Dr. Antonio Alvi Armani

Trichotillomania and hair loss among children

Hair loss among children can occur as a result of a common, but usually unrecognized, behavioural disorder known as trichotillomania, where hair loss is a side effect of the condition.  It manifests itself as uncontrollable hair pulling, similar to impulsive disorders such as pyromania or kleptomania.  The disorder usually presents itself in males at the age of 8 and in females at the age of 12 and has a prevalence of about 1%.

Sufferers of trichotillomania generally spend about an hour per day pulling their hair out, for a few seconds or minutes, or for prolonged periods of time.  Some may try to resist the urge, but some are unaware of its occurrence, pulling hair absent-mindedly while driving, reading or watching television.  Many also engage in oral behaviour while pulling as well, such as touching the lip.  Another occurrence associated with trichotillomania is trichophagy, where the patient eats the hair, resulting in the development of bezoars (hair balls) in the stomach and small intestine.

While the disorder itself is a stressful and complicated condition, the hair loss that may result is an unfortunate, additional complication that affects many children and teenagers psychologically and emotionally.  The hair loss that occurs is usually focused on the scalp, but also occurs among the eyebrows, lashes and pubic region.  Hair loss is usually patchy, irregularly shaped and occurs predominantly on the side of the body that coincides with the person’s predominant hand.  Most sufferers of trichotillomania try to hide their hair loss, prolonging diagnosis and complicating treatment.

A significant side effect of this disorder is the loss of self-esteem and compromised social development.  A child or teenager coping with this disorder is likely to feel embarrassed or ashamed of the habit.  Furthermore, most parents misinterpret the condition as bad behaviour, responding with criticism, anger and punishment.  It is important that all family members are educated in the disorder and are involved in the treatment. 

Treatment for trichotillomania includes behaviour therapy and/or medication.  Possible drugs may include clomipramine, sertraline, citalopram, paroxetene, venflaxafine, naloxone, as well as mood stabilizers, anxiolytics (drugs that work on the central nervous system to relieve anxiety), neuroleptics (also known as antipsychotics) and topical agents including steroids. 

However, behavioural therapy has been found to be superior to drug therapy, especially if the hair pulling has only been occurring for less than six months, and because there is as of yet no clear guidelines for how drugs should be used to treat trichotillomania.  One of the most effective types of behavioural therapy is ‘habit-reversal-training’.  This method involves the patient identifying common patterns in the hair pulling including what triggers the urge.  The patient can then anticipate when the urge is about to occur and can take steps to prevent it.  To do so, he or she performs a competing response, such as tightening the fist, which should interrupt the urge to pull their hair.

With help, sufferers of this behavioural disorder, and its subsequent hair loss, can slowly but surely overcome the condition.  If it is taken under control, further hair loss can be prevented and the child or teenager can resume their normal lives without worry of uncontrollable urges or hair loss.

- Gerstein, Betty F., M.D. “Trichotillomania: A hair-raising dilemma”.  Patient Care Canada.  Vol. 17, No. 2.  February 2006.  pp. 27-34.