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LETTER TO EDITOR
Year : 2013  |  Volume : 35  |  Issue : 4  |  Page : 425-427  

New avenues in management of trichotillomania


1 Department of Physiology, Gian Sagar Medical College and Hospital, Ram Nagar, Patiala, Punjab, India
2 Department of Psychiatry, Gian Sagar Medical College and Hospital, Ram Nagar, Patiala, Punjab, India
3 Department of Dermatology and Venereology, Gian Sagar Medical College and Hospital, Ram Nagar, Patiala, Punjab, India

Date of Web Publication27-Nov-2013

Correspondence Address:
Naveen Kumar Kansal
Department of Dermatology and Venereology, Gian Sagar Medical College and Hospital, Ram Nagar, Patiala 140 601, Punjab
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0253-7176.122252

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How to cite this article:
Chawla O, Singh GP, Kansal NK. New avenues in management of trichotillomania. Indian J Psychol Med 2013;35:425-7

How to cite this URL:
Chawla O, Singh GP, Kansal NK. New avenues in management of trichotillomania. Indian J Psychol Med [serial online] 2013 [cited 2020 Jun 3];35:425-7. Available from: http://www.ijpm.info/text.asp?2013/35/4/425/122252

Sir,

In 1889, Hallopeau coined the term trichotillomania, meaning a 'morbid craving to pull out one's hair'. [1] Trichotillomania is basically a primary psychiatric disorder with a typical dermatologic manifestation (alopecia). Originally, trichotillomania was classified as an impulse control disorder; however, it is now widely accepted that there is a possibility of a broad spectrum of additional psychopathology such as obsessive compulsive disorder (OCD), dysmorphophobia/body dysmorphic disorder, and mood disorders. [2],[3] Trichotillomania causes varying degrees of functional impairments, apart from significant hair loss/alopecia. The Diagnostic and Statistical Manual of Mental Disorders (DSM)-IV-TR diagnostic criteria for trichotillomania includes: (1) Recurrent pulling out of one's own hair resulting in hair loss; (2) an increasing sense of tension immediately before pulling out the hair or when attempting to resist the behavior; (3) pleasure, gratification, or relief when pulling out the hair; (4) the disturbance is not better accounted for by another mental disorder; and (5) the disturbance provokes clinically marked distress and/or impairment in occupational, social, or other areas of functioning. [4] Pulled out hair may be ingested by the patient leading to trichobezoar (a compact mass of hair occupying the gastric cavity to a variable extent) and Rapunzel syndrome (a trichobezoar extending past the duodenum); these conditions usually require surgical interventions.

Management of trichotillomania is challenging. A number of treatment modalities have been used including psychotherapy, hypnotherapy, and pharmacotherapy; though treatment response is variable and relapses are frequent.

Dialectical behavior therapy enhanced habit reversal treatment offers significant promise for improved long-term treatment benefits in trichotillomania. [5] In a recent study, Keuthen et al., reported significant improvement from baseline at 3-and 6-month follow-up on all measures of hair pulling severity and emotion regulation following dialectical behavior therapy enhanced habit reversal therapy. [6] Hypnotherapy has also been reported to be effective in trichotillomania. [7]

Dronabinol is a cannabinoid agonist which is hypothesized to reduce the excitotoxic damage caused by glutamate release in the striatum. This medication offers a new promise in reducing compulsive behaviors. In a study, the use of dronabinol, at an average dose of 11.6 mg/day, decreased the Massachusetts General Hospital Hair Pulling Scale scores (MGH-HPS) from a mean of 16.5±4.4 at baseline to 8.7±5.5. About 64% of patients responded with ≥35% reduction on the MGH-HPS and there was 'much or very much improvement' on the Clinical Global Impression (CGI) scale. [8]

N-acetylcysteine is a glutamate modulator which has shown some promise in treatment of compulsive behaviors. Rodrigues-Barata et al., described clinical improvement of two patients of trichotillomania with N-acetylcysteine. [9] A large trial of 50 trichotillomania patients also reported significant improvement with this medication. [10] However, a recent randomized, double-blind, controlled trial of N-acetylcysteine in pediatric age group (8-17 years) failed to show a statistical benefit over placebo (response rate of 25 versus 21%, respectively). [11] The authors of this study stressed the importance of referring pediatric patients of trichotillomania to appropriate behavioral therapy before starting pharmacological interventions.

In another important study, a second generation (atypical) antipsychotic (SGA), olanzapine at an average dose of 10.8 mg/day was used. The intervention showed significant improvement of trichotillomania responders as per Clinical Global Impressions-Improvement (CGI-I) scale. There was also a significant change from baseline to end point in the Yale-Brown Obsessive Compulsive Scale for Trichotillomania (TTM-YBOCS) and the Clinical Global Impressions-Severity of Illness (CGI-S) scale. [12] In addition, aripiprazole, another SGA, has also shown promise in treatment of trichotillomania. [13]

Bimatoprost is a synthetic prostaglandin analogue used for glaucoma and ocular hypertension. Peabody et al., recently reported successful treatment of eyelash madarosis (due to trichotillomania) in a female patient with use of bimatoprost 0.03% ophthalmic solution. [14] Treatment of trichotillomania with mood stabilizers, for example, lithium has also been suggested. [15]

Thus, starting with successful but relatively older pharmacotherapy options of clomipramine and selective serotonin reuptake inhibitors (SSRIs), there are now a number of new treatment modalities for this difficult to manage entity. Most of these require validation in controlled clinical trials. And still, the role of psychotherapeutic interventions in both pediatric as well as adult patients cannot be over-emphasized.

 
   References Top

1.Hallopeau M. Alopecia par grottage (trichomania ou trichotillomania). Ann Dermatol Venerol 1889;10:440-1.  Back to cited text no. 1
    
2.Hautmann G, Hercogova J, Lotti T. Trichotillomania. J Am Acad Dermatol 2002;46:807-21.  Back to cited text no. 2
    
3.Olza-Fernández I, Palanca-Maresca I, Jiménez-Fernández S, Cazorla-Calleja MR. Trichotillomania, bipolar disorder and white matter hyperintensities in a six-year old girl. J Can Acad Child Adolesc Psychiatry 2012;21:213-5.  Back to cited text no. 3
    
4.American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders; DSM-IV, 4 th ed. Text revision. Washington DC: American Psychiatric Press, Inc.; 2000.  Back to cited text no. 4
    
5.MacPherson HA, Cheavens JS, Fristad MA. Dialectical behavior therapy for adolescents: Theory, treatment adaptations, and empirical outcomes. Clin Child Fam Psychol Rev 2013;16:59-80.  Back to cited text no. 5
    
6.Keuthen NJ, Rothbaum BO, Falkenstein MJ, Meunier S, Timpano KR, Jenike MA, et al. DBT-enhanced habit reversal treatment for trichotillomania: 3-and 6-month follow-up results. Depress Anxiety 2011;28:310-3.  Back to cited text no. 6
    
7.Robiner WE, Edwards PE, Christenson GA. Hypnosis in the treatment of trichotillomania. In: Stein DJ, Christenson GA, Hollander E, editors. Trichotillomania. Washington, DC: American Psychiatric Publishing; 1999. p. 167-200.  Back to cited text no. 7
    
8.Grant JE, Odlaug BL, Chamberlain SR, Kim SW. Dronabinol, a cannabinoid agonist, reduces hair pulling in trichotillomania: A pilot study. Psychopharmacology (Berl) 2011;218:493-502.  Back to cited text no. 8
    
9.Rodrigues-Barata AR, Tosti A, Rodríguez-Pichardo A, Camacho-Martínez F. N-acetylcysteine in the Treatment of Trichotillomania. Int J Trichology 2012;4:176-8.  Back to cited text no. 9
    
10.Grant JE, Odlaug BL, Kim SW. N-acetylcysteine, a glutamate modulator, in the treatment of trichotillomania: A double-blind, placebo-controlled study. Arch Gen Psychiatry 2009;66:756-63.  Back to cited text no. 10
    
11.Bloch MH, Panza KE, Grant JE, Pittenger C, Leckman JF. N-acetylcysteine in the treatment of pediatric trichotillomania: A randomized, double-blind, placebo-controlled add-on trial. J Am Acad Child Adolesc Psychiatry 2013;52:231-40.  Back to cited text no. 11
    
12.Van Ameringen M, Mancini C, Patterson B, Bennett M, Oakman J. A randomized, double-blind, placebo-controlled trial of olanzapine in the treatment of trichotillomania. J Clin Psychiatry 2010;71:1336-43.  Back to cited text no. 12
    
13.White MP, Koran LM. Open-label trial of aripiprazole in the treatment of trichotillomania. J Clin Psychopharmacol 2011;31:503-6.  Back to cited text no. 13
    
14.Peabody T, Reitz S, Smith J, Teti B. Clinical management of trichotillomania with bimatoprost. Optom Vis Sci 2013;90:e167-71.  Back to cited text no. 14
    
15.Gupta MA. Emotional regulation, dissociation, and the self-induced dermatoses: Clinical features and implications for treatment with mood stabilizers. Clin Dermatol 2013;31:110-7.  Back to cited text no. 15
    




 

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