A rare case of very early onset trichotillomania

Abstract Trichotillomania is a chronic impulse control disorder characterized by pulling out one’s own hair, resulting in noticeable hair loss. Prevalence is 1% and 3.5% among older adolescents and young adults. Onset in pre- or mid-adolescence appears to be the norm, yet the research literature involving pediatric samples is particularly sparse. Studies suggest very early onset pulling may co-occur with other self-soothing behaviors. A 6-year-old child presented with 3-year history of scalp hair loss secondary to hair pulling. Mother noticed pulling hair from the right side of the scalp region while watching TV, sitting alone and while lying down on the bed before sleeping. She pulls out the hair and rolls it on her left thumb and sucks the thumb. Family members tried to reduce the behavior by covering her head with a cap, trimming her hair short and tonsuring her hair nine times, but most of these efforts were futile. With an uneventful antenatal and perinatal period, there was no history suggestive of comorbid depression, anxiety, attention-deficit hyperactivity disorder, or autism spectrum disorder. Family history of similar complaints was present in the elder sibling. Physical examination revealed diffuse, nonscarring, predominantly right temporoparietal alopecia. Both pediatric and dermatological consultations supported that hair-pulling was not due to another medical condition. Diagnosis of Trichotillomania was made. Treatment included habit reversal training, behavior modification program with a positive approach for thumb-sucking, and was started on fluoxetine 10 mg and was gradually titrated to 20 mg over 2 weeks. Significant reduction of symptoms was observed in 4 weeks. Practicing psychiatrists should be aware of the possibility of trichotillomania in very young children. This shows adequate response to behavioral therapy targeting associated soothing behaviors and treatment with a selective serotonin reuptake inhibitor.