Trichotillomania in long COVID successfully treated with escitalopram: A case report

Coronavirus disease 2019 (COVID-19) caused a global pandemic that infected many individuals worldwide. Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) can directly infect multiple tissues and organs, including the nervous system, and cause neuropsychiatric complications.1 Some patients may develop neuropsychiatric symptoms such as depression, fatigue, anxiety, sleep disorders, and neurocognitive impairments after COVID-19, and the condition in which such neuropsychiatric symptoms persist after COVID-19 is called “long COVID.”2 Trichotillomania (TTM), characterized by repeated pulling out of the patient's own hair, resulting in hair loss and significant social dysfunction,3 has not yet been reported as a symptom of long COVID. SARS-CoV-2 may also directly or indirectly infect hair follicles through systemic changes in the immune and hormonal systems.4 Several studies have reported the clinical manifestations and pathophysiology of COVID-19-associated hair problems, such as alopecia and increased hair graying.5 TTM is categorized as body-focused repetitive behavior (BFRB) disorders, and all BFRBs are now classified as obsessive–compulsive and related disorders (OCRDs) in the Diagnostic and Statistical Manual of Mental Disorders, 5th edition (DSM-5). Many TTM patients have been reported that hair pulling is preceded by urges and that hair pulling involves ritualistic behaviors redolent of OCD,6 suggesting that TTM after COVID-19 may not be a COVID-19-associated hair disorder but rather a part of various neuropsychiatric complications. This report details the case of TTM in long COVID and successfully treated with escitalopram. Written informed consent was obtained from the patient for the publication of any potentially identifiable images or data included in this article. A 53-year-old woman, who had no history of psychiatric disorders before COVID-19, lived with her husband and son and performed household chores. One week after the onset of COVID-19, the patient began to have difficulty in performing daily routines and making decisions. Furthermore, she became irritable and restless, continued to pull out her hair, and ripped off her nails. Finally, she was admitted to our department 2 months after COVID-19. Upon admission, she was bald, wore a low-hanging hat, and had ripped nails. Her facial expressions were stiff, and she barely responded to our questions. Her family stated that they could not think of any psychological or environmental factors that could contribute to the condition, and it was difficult to get her to talk about these factors. Brain magnetic resonance imaging, electroencephalography, and cerebrospinal fluid tests revealed no findings suggestive of encephalitis. Physical examination revealed no significant abnormalities, and skin and hair disorders were ruled out by a dermatologist. Her sleep pattern and appetite were normal, and there was no obvious evidence of depressed mood, guilt, or suicidal ideation, so her condition did not meet the diagnostic criteria for major depressive episode. She was diagnosed with TTM in long COVID since the onset of symptoms occurred after COVID-19, and escitalopram 10 mg/day was initiated (Day 17). She gradually became more communicative and touched her head and nails less frequently. Escitalopram was increased to 20 mg/day (Day 27), and she became expressive and talkative, and stopped pulling out her hair. No adverse events occurred with continued escitalopram 20 mg/day. Over the course of hospitalization, her hair gradually returned (Figure 1), and she was discharged to her home after approximately 3 months of hospitalization. Women are more likely to develop long COVID than men,7 suggesting that such sex differences, like autoimmune diseases, which are more frequent in women, may be associated with the cause of long COVID. Persistently elevated autoantibodies against nervous system proteins have been found in some individuals with long COVID,8 suggesting that autoantibodies produced in response to COVID-19 may attack the patients' brains. However, there is still insufficient evidence regarding the association between epidemiological sex differences and autoimmune mechanisms in long COVID, and further research is needed to elucidate the involvement of autoantibodies in the pathophysiology of long COVID. The prevalence of TTM in the general population has been reported to be 0.5%–2.0%.3 Another study, which examined the prevalence of hair problems in women with COVID-19, reported that the primary hair problems were telogen effluvium (60.8%), increased gray hair (13.8%), seborrheic dermatitis (5.6%), and TTM (3.6%).5 Because the populations and study designs differ significantly between them, and sex-specific effects were not directly examined in them, it is unclear whether SARS-CoV-2 infection may increase the prevalence of TTM in women. Although most COVID-related hair disorders can be explained by SARS-CoV-2 infection of hair follicles directly or indirectly through systemic changes in the immune or hormonal systems, TTM could be associated with autoantibodies against the central nervous system during long COVID. A previous review concluded that several pharmacological agents, such as clomipramine, N-acetylcysteine, and olanzapine, have demonstrated some benefits in TTM9; however, there is no strong evidence of the treatment efficacy of selective serotonin reuptake inhibitors (SSRIs). In contrast, a recent retrospective population-based study demonstrated a statistically significant reduction in the relative risk of long COVID among patients receiving SSRIs compared with patients not receiving SSRIs.10 Because in the present case, which was not typical TTM, the patient developed TTM during long COVID, it is possible that escitalopram, which is an SSRI, was extremely effective. This is a rare case report of TTM in long COVID that was successfully treated with escitalopram. Further studies are required to elucidate the pathophysiology and pharmacological treatment of both long COVID and TTM. Rinka Hata and Hiroko Sugawara drafted and edited the manuscript. Rinka Hata, Reo Hayashi, Yuta Okamoto, Akito Hatanaka, and Kohei Harada treated the patient. Reo Hayashi and Tomomi Yamasaki cared for the patient. Hikaru Hori coordinated the approval of the final draft. All the authors contributed to the manuscript and approved the submitted version. We would like to thank Editage (www.editage.jp) for English language editing. The authors declare no conflicts of interest. N/A. Written informed consent was obtained from the patient for the publication of any potentially identifiable images or data included in this article. N/A. The data that support the findings of this study are available from the corresponding author upon reasonable request.