158 Trichotillomania: A review of 28 biopsies

Wilma Bergfeld, Colleen Embi, Fabiane Mulinari-Brenner, Karen McCarron Departments of Dermatology and Pathology, The Cleveland Clinic Foundation, Cleveland, Ohio - USA

Trichotillomania (TM) is a chronic disorder in which patients traumatically remove their own hair in a bizarre pattern. TM can mimic other diseases and it is frequently not clinically suspected as patients typically do not disclose their actions. We reviewed 28 scalp biopsies on 26 patients with clinical diagnosis of TM. The biopsies were vertically sectioned and examined with H&E. Additional sections were used in all cases as well as special stains which included PAS, elastic, colloidal iron, Giemsa, melanin, and iron. The clinical charts were reviewed in all cases. Twenty-six patients (24 female, 2 male) were in the cohort, 2 patients had 2 sets of biopsies. Age range was 13–78 years (mean 42 years). The histologic findings included: follicular plugging (96%), decreased total numbers of follicles (93%), reversed anagen: telogen ratio (86%), decreased numbers of sebaceous glands (68%), increased vellus hairs (57%), melanoderma, the presence of pigment containing macrophages in the dermis, (68%), fibrous tracts (64%), trichomalacia (57%), pigmented casts (36%), hair granulomas (18%), and dermal inflammation (43%). This review contains an older mean age group than previously reported. Trichomalacia and pigmented casts are considered to be infrequent but specific histologic signs for TM. This study reveals a higher percentage of trichomalacia, but fewer pigmented casts when compared with previous studies. Melanoderma, a non-specific sign, has not been previously reported in TM and it was found in over 60% of our cases. Scalp biopsies are valuable in the diagnosis of TM.