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Year : 2014  |  Volume : 6  |  Issue : 4  |  Page : 160-163  

Trichoscopy in trichotillomania: A useful diagnostic tool

Department of Dermatology, S. Nijalingappa Medical College, Bagalkot, Karnataka, India

Date of Web Publication14-Oct-2014

Correspondence Address:
Balachandra S Ankad
Department of Dermatology, S. Nijalingappa Medical College, Navanagar, Bagalkot - 587 102, Karnataka
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/0974-7753.142856

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Introduction: Trichotillomania (TTM) is characterized by patchy alopecia of hair bearing areas. This is because of compulsive urge to pull the hair. Scalp is the most common site for pulling hair. Usually, patients may have only small areas of baldness, in severe forms, tonsure pattern of baldness is observed. Diagnosis is by history and clinical examination. However, it is difficult to differentiate from other causes of noncicatricial alopecia. Here, authors observed trichoscopic patterns and evaluated their importance in the diagnosis of TTM. Materials and Methods: This study was conducted in S. Nijalingappa Medical College, Bagalkot, from January 2014 to July 2014. Ten patients with clinically suspected TTM were included in the study. Informed consent was taken and ethical clearance was obtained. Dermlite3 dermoscope was used with Sony camera attachment to save the images. Histopathological examination was conducted in all the patients to confirm the diagnosis. Results: Ten patients were included in the study. Mean age of the patients was 34 years. Most common symptom was patchy loss of hair in the frontal area (100%). Common trichoscopic feature was decreased hair density and broken hairs. Trichoptilosis ("split ends") and irregular coiled hairs were seen in 80% patients. Novel diagnostic signs like black dots, flame hair, v-sign, follicular hemorrhages, were seen in 30% each. Tulip hair and hair powder were observed in 10% of patients. All patients had the noninflammatory alopecia with distorted and collapsed inner root sheath in histopathology. Conclusion: Trichotillomania is often chronic and difficult to treat. Hence, early diagnosis and treatment is necessary. Authors believe that the trichoscopy plays a vital role in the diagnosis of this condition by demonstrating specific trichoscopic patterns.

Keywords: Trichomalacia, trichoptilosis, trichoscopy, trichotillomania, tulip hair, v-sign

How to cite this article:
Ankad BS, Naidu M V, Beergouder SL, Sujana L. Trichoscopy in trichotillomania: A useful diagnostic tool. Int J Trichol 2014;6:160-3

How to cite this URL:
Ankad BS, Naidu M V, Beergouder SL, Sujana L. Trichoscopy in trichotillomania: A useful diagnostic tool. Int J Trichol [serial online] 2014 [cited 2023 May 31];6:160-3. Available from: https://www.ijtrichology.com/text.asp?2014/6/4/160/142856

   Introduction Top

Trichotillomania (TTM) literally means morbid craving to pull out hair. [1] The term was used by Hallopeau in 1889 and is derived from the Greek; thrix-hair, tillein-pull out and mania-madness. [2] Scalp is the most common site for pulling hair although other hair bearing areas may be involved. In less severe forms, patients may have only small areas of baldness. Whereas in more severe forms, tonsure pattern of baldness, known as "Friar Tuck sign" is seen. [3] Diagnosis is mainly by history and clinical examination, nevertheless, sometimes it is very diffi cult to differentiate it from other causes of noncicatricial alopecia. Trichoscopy, dermoscopy hair and scalp, is a noninvasive technique for differential diagnosis of various hair and scalp diseases. [4,5] Here authors evaluated trichoscopic patterns in TTM and authors believe that these patterns are specific to TTM, which can aide in early diagnosis of this chronic condition.

   Materials and methods Top


This study was carried out on 10 patients attending department of Dermatology in a tertiary hospital attached to S. Nijalingappa Medical College at Bagalkot, South India between January 2014 and July 2014. It was an observational study. Ten patients with clinical features of TTM were subjected for a complete history and dermatological examination. Written informed consent was obtained from patients in the study. The ethical clearance for the study was obtained by the institutional Ethical Committee. Demographic data such as age and gender and clinical variables in terms of site of lesions and disease duration were documented. Data were collected and analyzed. The results were statistically described in terms of frequencies and types of trichoscopic patterns. All TTM lesions were subjected for histopathological examination to confirm the diagnosis.

Trichoscopic examination

Dermlite 3 dermoscope (×10 magnifications) with both polarized and nonpolarized lights was employed in the study. However, only polarized light version was used in our study. Sony camera (digital, 14 mega pixels) was attached to save the images. Initially, ultrasound gel was applied either on the faceplate of dermoscopy or on the skin lesions and then lesions were observed through the eyepiece of dermoscopy. Although polarized dermoscopy was employed, ultrasound gel was applied for clarity of images and to lessen distortions associated with light.

   Results Top

There were 10 patients (female-9, male-1) in the study. Mean age of the patients was 34 years (Minimum age 13 years and maximum age 55 years). Mean duration of disease was 19 months (minimum 2 months and maximum 36 months). Most common symptom was patchy loss of hair over the scalp (100%) especially in the frontal area [Figure 1] and one patient (10%) had tonsure pattern of hair loss. Four patients agreed to knowingly pulling of hair, and one patient (10%) gave a history of eating them (trichophagia). The most common trichoscopic pattern observed in all patients was decreased hair density and hairs broken at different lengths (100%) [Figure 2].
Figure 1: Diffuse alopecia on the frontal area as a result of hair pulling. Excoriations are also seen on the forehead

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Figure 2: Trichoscopy showing decreased hair density, trichoptilosis (yellow arrows), tulip hairs (red arrows) and perifollicular whitish areas (red stars)

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Short hair with trichoptilosis ("split ends") [Figure 2], [Figure 3], [Figure 4] and [Figure 5], irregular coiled hairs [Figure 3] and upright re-growing hairs were demonstrated in 8 patients (80%) each. The novel diagnostic signs like black dots and flame hair [Figure 4], v-sign [Figure 3], follicular hemorrhages [Figure 5] were observed in 3 patients (30%) each. Tulip hair and hair powder [Figure 6] patterns were observed in 1 (10%) patient each. All patients (100%) had the noninflammatory alopecia with follicles having distorted and collapsed inner root sheath [Figure 7] in histopathology. Three patients (30%) showed trichomalacia [Figure 8].
Figure 3: Trichoscopy showing coiled hairs (red arrows) and v-hairs or v-sign (yellow arrows)

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Figure 4: Trichoscopy showing flame hairs (red arrows) and black dots (yellow arrows)

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Figure 5: Trichoscopy showing decreased hair density, follicular hemorrhage (black arrow) and trichoptilosis (red arrows)

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Figure 6: Trichoscopy showing tulip hairs (red arrows) and hair powder (yellow arrows)

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Figure 7: Histopathology showing diffuse, noninflammatory alopecia, missing hair shafts (black stars) and inward collapse of outer root sheath (black arrows). Few unaffected follicles are also seen (yellow arrows) (H and E, ×4)

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Figure 8: Histopathology showing an irregular, deformed and pigmented shaft characteristic of trichomalacia (H and E, ×40)

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   Discussion Top

Trichotillomania is a chronic impulse control disorder characterized by repetitive hair pulling resulting in alopecia. [2] In young children, it is usually a habit that resolves spontaneously or with minimal treatment. In older age groups, adolescents and adults, seen predominantly in females and evidence of some form of psychological or behavioral stress is often apparent. [3] The favorite site is the easily reached fronto-parietal region of the scalp followed by eyelashes, eyebrows, pubic hair, body hair and facial hair. This results in patchy loss of hair, often in a bizarre or angular pattern, in which the hairs are twisted and broken at various distances from the clinically normal scalp. [1,2] A hairball, trichobezoar, is a rare accompaniment of TTM in those who also eat the plucked hair (trichophagia). [4] In our study, most of the patients belonged to adolescent, and middle age group and most of them were females. All of them presented with patchy hair loss over the scalp, none of the patients gave a history of hair loss in other areas. Only one patient had a history of eating of pulled hairs, but there were no signs and symptoms of trichobezoar in her.

The diagnosis of TTM is often difficult as other hair loss diseases appear similar in clinical manifestations. This difficulty is encountered especially with alopecia areata (AA). As TTM often coexists with AA, the methodology enabling reliable detection of TT in AA needs to be developed. [5]

Trichoscopy is a novel diagnostic technique, both simple and noninvasive, can be used as a handy bed side tool for diagnosing common hair and scalp disorder. Several common trichoscopy features of TTM were identified. Decreased hair density, hairs broken at different lengths, short hairs with trichoptilosis ("split ends") are described in the literature as diagnostic of TTM. [6,7] Authors observed these findings in all the patients, and this is due to irregular and repetitive pulling of hairs leading to damage to the cuticle.

Irregular coiled hairs and upright re-growing hairs are also reported to be seen in TTM. [8,9] In this study, these findings were demonstrated in 80% of patients. Coiled hair results from hair shaft fracture and coiling of the remaining proximal part which is fixed to the scalp. Black dots are believed to be remnants of hair shafts arising from tapering hairs, broken hairs, and bent hairs. In a study conducted by Shim et al. black dots were observed in patients with TTM, AA, discoid lupus erythematosus. Therefore, black dots seem to be a nonspecific trichoscopic pattern in TTM. [10] Rakowska et al. observed that black dots tend to be uniform in size and shape in AA, whereas in TTM and tinea capitis they are variable in diameter and round, oval, irregular in shape. [11]

Peralta and Morais identified extravasations or hemorrhages as an additional trichoscopic feature of TTM. [12] Ise et al. described follicular microhemorrhage has a diagnostic sign in TTM. It presents as a red dot corresponding to follicular ostia capped or stuffed with the blood clot and suggests a history of traumatic forced plucking. [13] Authors could observe this pattern in 30% of patients in the present study.

Recently, flame hairs, v-sign, tulip hairs, and hair powder are described, and authors claim these signs are specific only for TTM. [11] Flame hairs are semi-transparent, wavy and cone-shaped hair residues, which develop as a result of severe mechanical hair pulling and shredding. V-sign is created when two or more hairs emerge from one follicular ostium, which are pulled simultaneously and break at the same length above scalp surface. Tulip hairs are short hairs with darker, tulip flower shaped ends. These hairs develop when a hair shaft fractures diagonally. When hair shafts are almost totally damaged by mechanical manipulation, only a sprinkled hair residue is visible. This finding is referred to as "hair powder." [11] In the present study, these trichoscopic patterns were demonstrated in variable frequency.

In AA, the common trichoscopic findings are yellow dots, uniform black dots, broken hair, trichoptilosis, upright re-growing hair, and vellus hair. [6,7] As some of the trichoscopic features are overlapping in TTM and AA, histopathology plays a corroborative role in definitive diagnosis. The histopathological features of TTM include empty follicles, incomplete disrupted follicular anatomy, trichomalacia, and pigment casts without significant inflammation. [14] Collapsed inner root sheath and missing hair shaft indicate the extraction of the hair follicle due to forcible hair pulling. Partially extracted and distorted root sheath material with fragments of pigment can be identified as "pigment cast" in the follicular lumen. The germinative follicular epithelium may produce abnormally formed, diminished and distorted hair shaft with irregular pigmentation as a result of trauma. This is referred to as trichomalacia. [15] This characteristic histopathological feature was observed in 3 patients in this study. A new trichoscopic pattern was observed by the authors in one patient, in the form of perifollicular whitish areas [Figure 2]. Authors believe these whitish areas represent hyperkeratosis that is due to perifollicular damage as a result of repeated hair pulling. However, this is a preliminary observation, further elucidation is required.

   Conclusion Top

Trichotillomania is often chronic and difficult to treat. Patients may attempt to disguise the condition due to its social implications. Hence, early diagnosis and treatment is necessary. Trichoscopy, being a noninvasive and in vivo diagnostic technique, can be utilized in this condition as it plays a vital role in the diagnosis of this condition by demonstrating specific trichoscopic patterns. Further studies on trichoscopic patterns correlating with duration of disease and histopathology of TTM are suggested.

   References Top

1.Messenger AG. Disorders of Hair. In: Burns T, Breathnach S, Cox N, Griffiths C, editors. Rook's Textbook of Dermatology. 8 th ed. Malden: Blackwell; 2010. p. 66.54.  Back to cited text no. 1
2.Sperling LC. Alopecias. In: Bolognia JL, Jorizzo JL, Rapini RP, editors. Dermatology. 2 nd ed. Spain: Mosby, Elsevier Limited; 2008. p. 987-1005.  Back to cited text no. 2
3.Dimino-Emme L, Camisa C. Trichotillomania associated with the "Friar Tuck sign" and nail-biting. Cutis 1991;47:107-10.  Back to cited text no. 3
4.Bouwer C, Stein DJ. Trichobezoars in trichotillomania: Case report and literature overview. Psychosom Med 1998;60:658-60.  Back to cited text no. 4
5.Trüeb RM, Cavegn B. Trichotillomania in connection with alopecia areata. Cutis 1996;58:67-70.  Back to cited text no. 5
6.Rudnicka L, Olszewska M, Rakowska A, Slowinska M. Trichoscopy update 2011. J Dermatol Case Rep 2011;5:82-8.  Back to cited text no. 6
7.Jain N, Doshi B, Khopkar U. Trichoscopy in alopecias: Diagnosis simplified. Int J Trichology 2013;5:170-8.  Back to cited text no. 7
8.American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 4 th ed. Washington, DC: American Psychiatric Association; 1994. p. 674-7.  Back to cited text no. 8
9.Abraham LS, Torres FN, Azulay-Abulafia L. Dermoscopic clues to distinguish trichotillomania from patchy alopecia areata. An Bras Dermatol 2010;85:723-6.  Back to cited text no. 9
10.Shim WH, Jwa SW, Song M, Kim HS, Ko HC, Kim BS, et al. Dermoscopic approach to a small round to oval hairless patch on the scalp. Ann Dermatol 2014;26:214-20.  Back to cited text no. 10
11.Rakowska A, Slowinska M, Olszewska M, Rudnicka L. New trichoscopy findings in trichotillomania: Flame hairs, V-sign, hook hairs, hair powder, tulip hairs. Acta Derm Venereol 2014;94:303-6.  Back to cited text no. 11
12.Peralta L, Morais P. Photoletter to the editor: The Friar Tuck sign in trichotillomania. J Dermatol Case Rep 2012;6:63-4.  Back to cited text no. 12
13.Ise M, Amagai M, Ohyama M. Follicular microhemorrhage: A unique dermoscopic sign for the detection of coexisting trichotillomania in alopecia areata. J Dermatol 2014;41:518-20.  Back to cited text no. 13
14.Muller SA. Trichotillomania: A histopathologic study in sixty-six patients. J Am Acad Dermatol 1990;23:56-62.  Back to cited text no. 14
15.Sperling LC, Cowper SE, Knopp EA, editors. Trichotillomania. In: An Atlas of Hair Pathology with Clinical Correlation. 2 nd ed. New York: CRC press; 2013. p. 60-6.  Back to cited text no. 15


  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8]

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