Psychological components of hair disorders require co-management

Key Points

Cleveland - Hair disorders such as alopecia areata and trichotillomania often involve a complex mind-body connection that dermatologists must untangle, according to Wilma Bergfeld, M.D., in practice at the Cleveland Clinic.

Tricky diagnosis

"Both of these conditions present as patchy hair loss, of complete or near complete hair loss," she says. "In both conditions, the scalp can have a sensation of pain, tingling or itching. Patients may have relief of these symptoms by removing the hair."

Making a definitive diagnosis and differentiating between these two hair disorders is challenging because of the overlapping clinical features, Dr. Bergfeld says. Even on biopsy, there can be overlapping features - unless it presents as an acute alopecia areata with a specific finding of peribulbar anagen lymphocytic inflammatory infiltrate. Therefore, the diagnosis is often made by clinical inspection of the alopecic condition.

One clue is the patch characteristics, Dr. Bergfeld says. "In alopecia areata, the patches are usually smooth and round, while the trichotillomania patches usually have a bizarre shape. Both conditions can have hair stubble which represents breakage or regrowth. Only on examination of these hairs, one can determine which it represents.

"Broken hair is seen as exclamatory hair in alopecia areata most commonly but can be a result of pulling or tugging in trichotillomania," she adds. "Hair regrowth in either condition presents with a tapered hair and can be seen in both conditions. However, regrowth in alopecia is frequently of hypopigmented vellus hair first prior to pigmented terminal hair."