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Chronic Alopecia

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									Chronic             Alopecia
Johnson Clark, Jr, MD,Thomas N. Helm, MD, Wilma F.           Bergfeld, MD,
The Cleveland (Ohio) Clinic Foundation (Contributors);
Antoinette F. Hood, MD (Section Editor)




                 REPORT OF A CASE                                to about 1 cm in length. There was no evidence of skin
                                                                 scaling, erythema, atrophy, or crusting on the scalp. Nor-
A  27-year-old well-nourished, anxious woman pre-                mal hair completely surrounded this alopecia. Eye-
sented with a 6-year history of hair loss. She reported no       brows and eyelashes were normal. The skin on the rest
significant medical problems and took no medications             of her body and inner fingernails was unremarkable. A
or extra vitamins. She had normal and regular men-               biopsy specimen was obtained. Histologic findings are
strual periods. She described her mother and aunt as hav-        shown in Figure 3 and Figure 4.
ing thinning hair and her father as having male pattern               What is your diagnosis?
baldness.
      The physical examination revealed a large irregu-
lar area of alopecia on the vertex and crown of her head
(Figure 1 and Figure 2) with some residual hairs up




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DIAGNOSIS: Trichotillomania.                                       and the usual anagen-to-telogen ratio of four to one
                                                                   may be reversed.2·10
           HISTOPATHOLOGIC FINDINGS                                      Other findings may include numerous empty fol¬
                                                                   licles, intraepithelial as well as perifollicular hemor¬
A diagnostic hair pluck revealed only anagen hairs. A              rhage, dilated follicular infundibula with horny plugs, hair
4-mm punch biopsy specimen of the scalp revealed a re¬             fiber granulomata, and abnormal corkscrewlike shapes
versal of the anagen-telogen ratio with an increased num¬          of hair shafts. Although there are many signs of trauma,
ber of catagen hairs, pigment casts within a follicle, and         alopecia is not evident histologically.5·9
several hair granulomata.                                                Areas of recent hair loss may demonstrate the most
                                                                   characteristic features, but many serial sections may need
                     DISCUSSION                                    to be examined.5 The absence of perifollicular lympho-
                                                                   cytic infiltrate on biopsy helps to exclude alopecia, and
Trichotillomania is a traumatic hair loss caused by the            the absence of numerous vellus hairs helps to exclude
irresistible urge to pluck out one's hair. It is not an un¬        androgenic alopecia, although sometimes a "mixed pic¬
common habit in children and is usually considered be¬
                                                                   ture" is seen when these disorders occur in conjunction
                                                                   with trichotillomania.
nign, similar to thumb-sucking. In adults, however, it can               An alternate technique to biopsy that allows for di¬
be a serious condition that may lead to permanent alo¬
pecia and may signal an underlying psychiatric condi¬              agnosis is to shave a part of the involved area and watch
tion.1·2                                                           for the regrowth of normal hair.3
                                                                         Treatment is difficult. Affected children can
      Trichotillomania   can   clinically   mimicalopecia          sometimes learn to stop their habit after discussions
areata, androgenic alopecia,   tineacapitis, monilethrix,          from the physician and parents.2 Adults are much
pili torti, pseudopalade of Brocq, as well as forms of             more resistant to persuasion. Some may respond to
traumatic baldness (ie, traction alopecia). It can mimic
                                                                   behavioral modification techniques or hypnosis. Oth¬
alopecia due to systemic diseases such as endocrinopa-             ers may require antidepressant medications, particu¬
thy, lymphoma, systemic lupus erythematosus, nutri¬
tional deficiency, and syphilis.1"4 The average derma¬             larly if there is an underlying psychiatric disorder that
                                                                   would respond to this medication. Tricyclic antide-
tologist may see only a few cases of trichotillomania
yearly.2 These patients are particularly challenging               pressants have been used with some success. A study
because they may deny plucking. The characteristic                 in 1989 found clomipramine to be superior to desipra-
                                                                   mine in trichotillomania.11 Müller1 feels a psychiatric
physical presentation, negative medical work-up, and               consultation should be obtained if there is a major
biopsy findings are useful guides in its diagnosis.                cosmetic impairment. In prescribing some tricyclic
There is a wide range in age of presentation, from pre¬
schoolers to old age. In preschoolers, the numbers of              drugs, caution is advised in patients with known car¬
                                                                   diovascular disease or risk of suicide. There are also a
boys and girls are similar, but above this age group,
there is a marked female predominance. The largest                 variety of neuropsychiatrie as well as somatic anticho-
single group is girls 11 to 17 years old.5                         linergic side effects.11
      A classic presentation is a tonsure or "Friar Tuck"
form of vertex and crown alopecia with peripheral spar¬            Selected from Arch Dermatol. 1995;131:719-724.                                   Off-
                                                                   Center Fold.
ing.3 Any other pattern of alopecia can be seen, from ill-
defined patches to a linear or wedge shape. Onychopha-
gia (nail biting) is common as is eyebrow and eyelash                                               REFERENCES
plucking.
    Rarely, the patient will swallow enough hair to cause           1. Muller S. Trichotillomania. Dermatol Clin. 1987;5:595-601.
                                                                    2. Mehregan A. Trichotillomania. Arch Dermatol. 1970;102:129-133.
trichobezoars that may lead to gastrointestinal obstruc¬
                                                                    3. dimino-Emme L, Camisa C. Trichotillomania associated with the 'Friar Tuck
tion.6
                                                                       sign' and nail biting. Cutis. 1991;47:107-110.
      A trichogram may demonstrate a complete lack of               4. Slagle D, Martin T. Trichotillomania. Am Fam Pract. 1991;43:2019-2024.
telogen hairs because these have been selectively                   5. Muller S. Trichotillomania. J Am Acad Dermatol. 1990;23:56-62.
pulled out.                                                         6. Steck W. The clinical evaluation of pathologic hair loss. Cutis. 1979;24:293\x=req-\
     A scalp biopsy     is often helpful in diagnosing                 301.
                                                                    7. Bergfeld WF. Noninflammatory reactions of the pilosebaceous unit and disor-
trichotillomania and eliminating other causes of alope¬                ders of the hair shaft. In: Farmer ER, Hood AF, eds. Pathology of the Skin.
cia. Characteristic features of trichotillomania include               East Norwalk, Conn: Appleton & Lange; 1990:941-943.
traumatized hair follicles with perifollicular hemor¬               8. Mehregan AH. Lesions of the hair and nail. In: Mehregan and Pinkus' Guide to
rhage, fragmented hair fibers in the dermis, and                       Dermatohistopathology. 4th ed. East Norwalk, Conn: Appleton & Lange; 1986:
                                                                       621.
deformed hair shafts (trichomalacia) that may have a                9. Muller S, Winkleman R. Trichotillomania. Arch Dermatol. 1972;105:535-540.
ruffled appearance.5,7"9 Follicular ectasia may be noted           10. Bergfeld W. Alopecia. Adv Dermatol. 1989;4:301-322.
along with melanin pigment casts and granules.1·2·3'7,9            11. Swedo S, Leonard H. A double-blind comparison of clomipramine and desip-
The number of catagen follicles is typically increased,                ramine in the treatment of trichotillomania. N Engl J Med. 1989;321:497-501.




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