Sir,
Trichotillomania is an obsessive–compulsive related disorder characterized by irresistible urges to pull out hair, resulting in secondary alopecia and functional impairment.[1] Trichotillomania can affect any body area, although exclusive involvement of the pubic area is very infrequent. Trichotillomania is a major psychiatric disorder,[1] even though many patients may consult a dermatologist rather than a psychiatrist. Here, we present the case of a young woman with trichotillomania affecting exclusively the pubic area and who showed a good response to N-acetylcysteine and behavioral therapy.
An otherwise healthy 23-year-old woman presented with hyperpigmentation and hair loss on the pubic area of 3 years’ duration. Physical examination revealed patchy alopecia, scattered short hairs of varying length, follicular hyperkeratosis, and hyperpigmentation on the pubic area [Figure 1]. Dermoscopy showed broken hairs of different sizes, multiple black dots, and a V-sign. The hair pull test was negative. Laboratory tests including complete blood count, biochemical parameters, thyrotropin, antithyroid peroxidase antibodies, and potassium hydroxide preparation were normal or negative. After exhaustive questioning, the patient admitted pubic hair pulling since participating in a beauty pageant. The disorder worsened during stressful events. A psychiatric examination was requested and confirmed the diagnosis of trichotillomania together with mild depressive episodes. Behavioral therapy and N-acetylcysteine 1200 mg/day were initiated. Dosage was increased after 4 weeks to 1800 mg/day, and complete response was observed after 12 weeks of treatment. The patient did not present recurrences during 6 months of follow-up.
Figure 1.
Pubic trichotillomania. Patchy alopecia, scattered short hairs of varying length, erythema, follicular hyperkeratosis, and hyperpigmentation on the pubic area
Trichotillomania affects 0.5%–3% of the general population and is more common in women. Exclusive involvement of the pubic area has been reported in only 2%–5% of cases. However, pubic trichotillomania may be underreported: a recent study described pubic hair pulling in more than 40% of patients with trichotillomania when a nonpresential interview was carried out, suggesting that feelings of shame may lead to underreporting in face-to-face interviews.[1] Trichotillomania symptoms typically initiate in early adolescence and can cause a severe impact on the patient's quality of life, interfering with sentimental relationships, studying/working, and social life. Patients may present with low self-esteem, high social anxiety, a history of substance abuse, and major depressive disorders. Trichotillomania is often a chronic condition with a mean illness duration of 21.9 years, and less than 30% of patients seek psychiatric treatment.[2]
The diagnosis of trichotillomania remains challenging and is established on clinical, dermoscopic, and histopathological features. Dermoscopy can be useful and may reduce the need for biopsy. Trichotillomania management is difficult. There is no medication universally accepted as first-line treatment. N-acetylcysteine is a glutamate-modulating agent which has shown positive results (1200–2400 mg/day) with only mild side effects.[3] Other options include clomipramine (tricyclic antidepressant) and olanzapine (antipsychotic). There is no high-quality evidence to support the use of fluoxetine, lamotrigine, inositol, or naltrexone.[4] Among the nonpharmacologic therapies, habit reversal therapy has shown good responses in eight randomized clinical trials.[5]
Pubic trichotillomania may be more frequent than previously thought. Dermatologists may be the first health providers to be consulted, and a thorough anamnesis and clinical examination should be performed.
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
Nil.
Conflicts of interest
There are no conflicts of interest.
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