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The Band-Aid Sign of Trichotillomania: A Helpful Diagnostic Technique in the Setting of Hair Loss

The Band-Aid Sign of Trichotillomania: A Helpful Diagnostic Technique in the Setting of Hair Loss Indeed I think that the men who pluck out their hairs do what they do without knowing what they do. Epictetus, The Discourses, 3:1, 101 AD Historically, self-inflicted hair loss, or trichotillomania, was first recognized and named by François Henri Hallopeau, a French dermatologist who combined 3 Greek words to describe this condition: thrix (hair), tillein (pulling), and mania (madness).1 Patients with trichotillomania, a neuropsychiatric disorder classified by Diagnostic and Statistical Manual of Mental Disorders (Fourth Edition) criteria, are not always cognizant of their hair-pulling habits and may seek a medical “cure” from dermatologists. Clinic visits can be difficult and lengthy while the physician tries to obtain the history, confirm the diagnosis, and convince the patient of the underlying psychiatric disorder. We report herein a case demonstrating a practical method to confirm the diagnosis of trichotillomania and help the patient understand the extrinsic nature of this condition. Report of a Case A tearful 45-year-old woman with depression presented for evaluation of a 2-year history of hair loss that began after a thermal burn suffered while she was lighting a cigarette over a gas stove. Since that event, she reported persistent hair loss. She admitted to wax epilation of her frontal hairline to “even out” the affected areas but insisted that this was unrelated to the alopecia on her temporal scalp. Physical examination revealed nonscarring alopecia in a frontal and ophiasis pattern with few broken hairs, sparse regrowth, and intact follicular openings. Unaffected surrounding areas of hair were dense. Hair-pull test results were negative. Her eyelashes and eyebrows were normal. A 4-mm punch biopsy specimen was taken from the left temporal scalp, and the patient was instructed to cover the wound site with a small bandage until her follow-up appointment. At her 2-week follow-up appointment, the patient was emotional and continued to complain of hair loss. After removal of a linear Band-Aid–type bandage (Johnson & Johnson, New Brunswick, New Jersey), examination revealed the biopsy scar with a surrounding patch of normal hair in the distribution of the bandage (Figure 1). Histopathologic examination demonstrated trichomalacia, pigment within hair shafts, and empty hair follicles. A diastase-digested periodic acid–Schiff staining was negative for fungi (Figure 2). These findings were consistent with traction alopecia, such as trichotillomania. Figure 1. View LargeDownload “Band-Aid sign” demonstrating a linear patch of hair regrowth 2 weeks after punch biopsy corresponding to the area of bandage placement. Figure 2. View LargeDownload Histopathologic findings demonstrating trichomalacia, pigment within hair shafts, and empty hair follicles consistent with trichotillomania (hematoxylin-eosin, original magnification ×10 [A] and ×60 [B]). Comment While clinical findings can be suggestive of trichotillomania, diagnostic confirmation remains difficult, particularly when patients refuse to believe the problem is self-inflicted. Although punch biopsy results can be informative, the finding of pigmented hair casts is not specific and can also be seen in traction alopecia. Recently, dermoscopy has been used to illuminate the otherwise not-visible broken hair shafts on examination with polarized light to assist in the diagnosis.2 Band-Aid–type bandages, however, offer a simple means to prevent hair pulling, and consequently demonstrate trichotillomania by stimulus control. Similar to a method used by psychiatrists in which the thumbs of patients are covered by bandages to interfere with the ability to grip the hair, this case demonstrates the utility of placing a semipermanent bandage over the affected site to shield against patient-induced hair pulling, allowing normal hair to regrow. The resulting “Band-Aid sign” provides a noninvasive method to hone in on the diagnosis of trichotillomania and to assist in counseling patients about the self-induced nature of the condition. Correspondence: Dr Mahlberg, Ronald O. Perelman Department of Dermatology, New York University Medical Center, 560 First Ave, Ste H-100, New York, NY 10016 (mahlberg@alumni.med.upenn.edu). Financial Disclosure: None reported. References 1. Hautmann GHercogova JLotti T Trichotillomania. J Am Acad Dermatol 2002;46 (6) 807- 826PubMedGoogle ScholarCrossref 2. Lee DYLee JHYang JMLee ES The use of dermoscopy for the diagnosis of trichotillomania. J Eur Acad Dermatol Venereol 2009;23 (6) 731- 732PubMedGoogle ScholarCrossref http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Archives of Dermatology American Medical Association

The Band-Aid Sign of Trichotillomania: A Helpful Diagnostic Technique in the Setting of Hair Loss

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Publisher
American Medical Association
Copyright
Copyright © 2010 American Medical Association. All Rights Reserved.
ISSN
0003-987X
eISSN
1538-3652
DOI
10.1001/archdermatol.2010.230
Publisher site
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Abstract

Indeed I think that the men who pluck out their hairs do what they do without knowing what they do. Epictetus, The Discourses, 3:1, 101 AD Historically, self-inflicted hair loss, or trichotillomania, was first recognized and named by François Henri Hallopeau, a French dermatologist who combined 3 Greek words to describe this condition: thrix (hair), tillein (pulling), and mania (madness).1 Patients with trichotillomania, a neuropsychiatric disorder classified by Diagnostic and Statistical Manual of Mental Disorders (Fourth Edition) criteria, are not always cognizant of their hair-pulling habits and may seek a medical “cure” from dermatologists. Clinic visits can be difficult and lengthy while the physician tries to obtain the history, confirm the diagnosis, and convince the patient of the underlying psychiatric disorder. We report herein a case demonstrating a practical method to confirm the diagnosis of trichotillomania and help the patient understand the extrinsic nature of this condition. Report of a Case A tearful 45-year-old woman with depression presented for evaluation of a 2-year history of hair loss that began after a thermal burn suffered while she was lighting a cigarette over a gas stove. Since that event, she reported persistent hair loss. She admitted to wax epilation of her frontal hairline to “even out” the affected areas but insisted that this was unrelated to the alopecia on her temporal scalp. Physical examination revealed nonscarring alopecia in a frontal and ophiasis pattern with few broken hairs, sparse regrowth, and intact follicular openings. Unaffected surrounding areas of hair were dense. Hair-pull test results were negative. Her eyelashes and eyebrows were normal. A 4-mm punch biopsy specimen was taken from the left temporal scalp, and the patient was instructed to cover the wound site with a small bandage until her follow-up appointment. At her 2-week follow-up appointment, the patient was emotional and continued to complain of hair loss. After removal of a linear Band-Aid–type bandage (Johnson & Johnson, New Brunswick, New Jersey), examination revealed the biopsy scar with a surrounding patch of normal hair in the distribution of the bandage (Figure 1). Histopathologic examination demonstrated trichomalacia, pigment within hair shafts, and empty hair follicles. A diastase-digested periodic acid–Schiff staining was negative for fungi (Figure 2). These findings were consistent with traction alopecia, such as trichotillomania. Figure 1. View LargeDownload “Band-Aid sign” demonstrating a linear patch of hair regrowth 2 weeks after punch biopsy corresponding to the area of bandage placement. Figure 2. View LargeDownload Histopathologic findings demonstrating trichomalacia, pigment within hair shafts, and empty hair follicles consistent with trichotillomania (hematoxylin-eosin, original magnification ×10 [A] and ×60 [B]). Comment While clinical findings can be suggestive of trichotillomania, diagnostic confirmation remains difficult, particularly when patients refuse to believe the problem is self-inflicted. Although punch biopsy results can be informative, the finding of pigmented hair casts is not specific and can also be seen in traction alopecia. Recently, dermoscopy has been used to illuminate the otherwise not-visible broken hair shafts on examination with polarized light to assist in the diagnosis.2 Band-Aid–type bandages, however, offer a simple means to prevent hair pulling, and consequently demonstrate trichotillomania by stimulus control. Similar to a method used by psychiatrists in which the thumbs of patients are covered by bandages to interfere with the ability to grip the hair, this case demonstrates the utility of placing a semipermanent bandage over the affected site to shield against patient-induced hair pulling, allowing normal hair to regrow. The resulting “Band-Aid sign” provides a noninvasive method to hone in on the diagnosis of trichotillomania and to assist in counseling patients about the self-induced nature of the condition. Correspondence: Dr Mahlberg, Ronald O. Perelman Department of Dermatology, New York University Medical Center, 560 First Ave, Ste H-100, New York, NY 10016 (mahlberg@alumni.med.upenn.edu). Financial Disclosure: None reported. References 1. Hautmann GHercogova JLotti T Trichotillomania. J Am Acad Dermatol 2002;46 (6) 807- 826PubMedGoogle ScholarCrossref 2. Lee DYLee JHYang JMLee ES The use of dermoscopy for the diagnosis of trichotillomania. J Eur Acad Dermatol Venereol 2009;23 (6) 731- 732PubMedGoogle ScholarCrossref

Journal

Archives of DermatologyAmerican Medical Association

Published: Sep 1, 2010

Keywords: alopecia,bandages,trichotillomania

References