|LETTER TO EDITOR
|Year : 2019 | Volume
| Issue : 4 | Page : 180-181
Trichodynia – A condition worth treatment-directed evaluation rather than “silencing”
Sidharth Sonthalia1, Poonam Sharma2, Mahima Agrawal3, Jyoti Kapoor4
1 The Skin Clinic and Research Centre, Paras Hospital, Gurugram, Haryana, India
2 Skin Institute and School of Dermatology, New Delhi, India
3 Department of Dermatology and STD, LHMC and Associated Hospitals, New Delhi, India
4 Department of Psychiatry, Paras Hospital, Gurugram, Haryana, India
|Date of Web Publication||19-Aug-2019|
Dr Sidharth Sonthalia
The Skin Clinic and Research Centre, C-2246, Sushant Lok-1, Block-C, Gurugram - 122 009, Haryana
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
Sonthalia S, Sharma P, Agrawal M, Kapoor J. Trichodynia – A condition worth treatment-directed evaluation rather than “silencing”. Int J Trichol 2019;11:180-1
|How to cite this URL:|
Sonthalia S, Sharma P, Agrawal M, Kapoor J. Trichodynia – A condition worth treatment-directed evaluation rather than “silencing”. Int J Trichol [serial online] 2019 [cited 2020 Aug 13];11:180-1. Available from: http://www.ijtrichology.com/text.asp?2019/11/4/180/264732
The suggestion of oral propranolol as an experimental therapy in patients with trichodynia in the case letter by Brzezinski et al., published in a recent issue of the journal, merits deliberation. The recommendation was based on experience with a single patient, a 76-year-old Caucasian female with hair loss of 5-year duration and on oral trazodone for 6 years for depression, who apparently sustained short-term improvement in trichodynia following 2-month oral propranolol.
First, we believe that a detailed evaluation for making a specific diagnosis of hair loss was warranted. The reported common causes of nonscarring chronic hair loss in an elderly woman include androgenetic alopecia (AGA), telogen effluvium (TE), AGA with superimposed TE, senile/senescent alopecia (SA), alopecia areata, and trichotillomania (TTM). The limited history and single clinical image that shows substantial (not mild) thinning suggests AGA with superimposed TE as the highest possibility. Other distinct possibilities include SA with co-existing AGA and trichoteiromania. Trichoteiromania, an artificial form of hair loss caused by perpetual rubbing of the scalp with fracturing of hair shafts associated with impulse-control impairment, is most commonly seen in senile women., Clinically characterized by frizzy ends, mild scalp erythema, and broken hair shafts of varying length, trichoteiromania does not show any specific histopathologic findings in contrast to TTM. Although trichodynia may seem to be a deterrent to rubbing, trichoteiromania associated with progressive AGA and TE might have preceded the onset of scalp dysesthesia and remains a possibility given the unevaluated but definite psychiatric comorbidity of the patient.
The patient should have been evaluated with at least trichoscopy, diagnostically more useful and nontraumatic than a biopsy.
Second, persistent/worsening hair loss with increasing age in an elderly woman with AGA should have prompted the authors to evaluate for androgen-producing tumor by hormonal and radiological assessment of the ovaries and adrenals. Moreover, although the authors mentioned the absence of associated cutaneous lesions, it is noteworthy that the typical virilizing features seen with these functioning tumors in prepubertal girls are inconspicuous in senile women.,
Third, we were discomforted by the authors' overcompendious documentation of the patient's psychiatric status. She deserved psychiatric re-evaluation before the authors' experimental treatment for several reasons in addition to a long-pending mental health review, especially a more aggressive yet safe treatment for her depression and comorbidities. Trazodone is a tetracyclic serotonin reuptake inhibitor antidepressant well documented to cause worsening of hair loss, a possibility ignored by the authors. The authors did not even comment on the status of hair loss after propranolol initiation. An alternate antidepressant with lesser likelihood of worsening of hair fall by the psychiatrist might have improved her depression and eliminated the possibility of trazodone-worsened hair loss, thereby improving trichodynia. The authors should also have considered the possibility of worsening of depression with propranolol (despite the low dose), a nonselective beta-blocker with depression as an adverse effect. In fact, the major depressive episode sustained by the patient  may be attributable to improper psychiatric management, continuation of trazodone with probable unchecked hair shedding, and the depressive effect of propranolol.
Lastly, the authors' experimental use of an unproven therapy for a condition for which other treatments with substantial evidence levels were not even tried suggests overvaluation. The authors should have tried hair growth stimulators such as minoxidil and specific treatments for trichodynia such as L-cystine-containing oral preparations, topical corticosteroids, substancePinhibitors especially topical cannabinoids, and pregabalin. Small-dose botulinum toxin could have been tried, which has proven effects in the improvement of AGA  as well as pain control in cephalalgia alopecia.
To conclude, a thorough evaluation of both symptoms (hair loss and trichodynia) with simple approach including trichoscopy and psychiatric referral, consideration of various factors that regrettably were ignored, and a therapeutic trial with evidence-backed medications for controlling hair loss and trichodynia constitute the proper approach in this case instead of directly instituting a purely experimental drug that too in an elderly depressed female.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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