New-onset trichotillomania in a 50-year-old patient

To the Editor

Trichotillomania presents with very early, early and late onset (>18 years) variants, among which the late onset variant is relatively uncommon (Flessner et al., 2010). Its management entails a detailed psychiatric evaluation, pharmacological and psychological interventions, and it is also associated with a higher incidence of complications (Sah et al., 2008). Herein, we present a case of new onset trichotillomania in a 50-year-old lady who was treated with selective serotonin reuptake inhibitors (SSRIs).

Mrs A who was diagnosed to have contact dermatitis and treated with prednisolone 20 mg and azathioprine 50 mg subsequently developed a large 14 × 20 cm² well-defined, bilaterally symmetrical patch of non-scarring alopecia involving the frontal and bilateral temporal aspect of the scalp with loss of eyebrow hair (Figure 1(a)). There was no active dermatitis over the alopecic area, and a scalp biopsy revealed normal ratio of anagen to telogen hairs and absence of any inflammatory infiltrate.

Figure 1.

(a) Well-defined, bilaterally symmetrical patch of non-scarring alopecia involving the frontal and bilateral temporal aspect of the scalp with loss of eyebrow hair. (b) Regrowth of hair over alopecic area following 6 months of treatment with fluoxetine.

Following referral and detailed evaluation by the psychiatry unit, she was diagnosed to have trichotillomania (F63.3) as per the International Statistical Classification of Diseases and Related Health Problems–10th Revision Diagnostic Criteria for Research (ICD-10 DCR) based on her report of an irresistible urge to pull her hair and a sense of intense albeit short-lasting relief upon doing so. She was prescribed fluoxetine up to a dose of 40 mg and over the past 6 months has shown marked improvement with re-growth of hair over the bald patch (Figure 1(b)).

There was no underlying psychiatric illness, seizures, other neurological disorders, substance use or intellectual impairment. There was also no past or family history of any mental disorder.

Trichotillomania typically starts in childhood or adolescence, and an onset this late is extremely rare (Flessner et al., 2010), with hair pullers who present at this age usually having a protracted course or other underlying psychiatric illnesses (Sah et al., 2008). While drugs like amphetamines have been associated with trichotillomania (Narine et al., 2013), there is no documented etiological role of steroids or immunosuppressants. It is possible that in this case, the stress associated with exacerbations of her dermatological condition and associated dysfunction may have contributed to the expression of a diathesis to develop the illness. This case underlines that a high index of suspicion for atypical presentations and prompt liaison referral services can lead to good outcomes.