Trichotillomania: What Do We Know So Far?

Trichotillomania is defined as an obsessive-compulsive or related disorder in which patients recurrently pull out hair from any region of their body. The disease affects mainly female patients, who often deny the habit, and it usually presents with a bizarre pattern nonscarring patchy alopecia with short hair and a negative pull test. Trichoscopy can reveal the abnormalities resulting from the stretching and fracture of hair shafts, and biopsy can be necessary if the patient or parents have difficulties in accepting the self-inflicted nature of a trichotillomania diagnosis. Trichotillomania requires a comprehensive treatment plan and interdisciplinary approach. Physicians should always have a nonjudgmental, empathic, and inviting attitude toward the patient. Behavioral therapy has been used with success in the treatment of trichotillomania, but not all patients are willing or able to comply with this treatment strategy. Pharmacotherapy can be necessary, especially in adolescents and adult patients. Options include tricyclic antidepressants, selective serotonin reuptake inhibitors, and glutamate-modulating agents. Glutamate-modulating agents such as N-acetylcysteine are a good first-line option due to significant benefits and low risk of side effects. Physicians must emphasize that the role of psychiatry-dermatology liaison is extremely necessary with concurrent support services for the patient and parents, in case of pediatric patients. In pediatric cases, parents should be advised and thoroughly educated that negative feedback and punishment for hair pulling are not going to produce positive results. Social support is a significant pillar to successful habit reversal training; therefore, physicians must convey the importance of familial support to achieving remission. This is a review article that aims to discuss the literature on trichotillomania, addressing etiology, historical aspects, clinical and trichoscopic features, main variants, differential diagnosis, diagnostic clues, and psychological and pharmacological management.

Hair-pulling disorder (Trichotillomania): Etiopathogenesis, diagnosis and treatment in a nutshell.

Hair-pulling disorder (Trichotillomania) is a disabling mental disorder. Patient's behavior is characterized by the recurrent pulling of own hair with hair loss and a marked dysfunction in various areas of daily life. Trichotillomania is a relatively common disorder with pediatric onset, often associated with significant morbidity, comorbidity, and functional decline. Surprisingly, children or adolescents have been little studied in the research studies on the pathophysiology and psychopathology of trichotillomania. Furthermore, more evidences regarding the effective and evidence-based pharmacological interventions for the treatment of this condition are encouraged. This narrative review will report on the etiopathogenesis and clinical manifestations of trichotillomania including criteria for diagnosis and treatment issues of this complex mental disorder.

Measuring Treatment Response in Pediatric Trichotillomania: A Meta-Analysis of Clinical Trials.

Objectives: In clinical trials of pediatric trichotillomania (TTM), three instruments are typically employed to rate TTM severity: (1) the Massachusetts General Hospital Hair Pulling Scale (MGH-HPS), (2) the National Institute of Mental Health Trichotillomania Severity Scale (NIMH-TSS), and (3) the Trichotillomania Scale for Children (TSC). These instruments lack standardized definitions of treatment response, which lead researchers to determine their own definitions of response post hoc and potentially inflate results. We performed a meta-analysis to provide empirically determined accuracy measures for percentage reduction cut points in these three instruments. Methods: MEDLINE was searched for TTM clinical trials. A total of 67 studies were initially identified, but only 5 were clinical trials focused on TTM in pediatric populations and therefore were included in this meta-analysis (n = 180). A Clinical Global Impressions Improvement score ≤2 was used to define clinical response. Receiver operating characteristic principles were employed to determine accuracy measures for percentage reduction cut points on each one of the instruments. Meta-DiSc software was employed to provide pooled accuracy measures for each cut point for each instrument. The Youden Index and the distance to corner methods were used to determine the optimal cut point. Results: The optimal cut points to determine treatment response were a 45% reduction on the MGH-HPS (Youden Index 0.40, distance to corner 0.20), a 35% reduction on the NIMH-TSS (Youden Index 0.42, distance to corner 0.17), a 25% reduction on the TSC child version (TSC-C; Youden Index 0.40, distance to corner 0.18), and a 45% (distance to corner 0.30) or 50% reduction (Youden Index 0.33) on the TSC parent version (TSC-P). The TSC-C had less discriminative ability at determining response in younger children in comparison to older children; no age-related differences were observed on the TSC-P. Conclusions: This study provides empirically determined cut points of treatment response on three instruments that rate TTM severity. These data-driven cut points will benefit future research on pediatric TTM.

Alternativas diagnósticas de escabiose felina / Diagnostic alternatives of feline scabies

A sarna notoédrica é uma doença altamente pruriginosa, causada pelo ácaro Notoedres cati. O diagnóstico consiste na observação do ácaro no material analisado, sendo o raspado cutâneo o método mais utilizado. Outras técnicas têm surgido como alternativas menos invasivas no diagnóstico de sarnas, sobretudo para demodicose em cães, como a de fita de acetato e o arrancamento de pelos, que vêm se mostrando tão sensíveis quanto o raspado cutâneo no diagnóstico de tal dermatopatia. Desse modo, o objetivo deste estudo foi comparar o raspado cutâneo com dois métodos alternativos para diagnóstico de sarna notoédrica em gatos: fita de acetato e arrancamento de pelo, sendo possível concluir que o método da fita é tão sensível quanto o raspado cutâneo, ambos apresentando 100% de sensibilidade. A técnica de arrancamento de pelo apresentou sensibilidade significativamente menor para o diagnóstico de Notoedres cati, resultado esperado, uma vez que esse parasita habita principalmente porções superficiais da derme. Assim, o método da fita de acetato pode ser utilizado de forma eficaz e segura para o diagnóstico de sarna notoédrica em gatos, além de ser menos estressante aos animais, mais rápido e simples do que o raspado cutâneo.(AU)

Notoedric mange is a highly pruritic disease caused by the Notoedres cati mite. The diagnosis consists of the observation of the mite in the material analyzed, skin scrapings is the most used method. Other techniques have emerged as less invasive alternatives in the diagnosis of mange, especially for demodicosis in dogs, such as acetate tape and hair removal, which have shown to be as sensitive as skin scrapings in the diagnosis of such dermatopathy. Thus, the objective of this study was to compare skin scaling with two alternative methods for the diagnosis of notohedral scabies in cats: acetate tape and hair collection, and it is possible to conclude that the acetate tape method is as sensitive as skin scraping, both presenting 100% sensitivity. The hair pulling technique showed significantly lower sensitivity for the diagnosis of Notoedres cati, an expected result, since this parasite inhabits mainly superficial portions of the dermis. Thus, the tape method can be used effectively and safely for the diagnosis of notodroid mange in cats, as well as being less stressful to animals, faster and simpler than skin scraping.(AU)

Alternativas diagnósticas de escabiose felina / Diagnostic alternatives of feline scabies

A sarna notoédrica é uma doença altamente pruriginosa, causada pelo ácaro Notoedres cati. O diagnóstico consiste na observação do ácaro no material analisado, sendo o raspado cutâneo o método mais utilizado. Outras técnicas têm surgido como alternativas menos invasivas no diagnóstico de sarnas, sobretudo para demodicose em cães, como a de fita de acetato e o arrancamento de pelos, que vêm se mostrando tão sensíveis quanto o raspado cutâneo no diagnóstico de tal dermatopatia. Desse modo, o objetivo deste estudo foi comparar o raspado cutâneo com dois métodos alternativos para diagnóstico de sarna notoédrica em gatos: fita de acetato e arrancamento de pelo, sendo possível concluir que o método da fita é tão sensível quanto o raspado cutâneo, ambos apresentando 100% de sensibilidade. A técnica de arrancamento de pelo apresentou sensibilidade significativamente menor para o diagnóstico de Notoedres cati, resultado esperado, uma vez que esse parasita habita principalmente porções superficiais da derme. Assim, o método da fita de acetato pode ser utilizado de forma eficaz e segura para o diagnóstico de sarna notoédrica em gatos, além de ser menos estressante aos animais, mais rápido e simples do que o raspado cutâneo.(AU)

Notoedric mange is a highly pruritic disease caused by the Notoedres cati mite. The diagnosis consists of the observation of the mite in the material analyzed, skin scrapings is the most used method. Other techniques have emerged as less invasive alternatives in the diagnosis of mange, especially for demodicosis in dogs, such as acetate tape and hair removal, which have shown to be as sensitive as skin scrapings in the diagnosis of such dermatopathy. Thus, the objective of this study was to compare skin scaling with two alternative methods for the diagnosis of notohedral scabies in cats: acetate tape and hair collection, and it is possible to conclude that the acetate tape method is as sensitive as skin scraping, both presenting 100% sensitivity. The hair pulling technique showed significantly lower sensitivity for the diagnosis of Notoedres cati, an expected result, since this parasite inhabits mainly superficial portions of the dermis. Thus, the tape method can be used effectively and safely for the diagnosis of notodroid mange in cats, as well as being less stressful to animals, faster and simpler than skin scraping.(AU)