Trichorrhizophagia

ARTICLE

Auteur(s) : Ramon GRIMALT, Rudolf HAPPLE*

Department of Dermatology Hospital Clinic University of Barcelona, University of Barcelona, Villarroel 170 08036 Barcelona, Spain * Department of Dermatology, Philipp University of Marburg, Germany.

Article accepted on 17/02/2004

Trichotillomania (TTM) is a disorder characterized by the chronic compulsion of pulling out one’s own hair. It has been classified as an impulse control disorder [1]. The condition was first described by Hallopeau in 1889 [2]. TTM is usually observed in young children and adolescents, with an average age of onset of 12 years [3] but it can begin in adults and even in the elderly [4-6]. TTM should be considered in the differential diagnosis of non-scarring alopecia of the scalp, eyebrows, eyelashes or pubic hair.
Trichophagia consists in the compulsion of eating one’s own hair. It is usually but not exclusively associated with trichotillomania. The main complication of this habit is trichobezoar [7].

Case Report

A 65-year-old lady was seen in our clinic complaining of hair loss. The patient had already visited on numerous occasions for different complaints about her hair. She had been treated for a “diffuse alopecia areata (AA)” on 2 occasions “with satisfactory results”, she received the diagnosis of telogen effluvium twice and she was also characterized once as a case of “seasonal alopecia”.
Her clinical background was mainly highlighted by several transient psychiatric disorders. She had been under treatment for a depression with anxiolytics (lorazepam) and antidepressant drugs (fluoxetine) during the last ten years.
In her family history, one daughter was noted to be affected with patchy recurrent AA, one son with androgenetic alopecia and one brother with a schizophrenic disorder.
Clinical observation revealed the presence of an ill-defined hairless patch, tubular in shape, starting in the left occipital area and running across the temporary and parietal area to the front part of the scalp in a tonsured pattern (Fig. 1).
Under closer observation, short, twisted and broken hairs were present on the bald area (Fig. 2).
Psychological anamnesis of the patient revealed a stressful event 3 months earlier. Her schizophrenic brother who lived with her family finally succeeded (after 3 attempts) in committing suicide. Since that moment the patient’s anxiety and associated depression were totally unbalanced.
The psychiatrist added olanzapine 5 mg/day and diazepam 10 mg/day but the patient did not tolerate the treatment so she decided to stop these drugs herself.
After the patient was told by one of us that it looked like she was pulling her hair, she recognised that she spent part of her time pulling out the hair and eating the “white band” on the root.
The diagnosis in this situation was a mixture of trichotillomania with a highly selective form of trichophagia. We would like to propose the term trichorrhizophagia to describe it.

Discussion

Trichotillomania is a form of hair loss characterized by an irresistible compulsion to pull out or twist and break off one’s one hair [8]. The name trichotillomania derives from the Greek words thrix (hair), tillein (to pull) and mania (excessive excitement). Trichophagia derives from phagein (to eat). Because none of the existing terms appropriately describes our patient’s disorder, we suggest the new term trichorrhizophagia which means “eating the root of the hair” (from the Greek riza ριζα = root).
Trichotillomania is thought to represent a complex behavioral pattern of uncertain origin. The majority of TTM cases affecting children and adolescents represent a rather mild, temporary problem. On the other hand, TTM affecting adults is usually a much more severe disease. Some authors even hypothesized that it may be associated with biologic and perhaps biochemical brain abnormalities [8]. It is now recognized that many patients with TTM exhibit other obsessive or compulsive behavior patterns, and TTM is now categorized either as part of the obsessive-compulsive disorder spectrum or as an impulse control disorder [9-12].
The tonsured pattern of scalp hair in which the peripheral fringe remains, as in our patient, is not infrequent, perhaps because it is easier to comb the hair so as to hide the alopecic patches and because it is more painful to pluck hair from these regions of the scalp [13-14].
Extracted hairs are often manipulated, examined, or played with before being discarded or eaten. Only 9 percent of patients quickly discard the hairs [8]. Trichobezoars have been reported with trichotillomania necessitating surgical intervention and the term Rapunzel syndrome [15] has been used to report a rare manifestation of a gastric trichobezoar with a “tail” extending throughout the small intestine and sometimes even to the colon.
Our patient, in a kind of entertainment/distraction behaviour, selected the hair root and broke it with her teeth. She reported that she received pleasure with such a practice. Patients affected by trichorrhizophagia will never be affected by trichobezoar due the small amount of swollen keratin.
Treatment of TTM in adulthood is extremely difficult. The cooperation of a psychiatrist with the dermatologists in a “team approach” would be the best choice for most cases. In our patient, the psychiatric treatment was not tolerated and the patient discontinued it herself. n

References

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2. Hallopeau H. Alopecie par grattage (trichomanie ou trichotillomanie). Ann Dermatol Syphiligr (Paris) 1889; 10: 440-1.

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