Child abuse and trichotillomania
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《英国医生杂志》
1 Department of Dermatology, Era's Lucknow Medical College and Hospital, Lucknow 226 016, India abirsaraswat@yahoo.com
Introduction
A 12 year old boy was referred by his family physician to the dermatology outpatient department with a complaint of partial hair loss on his scalp that was noticed one week before. On examination, there were two patches of partial alopecia on the temporovertical scalp measuring 2 cm by 2 cm and 3 cm by 3 cm. The hair shafts were broken off at different levels and there was no evidence of scarring. The scalp was not tender or bruised. A hair pull test did not find his hair easy to pluck and hair shaft microscopy was normal. A potassium hydroxide preparation from the lesional skin did not show any fungal elements. A skin biopsy from one of the patches found many empty hair bulbs without any inflammation or scarring. Several catagen hair follicles were also identified.
Based on these clinical and histopathological findings, I diagnosed him as having trichotillomania and referred him for psychiatric evaluation. The parents refused psychiatric help, however, and insisted that the child had never pulled his hair. When this topic was broached with the child in the absence of his parents, he denied any knowledge of the possible cause of the hair loss. Several dermatology consultations later, the child volunteered that the hair was being pulled by a teacher who gave him private tuition after school hours. I informed his parents and covert surveillance of the teacher confirmed physical abuse in the form of twisting and pulling of hair. Inquiries to all students being tutored by the teacher found two more cases. I informed the school authorities, and the teacher was referred for psychiatric evaluation. The boy stopped the private tuition, which resulted in full regrowth of hair in both patches within four weeks.
Discussion
Raimer BG, Raimer SS, Hebeler JR. Cutaneous signs of child abuse. J Am Acad Dermatol 1981;5: 203-14.
Johnson CF. Inflicted injury versus accidental injury. Pediatr Clin N Am 1990;37: 791-814.
Kennedy CTC. Mechanical and thermal injury. In: Champion RH, Burton JL, Burns DA, Breathnach SM, eds. Textbook of dermatology. 6th ed. Oxford: Blackwell Science, 1999: 777.
Hallopeau H. Alopecie par grattage (trichomanie ou trichotillomanie). Ann Dermatol Syphiligr (Paris) 1889;10: 440-1.
Cohen LJ, Stein DJ, Simeon D, Spadaccini E, Rosen J, Aronowitz B, et al. Clinical profile, comorbidity, and treatment history in 123 hair pullers: a survey study. J Clin Psychiatry 1995;56: 319-26.
Mehregan AH. Trichotillomania: a clinicopathologic study. Arch Dermatol 1970;102: 129-33.
Schneider D, Janninger CK. Trichotillomania. Cutis 1994;53: 289-90, 294.
Oranje AP, Peereboom-Wynia JD, Raeymaecker DM. Trichotillomania in childhood. J Am Acad Dermatol 1986;15: 614-9.
Boughn S, Holdom JJ. The relationship of violence and trichotillomania. J Nurs Scholarsh 2003;35: 165-70.
Duarte AM, Pruksachatkunakorn C, Schachner LA. Life threatening dermatoses in pediatric dermatology. Adv Dermatol 1995;10: 329-70.
Trueb RM. "Chignon alopecia": a distinctive type of nonmarginal traction alopecia. Cutis 1995;55: 178-9.
Smith RA, Ross JS, Bunker CB. Localized trichorrhexis nodosa. Clin Exp Dermatol 1994;19: 441-2.(A Saraswat, assistant professor1)
Introduction
A 12 year old boy was referred by his family physician to the dermatology outpatient department with a complaint of partial hair loss on his scalp that was noticed one week before. On examination, there were two patches of partial alopecia on the temporovertical scalp measuring 2 cm by 2 cm and 3 cm by 3 cm. The hair shafts were broken off at different levels and there was no evidence of scarring. The scalp was not tender or bruised. A hair pull test did not find his hair easy to pluck and hair shaft microscopy was normal. A potassium hydroxide preparation from the lesional skin did not show any fungal elements. A skin biopsy from one of the patches found many empty hair bulbs without any inflammation or scarring. Several catagen hair follicles were also identified.
Based on these clinical and histopathological findings, I diagnosed him as having trichotillomania and referred him for psychiatric evaluation. The parents refused psychiatric help, however, and insisted that the child had never pulled his hair. When this topic was broached with the child in the absence of his parents, he denied any knowledge of the possible cause of the hair loss. Several dermatology consultations later, the child volunteered that the hair was being pulled by a teacher who gave him private tuition after school hours. I informed his parents and covert surveillance of the teacher confirmed physical abuse in the form of twisting and pulling of hair. Inquiries to all students being tutored by the teacher found two more cases. I informed the school authorities, and the teacher was referred for psychiatric evaluation. The boy stopped the private tuition, which resulted in full regrowth of hair in both patches within four weeks.
Discussion
Raimer BG, Raimer SS, Hebeler JR. Cutaneous signs of child abuse. J Am Acad Dermatol 1981;5: 203-14.
Johnson CF. Inflicted injury versus accidental injury. Pediatr Clin N Am 1990;37: 791-814.
Kennedy CTC. Mechanical and thermal injury. In: Champion RH, Burton JL, Burns DA, Breathnach SM, eds. Textbook of dermatology. 6th ed. Oxford: Blackwell Science, 1999: 777.
Hallopeau H. Alopecie par grattage (trichomanie ou trichotillomanie). Ann Dermatol Syphiligr (Paris) 1889;10: 440-1.
Cohen LJ, Stein DJ, Simeon D, Spadaccini E, Rosen J, Aronowitz B, et al. Clinical profile, comorbidity, and treatment history in 123 hair pullers: a survey study. J Clin Psychiatry 1995;56: 319-26.
Mehregan AH. Trichotillomania: a clinicopathologic study. Arch Dermatol 1970;102: 129-33.
Schneider D, Janninger CK. Trichotillomania. Cutis 1994;53: 289-90, 294.
Oranje AP, Peereboom-Wynia JD, Raeymaecker DM. Trichotillomania in childhood. J Am Acad Dermatol 1986;15: 614-9.
Boughn S, Holdom JJ. The relationship of violence and trichotillomania. J Nurs Scholarsh 2003;35: 165-70.
Duarte AM, Pruksachatkunakorn C, Schachner LA. Life threatening dermatoses in pediatric dermatology. Adv Dermatol 1995;10: 329-70.
Trueb RM. "Chignon alopecia": a distinctive type of nonmarginal traction alopecia. Cutis 1995;55: 178-9.
Smith RA, Ross JS, Bunker CB. Localized trichorrhexis nodosa. Clin Exp Dermatol 1994;19: 441-2.(A Saraswat, assistant professor1)