An 11-year-old girl previously treated for tinea capitis presented a 3-month history of continuous decrease in hair density on the vertex, frontal, and parieto-temporal areas of the scalp. Hair pull test was negative. Trichoscopic findings showed black dots, micro-exclamation point hairs, regrowing vellus hair, and zigzag hairs. Histopathology showed CD3+ peribulbar lymphocytic infiltrates and occasional eosinophils around the anagen hair follicle consistent with a non-scarring alopecia. A diagnosis of diffuse alopecia areata was made. Patient was given methylprednisolone (0.5 mg/kg/day) for 2 weeks and noted marked increase in hair density except on focal areas of the scalp. Patient eventually admitted to occasional hair pulling. Trichoscopy revealed trichoptilosis, V-sign, tulip hairs, and multiple broken hairs of varying length while a second biopsy showed trichomalacia and pigment casts consistent with trichotillomania. In this case, where co-existence of alopecia areata and trichotillomania is considered to be uncommon, trichoscopy proved to be an important tool in differentiating hair disorders with similar presentation. Knowing key features of hair diseases can help elucidate the diagnosis when presented with an atypical case.
Alopecia Areata ; Trichotillomania

Rapunzel syndrome is caused by gastric trichobezoar with extended tail and small bowel obstruction. Patients with gastric trichobezoar can be asymptomatic until the bezoar increases in size. We report a case of a girl who visited the emergency department with abdominal pain. She was finally diagnosed with Rapunzel syndrome that causes multiple small bowel intussusceptions associated with trichophagia. Surgery was needed to reduce the multiple intussusceptions, and to remove the large trichobezoar. This case highlights to consider the possibility of Rapunzel syndrome when diagnosing the main cause of intussusceptions.
Abdominal Pain ; Bezoars ; Emergency Service, Hospital ; Female ; Humans ; Intestinal Obstruction ; Intussusception ; Pica ; Tail ; Trichotillomania

OBJECTIVE: Trichotillomania is a relatively common illness whose neurobiology is poorly understood. One treatment for adult trichotillomania, n-acetyl cysteine (NAC), has antioxidative properties, as well as effects on central glutamatergic transmission. Preclinical models suggest that excessive oxidative stress may be involved in its pathophysiology. METHODS: Adults with trichotillomania provided a blood sample for analysis of compounds that may be influenced by oxidative stress [glutathione, angiotensin II, ferritin, iron, glucose, insulin and insulin growth factor 1 (IGF1), and hepcidin]. Participants were examined on symptom severity, disability, and impulsivity. The number of participants with out-of-reference range oxidative stress measures were compared against the null distribution. Correlations between oxidative stress markers and clinical measures were examined. RESULTS: Of 14 participants (mean age 31.2 years; 92.9% female), 35.7% (n=5) had total glutathione levels below the reference range (p= 0.041). Other oxidative stress measures did not have significant proportions outside the reference ranges. Lower levels of glutathione correlated significantly with higher motor impulsiveness (Barratt Impulsiveness Scale sub-score) (r=0.97, p=0.001). CONCLUSION: A third of patients with trichotillomania had low levels of glutathione, and lower levels of glutathione correlated significantly with higher motor impulsiveness. Because NAC is a precursor for cysteine, and cysteine is a rate limiting step for glutathione production, these results may shed light on the mechanisms through which NAC can have beneficial effects for impulsive symptoms. Confirmation of these results requires a suitable larger follow-up study, including an internal normative control group.
Adult ; Angiotensin II ; Cysteine ; Ferritins ; Follow-Up Studies ; Glucose ; Glutathione ; Humans ; Impulsive Behavior ; Insulin ; Iron ; Neurobiology ; Oxidative Stress* ; Reference Values ; Trichotillomania*

Adolescent ; Bezoars ; surgery ; Duodenum ; surgery ; Female ; Hair ; Humans ; Stomach ; pathology ; Treatment Outcome ; Trichotillomania ; diagnosis ; surgery

Alopecia areata (AA) is a disease in which the patient experiences a sudden loss of scalp hair leaving round patches. It has a lifetime risk of 1.7%. AA is known to occur on any part of the body, including the scalp, beard area, axilla, and even the pubic area. Although the pathogenesis of AA is poorly understood, the consensus is that AA is an organ-specific autoimmune disease that typically presents in the hair follicles. Susceptibility to the development of AA may be modified by environmental factors, including exposure to pro-inflammatory agents and other modulators. The differentiation of AA can sometimes be challenging as several conditions (such as trichotillomania, tinea capitis, telogen effluvium, and lupus) may resemble AA. Obtaining the patient's history, performing a hair pull test, and skin biopsy or dermoscopic findings can be helpful for confirmation. Treatment for AA is usually based on patient age and the extent of hair loss, but there are no therapeutic agents that are curative or preventive for AA. AA can progress unpredictably. Indicators of poor prognosis include atopy, co-occurring immune diseases, positive family history, young age of onset, and ophiasis.
Age of Onset ; Alopecia Areata* ; Alopecia* ; Autoimmune Diseases ; Axilla ; Biopsy ; Consensus ; Diagnosis* ; Hair ; Hair Follicle ; Humans ; Immune System Diseases ; Prognosis ; Scalp ; Skin ; Tinea Capitis ; Trichotillomania

BACKGROUND: Various kinds of alopecia can show small round or oval hairless patch. Dermoscopy could be a simple, useful tool for making a correct diagnosis. OBJECTIVE: The aim of this study is to investigate clinical usefulness of dermoscopy for diseases with small round or oval hairless patch on the scalp. METHODS: Dermoscopic examination was performed for 148 patients with small round or oval hairless patch using DermLite(R) II pro. The type and its patient number of alopecia investigated in the study were as below: alopecia areata (n=81), trichotillomania (n=24), tinea captis (n=13), traction alopecia (n=12), lichen planopilaris (n=8), discoid lupus erythematosus (n=7), congenital triangular alopecia (n=2) and pseudopelade of Brocq (n=1). The significance of dermoscopic findings for each disease were evaluated. RESULTS: Characteristic dermoscopic findings of alopecia areata were tapering hairs and yellow dots. Those of trichotillomania and traction alopecia were broken hairs. Dermoscopic findings of tinea capitis included bent hairs, perifollicular white macules and greasy scales. Discoid lupus erythematosus and lichen planopilaris were characterized by dermoscopic findings of lack of follicular ostia. Furthermore, keratin plugs were frequently seen in discoid lupus erythematosus whereas perifollicular hyperkeratosis and erythema were frequently seen in lichen planopilaris. CONCLUSION: Dermoscopic examination for small round or oval hairless patch showed characteristic findings for each disease. Based on these results, we propose dermoscopic algorithm for small round or oval hairless patch on the scalp.
Alopecia ; Alopecia Areata ; Dermoscopy ; Diagnosis ; Erythema ; Hair ; Humans ; Lichens ; Lupus Erythematosus, Discoid ; Scalp* ; Tinea ; Tinea Capitis ; Traction ; Trichotillomania ; Weights and Measures

Rapunzel syndrome refers to a very rare condition in which swallowed hair forms a gastric trichobezoar that has a long tail extending into the small bowel. We describe a case of Rapunzel syndrome in an 8-year-old girl who presented with abdominal mass, epigastric pain and vomiting. Abdominal computed tomography scan showed a markedly dilated stomach filled with coarse heterogeneous materials. Upper gastrointestinal endoscopy revealed a huge hairy ball with a tail extending through the pylorus. We performed a surgical laparotomy and successfully removed a huge trichobezoar with a long tail extending into the middle portion of jejunum. Psychiatric consultation with review showed her past history of trichotillomania and trichophagia 4 years ago. But her parents denied further psychiatric therapy and she was lost to the follow-up. Rapunzel syndrome should be included in the differential diagnosis in children with chronic abdominal pain and trichophagia.
Abdominal Pain ; Bezoars ; Child ; Diagnosis, Differential ; Endoscopy, Gastrointestinal ; Follow-Up Studies ; Hair ; Humans ; Jejunum ; Laparotomy ; Parents ; Pylorus ; Stomach ; Trichotillomania ; Vomiting

Steatocystoma multiplex (SM) is an uncommon disorder of the pilosebaceous unit characterized by the development of numerous sebum-containing dermal cysts which rarely involves the scalp. Here, we report a case of a 50-year-old man with multiple cystic nodules and alopecic patches on his scalp. On histopathological examination, the folded cyst was found to be lined by stratified squamous epithelium, while flattened sebaceous gland cells were identified in the cystic wall. Pigment casts were present in the hair papillae and perifollicular regions, suggesting trichotillomania as a possible cause of the observed alopecia. This case appears to represent an unusual clinical manifestation of SM.
Alopecia ; Epithelium ; Hair ; Humans ; Middle Aged ; Scalp ; Sebaceous Glands ; Steatocystoma Multiplex ; Trichotillomania

Gastric trichobezoars are commonly observed in young women with trichotillomania and trichophagia. We encountered an 8-year-old girl who had trichotillomania and trichophagia with abdominal pain and a mass, which was diagnosed as a large gastric trichobezoar. On physical examination, a huge, firm nontender mobile mass was palpated in her epigastrium. An upper gastrointestinal series and abdominal computed tomography (CT) scan showed a large mass in the stomach. Endoscopic removal was tried but failed. Laparoscopic removal was therefore performed. The trichobezoar was successfully retrieved through a gastrotomy and removed through an extended umbilical trocar incision. This case demonstrates that laparoscopic removal of large gastric trichobezoars is feasible and safe without a large abdominal incision.
Abdominal Pain ; Bezoars ; Child ; Female ; Humans ; Physical Examination ; Stomach ; Surgical Instruments ; Trichotillomania

A 7 year-old girl had developed multiple bald patches on her scalp for two months and was treated as alopecia areata or trichotillomania at another institution. Biopsy findings of the scalp lesion showed catagen follicles, trichomalacia and pigment clumps in the hair canals with little inflammatory cell infiltrates. Careful history revealed the patient had had "a magic perm" - a hair-straightening perm - one month before the bald patch began to develop. The condition could be called "a magic perm alopecia" as a form of cosmetic traumatic alopecia. The alopecic lesions showed further extension for three to four months. The lesions were beginning to recover five months after they first developed.
Alopecia ; Alopecia Areata ; Biopsy ; Cosmetics ; Hair ; Humans ; Magic ; Polyenes ; Scalp ; Trichotillomania