92 International J ournal of Trichology / J ul-Dec 2011 / Vol-3 / Issue-2

INTRODUCTION
T
richotillomania is classifed by the American Psychiatric
Association Diagnostics and Statistics Manual for
Mental Health Disorders, Fourth Edition (DSM-IV)
[1]
as
an impulse-control disorder with recurrent hair pulling and
occurs with a prevalence of 0.6-1.6% if strict DSM-IV
criteria are applied.
[2]
Itch and infammation as a consequence of damaged
hair from plucking can lead to pseudofolliculitis.
[3]
This
is often seen in women who shave or wax the hair of
the legs, axillae and pubic region. We describe for the
frst time pseudofolliculitis occurring in trichotillomania.
The pseudofolliculitis becomes an organic reason for
scalp itch and discomfort, and contributes further to the
vicious itch-scratch cycle in trichotillomania. We outline
the clinical presentation of trichotillomania-associated
pseudofolliculitis, the approach to diagnosis and the
management of these individuals.
PATIENTS AND METHODS
We report fve patients with trichotillomania induced
pseudofolliculitis at the National Skin Centre, Singapore
Address for correspondence:
Dr. Hazel H Oon,
National Skin Centre,
1, Mandalay Road,
Singapore.
E-mail: hazeloon@nsc.gov.sg
Original Article
Treatment of Pseudofolliculitis in
Trichotillomania improves Outcome
Hazel H Oon, Joyce SS Lee
Department of Dermatology, National Skin Centre, Singapore
ABSTRACT
Trichotillomania is an impulse-control disorder. The underlying psychiatric comorbidity
or functional impairment is well recognized by clinicians. Patients with trichotillomania
pull their scalp hairs, resulting in damaged, distorted hair follicles, and broken hair shafts
within the skin. The local irritation and infammation resulting from reaction to the broken,
impacted hair shafts and malaligned regrowing hair can lead to pseudofolliculitis, much the
same as a patient who waxes or shaves her legs gets itchy papules of pseudofolliculitis.
Pseudofolliculitis becomes an organic reason for scalp itch and discomfort, and contributes
further to the vicious cycle of itch and scratching in trichotillomania. This phenomenon
has not been well documented. Treatment of trichotillomania would be more effective
if the pseudofolliculitis component is addressed. We describe a series of patients with
trichotillomania and pseudofolliculitis. These patients improved after topical steroid therapy,
topical or oral antibiotics. Hair regrowth was also visibly better, with patients reporting
improvement of symptoms of itch. All these patients were not placed on antidepressants
nor antipsychotics.
Key words: Hair disorders, pseudofolliculitis, therapy, trichotillomania
Access this ar ticle online
Website:
www.ijtrichology.com
DOI:
10.4103/0974-7753.90813
Quick Response Code:
over a period of 3 years (2007 to 2010). This study was
reviewed and approved by the local ethics review board.
We document the features, treatment, and clinical outcomes
of these fve patients.
RESULTS
Patient 1
A 7-year-old Chinese girl presented with two months
duration of trichotillomania and intractable scalp itch
arising from the site of the hairloss. She pulled and pressed
her hair to relieve the itch. Clinical examination showed an
area of hairloss consistent with trichotillomania, with an
excoriation adjacent to a papule [Figure 1a]. She was advised
not to pull her hair, and responded to betamethasone 0.1%
scalp lotion, erythromycin 2% solution, and cetrimide
shampoo to treat the pseudofolliculitis.
Patient 2
This 13-year-old Chinese female complained of itch and
hairloss for 6 months. Scalp papules, coiled and twisted
ingrowing hairs associated with bizarre areas of hair loss
were noted on closer examination [Figure 1b]. Apart
International J ournal of Trichology / J ul-Dec 2011 / Vol-3 / Issue-2 93
from advice to cease pulling her hair, oral erythromycin,
clobetasol scalp lotion, and selenium sulphide shampoo
improved the scalp itch and lead to resolution of the
papules one month later.
Patient 3
This 18-year-old Indian male with fve years duration of
hairloss, scalp itch and papules pulled his hair to relieve the
tension of a stressful relationship with his grandmother.
On examination, there were irregularly shaped areas of hair
loss associated with follicular papules. After three months
of treatment with betamethasone and clindamycin 1%
solutions, there was decrease in scalp itch with good regrowth
of hair at the vertex and left parietal regions [Figure 2].
Patient 4
An 18-year-old Malay female presented with hairloss for
six months. Although she readily admitted to an urge to
manipulate her hair when under stress from school work and
habitually tugging her hair while studying, a complaint of
itch was only elicited during her second consult when scalp
papules were discovered at the sites of alopecia. The patient
herself was unaware of the papules and did not associate
them with the scalp itch. She fulflled the DSM-IV criteria
for trichotillomania. A review at the National Skin Centre
psychodermatology clinic was offered but she declined.
Together with advice against hair pulling, doxycycline
100 mg twice daily for 6 weeks lead to less scalp papules,
decrease in scalp itch and improvement in hair regrowth.
Patient 5
This 46-year-old Malay woman was previously described with
a variant of trichotillomania termed leucotrichotillomania.
[4]

This refers to the selective pulling of white hairs. She
enlisted the help of family members and mirrors to assist
her in plucking the unsightly white hairs. Hair pulling
behaviour started 16 years prior when she developed white
hairs after child birth, but became more problematic of late
over the last 3 years when she developed more white hairs.
Figure 1: (a) Excoriated scalp papules at the sites of non-scarring
alopecia induced by trichotillomania (b) Distorted and inwardly curving
hairs of pseudofolliculitis
Figure 2: (a) Treatment of pseudofolliculitis with betamethasone and
clindamycin lotion resulting in objective improvement of alopecia.
Appearance at initial consultation (b) Appearance three months after
treatment
Oon and Lee: Treatment of pseudofolliculitis in trichotillomania improves outcome
b
a
b
a
94 International J ournal of Trichology / J ul-Dec 2011 / Vol-3 / Issue-2
The short, stubby regrowth of white hairs caused itch. Her
pruritus was relieved by plucking the hairs and this lead to a
vicious cycle of hair pulling. Large bizarre patchy areas of
alopecia were noted over the vertex and bifrontal regions.
Histology revealed trichomalacia with pigment casts,
consistent with the clinical diagnosis of trichotillomania.
She declined a psychiatric review. Betamethasone scalp
lotion and coal tar shampoo relieved the scalp itch from
the ingrown hairs, while hair dyeing helped to make the
white hairs less visible and improve her compliance to
advice against pulling her hair.
The clinical characteristics and outcomes of our patients
is summarized in [Table 1].
DISCUSSION
The psychiatric comorbidities of trichotillomania have
been well documented.
[2,5-7]
These include obsessive
compulsive disorder, depression, and anxiety. This is the
frst case series describing pseudofolliculitis associated with
trichotillomania. We feel that this entity is under-recognised
by clinicians.
As the affected patients in our series ranged in age from
7 to 46 years and spanned three different races, the true
prevalence of pseudofolliculitis amongst patients with
trichotillomania is likely signifcant.
Identifying features included the presence of scalp pruritus,
papules, excoriations and in some cases, distorted and
ingrown hairs. However, not all patients (Case 4) were
forthcoming with their symptoms of itch; this same patient
also did not realise she had scalp papules. If left untreated,
patients can harbour symptoms for an extended period of
time as Case 3 and 5 illustrate, with considerable pruritus
and hairloss. It is noteworthy that these patients improved
on a simple regimen of topical steroid, antipruritic
shampoo, topical or oral antibiotics. None were placed
on psychotropic medications or seen by a psychiatrist.
However, patients were taught habit reversal techniques
and counseled on stress management strategies by
dermatologists in a centre with a psychodermatology unit.
The pathogenesis of trichotillomania is multifactorial and
complex.
[2,5,8]
Patients with trichotillomania pull their hairs
either due to a habit tic or an obsessive compulsive need
to relieve a perceived or inorganic source of follicular itch.
In certain cases, rubbing of the hair or trichoteiromania
[9]

may occur either in isolation or concurrently with
trichotillomania. Pseudofolliculitis develops as a result
of a foreign body reaction to the sharp ends of the new,
ingrown and coiled hairs.
[3]
While it is unclear whether
the infammatory scalp papules preceded or followed
from the hair pulling, we postulate that the inwardly
curving, regrowing hairs from repeated pulling incite
a local infammatory reaction, culminating in a vicious
cycle of itching, scratching, and pulling. Treating the
pseudofolliculitis that is secondary to the trichotillomania
or trichoteiromania would remove an additional source of
organic scalp itch, thereby allowing patients to concentrate
on behaviour modification techniques for treatment
of the trichotillomania itself. Prospective studies are
required to assess the prevalence, relapse rate, psychiatric
comorbidities, and long term prognosis of this condition.
CONCLUSION
Trichotillomania-induced pseudofolliculitis is a newly
described condition. Treatment of the pseudofolliculitis
with topical steroids, oral, or topical antibiotics improves
hair regrowth.
Table 1: Clinical details of the case series
Case no. Age (years), gender Symptoms Examination fndings Treatment Outcome
1 7F Scalp itch, needs to press
scalp far relief
9.5 cm al opecia, excoriation
adjacent to papule
Betamethasone and
erythromycin lotion,
cetrimide shampoo
Reduction of itch and
size of alopecia
2 13F Itch Alopeda with scalp papules,
coiled and twisted hairs
P0erythromycin, selenium
sulphide shampoo, clob
etasol lotion
Resolution of scalp
papules and itch
3 18M Scalp itch, papules, hair
pulling to relieve tension from
family stress
Alopecia with scalp papules Betamethasone and
clindamycin lotion
Clearing of scalp
papules, reduction of
alopecia
4 18M Itch Scalp papules within
alopecia
PO doxycycline Relief of itch
5 46F Itch and discomfort from new
hairs growing
Bizarre pattern of alopecia,
excoriated papules
Betamethasone lotion Relief of itch and
alopecia
F Female; M Male
Oon and Lee: Treatment of pseudofolliculitis in trichotillomania improves outcome
International J ournal of Trichology / J ul-Dec 2011 / Vol-3 / Issue-2 95
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Oon and Lee: Treatment of pseudofolliculitis in trichotillomania improves outcome
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How to cite this article: Oon HH, Lee J S. Treatment of
pseudofolliculitis in trichotillomania improves outcome. Int J
Trichol 2011;3:92-5.
Source of Support: Nil, Confict of Interest: None declared.
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