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Patient Story

A 17-year-old Hispanic girl is brought to the office by her mother who is worried about the hair loss that has been going on for the past 3 months. The physician recognized the pattern of trichotillomania (Figure 159-1) and asked the girl if she was pulling on her hair. She told the doctor that this has been a very stressful year for her as she is currently taking four Advanced-Placement courses simultaneously. She admitted to playing with her hair while studying and sometimes that involved pulling on the hairs. The physician explained to the girl and her mother that this was a case of trichotillomania. He asked if the girl would be willing to stop pulling on her hairs and if she would like further counseling. She promised the doctor and her mother that she would stop pulling her hair and preferred to not enter counseling at this time. A follow-up appointment for one month was set.

FIGURE 159-1

Trichotillomania in his 17-year-old honors student who is currently taking four Advanced Placement courses simultaneously. (Used with permission from Richard P. Usatine, MD.)


Traction alopecia is hair loss caused by damage to the dermal papilla and hair follicle by constant pulling or tension over a long period. It often occurs in persons who wear tight braids, especially “cornrows” that lead to high tension, pulling, and breakage of hair. Trichotillomania (Greek for “hair-pulling madness”) is a traction alopecia related to a compulsive disorder caused when patients pull on and pluck hairs, often creating bizarre patterns of hair loss.


  • The prevalence of traction alopecia (Figures 159-1 and 159-2) is unknown and varies by cultural hairstyle practices. It is most commonly seen in females and children.1

  • The prevalence of trichotillomania (Figures 159-3 to 159-6) is also difficult to determine, but is estimated to be approximately 1.5 percent of males and 3.4 percent of females in the US. The mean age of onset of trichotillomania is 8 years in boys and 12 years in girls, and it is the most common cause of childhood alopecia.2

FIGURE 159-2

Traction alopecia in a young African American girl whose mom braids her hair tightly. (Used with permission from Richard P. Usatine, MD.)

FIGURE 159-3

Traction alopecia on the lateral aspect of the scalp of a young girl due to pulling the hair tightly with rubber bands. (Used with permission from Richard P. Usatine, MD.)

FIGURE 159-4

Trichotillomania in an 11-year-old boy. Note the incomplete hair loss and unusual geometric pattern. He was receiving help and ...

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