Cultural Trichotillomania: A Look at Eyebrow Loss in India

Dear Editor, Trichotillomania (TTM) is compulsive hair pulling linked to anxiety and stress, resulting in hair loss. Its relationship with cultural practices is underexplored. Cultural beliefs and family influences shape behavior and potentially contribute to TTM. A young female child of 10 years of age presented to the dermatology outpatient department with loss of eyebrow hair for 1-month duration. The patient’s medical history was unremarkable, with neither previous incidents of alopecia on other areas of the scalp or body, nor any associated comorbidities. On examination, symmetrical patches of non-scarring alopecia were present in the medial aspect of both eyebrows [Figure 1]. Scalp examination was within normal limits. On dermoscopic examination, uneven hair lengths, black dots, and tulip hairs were seen [Figure 2]. Upon further investigation, the mother revealed that the patient and her family follow Jainism. The family’s religious beliefs may have influenced the child’s practices, as parental factors often play a role in shaping a child’s behavior. The child had been observing Jain monks engage in the ritualistic practice of hair plucking since she was five years old. Over the next few years, the child gradually adopted this behavior, eventually learning to pluck her own eyebrows. By the time she came to us, the habit had caused significant eyebrow hair loss. The child also shared that she was influenced by the monks’ religious practice and believed her hair loss resulted from mimicking it. There was no history of associated psychiatric complaints, and scholastic performance was good. A thorough psychiatric evaluation confirmed that her mental health was normal. Based on the above findings, a diagnosis of trichotillosis was made. The patient was counseled regarding the disease and habit reversal techniques were advised.Figure 1: Non-scarring alopecia presenting symmetrically on the medial aspect of both eyebrowsFigure 2: Dermoscopy (Heine Delta, 30×, non-polarized mode) of an alopecia patch showing uneven hair lengths, black dots (blue arrow), and tulip hairs (orange arrow)Trichotillosis, previously known as TTM, is an illness that comes under the umbrella of obsessive-compulsive related disorders in the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders. It is described as a body-focused repetitive behavior. The disorder may present itself in different areas of the body, such as the scalp, eyebrows, or eyelashes. It can be difficult to manage due to the compulsive nature of the behavior. The condition can be episodic but is usually chronic and difficult to treat. Given the potential medical and psychiatric complications, it is important that the diagnosis is accurate and early. Jainism is an old Indian religion that believes in “Ahimsa” or nonviolence in any form. The Jain monks usually pluck their scalp hair in a ritualistic manner known as “Kesha lochan” because they do not want to harm even a nit, as they consider life in any form to be sacred.[1] Usually, the monks apply ash before plucking the hair from the scalp and endure the pain perceived during the act.[2] This act mirrors the compulsive behavior seen in TTM. It suggests that cultural practices can play a significant role in shaping an individual’s behavior when it comes to body-focused repetitive actions. The ritualistic pulling of hair has been considered culture-bound TTM.[3] Culture-bound syndromes refer to psychological disorders or behaviors influenced by specific cultural beliefs or practices. They are often complex to treat due to their deep connection with cultural and religious practices. Dermatologists and psychiatrists need to work in coordination, taking into account the patient’s cultural background and tailoring treatment to ensure it is both effective and respectful of the patient’s identity. By combining cultural understanding with psychological support, healthcare providers can help individuals overcome these unique challenges in a compassionate and empathetic manner. In our case, the young girl was influenced by the idea of the “Kesha lochan” by the Jain monks and was motivated to pluck her eyebrows as well to experience the pain and endure it. This culturally bound TTM is unique with its symmetrical presentation on both eyebrows, mimicking alopecia areata. The clues from the dermoscopy and the cultural history from the mother led to the diagnosis of this case. The treatment focused on counseling the patient and discussing her cultural beliefs while maintaining a sensible and open-minded environment. While TTM has been reported in various cultural contexts, including its association with cultural messages about hair, beauty, and appearance in African American females,[4] its connection with specific practices, such as Jainism, is rarely explored. This also highlights the importance of considering cultural and familial influences when assessing a TTM patient. Due to the unique presentation of the condition and the rarity of cultural dermatosis being reported, we decided to document and report this case. Declaration of patient consent The authors certify that they have obtained all appropriate parent consent forms. In the form a parent has given their consent for her images and other clinical information to be reported in the journal. The parent understands that her name and initials will not be published. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest. Use of artificial intelligence (AI) The preparation of this manuscript was carried out entirely by the authors without the use of artificial intelligence technologies.