False culprit

At the end of the consultation, while the dermatologist was writing up the clinical notes, the patient reached into her hair (photo 2) and pulled out a tuft, which joined a “ball” of hair (photo 3) previously removed in the same way, thus confirming trichotillomania.

Trichotillomania, defined as the compulsive habit of pulling out one’s own hair, is seven times more frequent in children than in adults. While its psychopathological origin is often absent in very young children, in whom it resembles a sleep ritual, it can have a more negative significance in older children and, as in our case, can occur in a context of anxious agitation or self-harm.

Diagnosis is sometimes difficult, as broken hairs, sometimes very short and of varying lengths, are not always easy to identify clinically. Dermoscopic examination can then provide evidence supporting this diagnosis: very short broken hairs at different lengths and microhemorrhages at the follicular openings.

• Drug-induced alopecia: Psychiatrists and parents are concerned about the iatrogenic nature of this alopecia and the need to discontinue and replace the psychotropic drug with another medication. Some psychotropic drugs and tricyclic antidepressants are responsible for abnormal hair loss, but this side effect has been described only once in the literature with the antipsychotic taken by the young patient, and its frequency is estimated at less than 0.01%.
   
• Diffuse alopecia areata: This is a rare form of alopecia (1%) that does not begin with patches but immediately involves the entire scalp, although not all hair follicles.
   
• Telogen effluvium: This is the most frequent cause of diffuse alopecia and it has a good prognosis, provided the cause is identified and treated. Our patient had no weight loss, iron deficiency or thyroid disorder.