her scalp". She feared poisoning by detergents she was exposed to during her job as a cleaning lady. During the past years, her hair problem had resulted in various internal examinations, including thyroid function test, thyroid scintigraphy and testing for autoantibodies, without yielding pathological findings.

Physical examination showed areas with 2 cm long hairs adjacent to areas with less than 1 mm long hairs, the latter giving the impression of bald spots (Fig. 1). Within these areas the skin was slightly erythematous and scaling. Closer examination revealed white tips at the end of the hair shafts in the form of distal splitting (Fig. 2). The remaining scalp was of normal appearance and the skin was likewise normal. In particular, no eczematous or psoriasiform lesions were found.

There were no abnormal laboratory findings and culturing of scalp debris for fungi was negative.

Light microscopy of the hair shafts showed brush-like splitting of the ends (Fig. 3).

Histopathological examination showed an acanthotic epidermis with compact orthohyperkeratosis, focal parakeratosis and intraepidermal microvesiculation but normal anagen hair follicles. There was no increase in the number of catagen hair follicles, no pigment casts, no trichomalacia and no perifollicular inflammation or hemorrhage.

Therapy of the patient started with occlusive application of 5% salicylic acid and 0.1% betamethasone as a symptomatic treatment of erythema and scaling. Additionally, 25 mg hydroxyzine was administered orally to treat the pruritus. Because this treatment was not sufficient to stop the patient's feeling that "something was happening in her scalp", oral treatment with 1 mg pimozide was initiated, which slightly alleviated the patient's delusion of being poisoned. Moreover, specialized psychiatric treatment was arranged.

Discussion

Hair loss in our patient was obviously caused by rubbing of the hair. An underlying mental disorder, a dilusion of being poisoned, made the patient believe that "something was happening in her scalp". For this reason she was compelled to rub her scalp and her hairs. The hair shafts were crushed by the patient's fingers like in a grinder, and they split and broke off. The brush-like ends of the otherwise normal hair shafts, as noted at microscopical examination, represent the consequence of such rubbing of the hair shafts. Macroscopically, these hairs presented as stubs with white tips. Erythema and scaling of the scalp can best be explained as a chronic eczematous reaction, caused by permanent rubbing. This is supported by the described histopathological features of chronic eczematous reaction. Alternatively, another type of eczema of the scalp such as seborrhoeic dermatitis might have caused the rubbing, but the patient's history is in favor of the first explanation.

However, even if it was possible to explain the pathogenesis of hair loss in our patient, it was impossible to categorize this hair disorder by use of the prevailing terminology.

A major differential diagnosis was trichotillomania, which is characterized by hairless lesions showing regrowth of short new hair [3]. In trichotillomania the patients pull out their hair for pychiatric reasons. By contrast, our patient did not pull out any hair, she rather rubbed it. Furthermore, histopathologically trichotillomania is characterized by an increased number of catagen hair follicles with pigment casts, follicular plugging and trichomalacia [1, 4]. None of these histopathological features of trichotillomania were found in our patient. On the other hand, the white tips at the ends of the remaining short hair shafts are usually not found in trichotillomania. For these reasons, trichotillomania was excluded in the present case.

In trichotemnomania the patients cut off their hair for psychiatric reasons [2]. This diagnosis was excluded because the patient obviously did not cut off her hair. The white tips at the end of the hair shafts are never found in trichotemnomania.

Because none of the existing terms were appropriate to our patient's disorder, we suggest the new name trichoteiromania, which means "compulsive rubbing of hair". This term characterizes a type of hair loss that is caused by a mental disorder making the patients rub their hair which results in splitting and breaking of hair. A hallmark of trichoteiromania are short hairs with split, brush-like ends, giving the impression of white tips.

A similar case was described by Runne [5], who noted split ends of hair shafts as well as multiple trichorrhexis nodosa lesions along the hair. Runne proposed the term "Kratz-Pseudoalopezie" (scratching-pseudoalopecia). We feel, however, that the term trichoteiromania is more suitable to describe a pathogenetically defined entity that had so far no name in our textbooks.

CONCLUSION

REFERENCES

1. Muller SA, Winkelmann RK. Trichotillomania: a clinicopathologic study of 24 cases. Arch Dermatol 1972; 105: 535-9.

2. Braun-Falco O, Vogel PG. Trichotemnomanie: eine besondere Hautmanifestation eines hirnorganischen Psychosyndroms. Hautarzt 1968; 19: 551-3.

3. Muller SA. Trichotillomania and related disorders. In: Orfanos CE, Happle R, eds. Hair and hair diseases. Berlin: Heidelberg, Springer-Verlag, 1990: 753-62.

4. Miescher G, Schmuziger P. Trichomalacie und Trichotillomanie. Dermatologica 1957; 114: 199-203.

5. Runne U. Chronische Pseudo-Alopezie durch ständiges Kratzen (Kratz-Pseudoalopezie). Z Hautkr 2000; 75: 444-5.