Trichotillomania in a Middle-Aged Man

Alopecia was noted on the right anterior scalp of a 53-year-old man who had been hospitalized for jaundice of 2 weeks' duration. The hairs in the affected area were broken off at various lengths (A). The patient, who was left-handed, repeatedly pulled individual hairs on his head; it was suspected that he occasionally swallowed them.He had a history of heavy alcohol consumption and end-stage liver disease.

During the hospital course, the patient complained of abdominal distention and pain. An abdominal radiograph revealed dilated loops of small bowel, consistent with small-bowel obstruction (B). Arun Swaminath, MD, of the University of California Medical Center in San Diego considered a trichobezoar as a possible cause of the obstruction. Failure of conservative management with nasogastric suction led to exploratory laparoscopy and enterotomy. A cause of the obstruction was not identified. The patient eventually died of multiorgan failure.

Trichotillomania is classified as an impulse-control disorder. The incidence is higher in alcoholic patients.^1,2 The patch of hair loss is typically on the side opposite the dominant hand and contains broken hairs of varying size.³

Trichophagia, which is sometimes associated with trichotillomania, can lead to the formation of a trichobezoar in the GI tract.The best way to identify and treat a bezoar is via upper endoscopy. An upper GI barium swallow can also identify a bezoar. Complications of trichobezoars include intestinal obstruction, gastric ulcer, and gastritis. Migration of a gastric bezoar distally leads to small-bowel involvement.⁴

Refer patients with trichotillomania to a psychiatrist for counseling, habit reversal therapy, and medical management.⁵ Selective serotonin reuptake inhibitors are the treatment of choice for these patients. *

References:

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Papadopoulos AJ, Janniger CK, Chodynicki MP, Schwartz RA. Trichotillomania.

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Erzurumlu K, Malazgirt Z, Bektas A, et al. Gastrointestinal bezoars: a retrospective analysis of 34 cases.

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Salaam K, Carr J, Grewal H, et al. Untreated trichotillomania and trichophagia: surgical emergency in a teenage girl.

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