Persistent Disorders: Can You Identify the Cause?

Pruritic Plaque

A 37-year-old man presents with a large, pruritic, hyperpigmented, lichenified plaque on the left side of his upper back. He states that the lesion seems to have worsened over the past few months. The patient has mild hypertension and bipolar disorder for which he takes hydrochlorothiazide, 12.5 mg/d, and quetiapine, 400 mg/d, respectively.

What do you suspect is the cause of this rash?

(Answer on page 780.)

Hair Loss in a Child

A 7-year-old boy is brought for evaluation of a noninflammatory, nonscarring 3.5-cm area of alopecia in the right occipital region, which has been present for 6 months. The patient has a history of attention-deficit hyperactivity disorder.

To what do you attribute the hair loss?

(Answer on page 782.)

Pruritic plaque: This patient has lichen simplex chronicus, a type of neurodermatitis, or psychodermatosis, that results from habitual scratching of a pruritic area of skin. The pruritus can be precipitated by anxiety, depression, or stress. The scratching then causes the lichenification and further itching. This "itch-scratch-itch" cycle perpetuates the condition. The rash can persist for weeks or decades unless the cycle is stopped.

Some patients with lichen simplex chronicus have a history of emotional or psychiatric problems. This patient's history of bipolar disorder was a contributing factor. However, for most, the rash is simply the result of a nervous habit.

The diagnosis is typically clinical; biopsy is nonspecific and shows chronic dermatitis. A rash that is located within the patient's reach is a clue to the diagnosis.

Treatment can be difficult, especially if the patient has poor insight into the nature and cause of the eruption. Topical corticosteroids used with occlusion and intralesional corticosteroids are helpful. Anxiolytic and antidepressant therapy or psychotherapy also may play a role.

This patient was given a prescription for flurandrenolide tape, which serves 2 purposes. The corticosteroid in the adhesive helps reduce inflammation and pruritus, and the tape protects the area from further scratching.

(Case and photographs courtesy of Robert Levine, DO.)

Hair loss in a child: Examination with a magnifying glass reveals a round patch of hair loss with broken hairs of different lengths--a common presentation of trichotillomania. The father, and sole caregiver, reports that his son rarely stands or sits still for more than a minute, is often anxious, and frequently "pulls his hair when he has nothing to do."

Children with trichotillomania repeatedly twist and pull their hair until it breaks off. Generally, the hair pulling is done in private, and children deny this behavior when questioned.

The degree of hair loss varies from small, thin, undetectable round patches to complete baldness. The scalp is the most common site; however, eyelashes and eyebrows may be involved. Trichotillomania affects children 7 times more often than adults and occurs twice as often in girls as in boys. The cause of trichotillomania is unclear. Emotional stress, depression, anxiety, and family relationship problems may play a role. In some cases, hair pulling is a bad habit that has developed over time.

History and physical examination findings are usually sufficient for diagnosis. Irregular patches of hair and incomplete, nonscarring, noninflammatory alopecia are typical findings. Microscopic examination of a potassium hydroxide preparation may be needed to rule out tinea capitis. In questionable cases, biopsy may be helpful. Specimens may show pigmented follicular casts, increased density of noninflamed catagen hair, and traumatized hair follicles.

There is no single effective treatment of trichotillomania in children. Several researchers recommend psychological therapies, including psychotherapy, hypnosis, behavioral therapy, stress-reduction therapy, and cognitive therapy, as first-line. Use of selective serotonin reuptake inhibitors (eg, sertraline, fluvoxamine, and fluoxetine) has shown some efficacy in certain patients.

(Case and photograph courtesy of Charles C. Tran, DO, MBA.)

References:

FOR MORE INFORMATION:

• Fitzpatrick TB, Johnson RA, Wolff K, et al. Color Atlas & Synopsis of Clinical Dermatology. 4th ed. New York: McGraw-Hill; 2001:36-38.
• Lookingbill DP, Marks JG. Principles of Dermatology. 3rd ed. Philadelphia: WB Saunders Co; 2000:145-147.
• Ellis CR, Zumpfe HJ. Anxiety disorder: trichotillomania. [eMedicine.com Inc Web site.] October 22, 2003. Available at: http://www.emedicine.com/ped/ topic2298.htm. Accessed April 27, 2005.
• Fitzpatrick JE, Aeling JL, eds. Dermatology Secrets in Color. 2nd ed. Philadelphia: Hanley & Belfus, Inc; 2000.
• Gupta MA, Guptat AK. The use of antidepressant drugs in dermatology. J Eur Acad Dermatol Venereol. 2001;15:512-518.
• Ihm CW. Trichotillomania. [eMedicine.com Inc Web site.] August 28, 2002. Available at: http://www.emedicine.com/derm/topic433.htm. Accessed April 27, 2005.
• Odom RB, James WD, Berger TG. Andrews' Disease of the Skin. 9th ed. New York: WB Saunders Co; 2000.
• Palmer CJ, Yates WR, Trotter L. Childhood trichotillomania. Successful treatment with fluoxetine following an SSRI failure. Psychosomatics. 1999;40:526-528.