Q: My nine-year-old daughter has been losing hair over the past two years. It is only affecting the central part of her scalp. It is serious now and she is becoming extremely reluctant to go to school.

Based on my provisional diagnostic impression, your daughter is most likely suffering from trichotillomania (TTM) also known as hair-pulling disorder. It is believed to be a debilitating psychiatric condition characterised by a long-term, persistent urge of pulling out one’s own hair leading to areas of significant hair loss. Rarely, TTM may run in families, but the exact nature of any inheritance pattern is very poorly understood.

[My nails are becoming rough]

As a common clinical observation, TTM is quite commonly associated with an obsessive-compulsive disorder (OCD) in most of the sufferers. The areas of hair loss in TTM are usually confined to one or two sites (which is true in your daughter’s case as well) but can also be seen involving multiple sites. The scalp is the most commonly affected site, particularly in children. However, in adult sufferers the eyebrows, beard and moustache, arms and legs, underarms and chest can also be impacted.

The classic presentation of TTM is known as the Friar Tuck, a form of vertex and crown alopecia (which again seems to be true in your daughter’s case).

Affected children with trichotillomania exhibit hair of different lengths – some are broken hair with blunt ends, some newly growing hair with tapered ends, some broken mid shafts or some uneven stubble. In most cases the TTM-suffering-individuals are found to be secretive and shameful of their hair-pulling behaviour. In addition, the psychosocial effect of TTM can be seen as lowered self-esteem of the sufferer, often associated with being shunned by peers and the fear of socialising due to appearance and the negative attention they might receive. This also fits through as the likely reason of your daughter’s reluctance in attending school.

Patients’ active attempts to disguise symptoms can make the diagnosis challenging. If patients continuously deny hair pulling, the treating dermatologist must pursue a differential diagnosis, including evaluation for alopecia areata, hair loss due to atypical fungal infection of the scalp, traction alopecia (hair loss due to very tightly pulled hair styles) and other suspected causes of hair loss that could have case-to-case variations.

The treatment of trichotillomania is usually based on the sufferer’s age. Most pre-school children outgrow the condition even through conservative management measures. In school-going kids and adolescents, non-pharmacological interventions including behaviour modification programmes are highly beneficial.

Referring the patient to a psychologist or psychiatrist should be considered. Majority of psychologists treat these sufferers through habit reversal training (HRT) programme, which has shown extremely positive results.

Dr Ikramullah Al Nasir is specialist dermatologist and medical director at Dermacare Dubai. Got a problem? Our fantastic panel of renowned experts is available to answer all your questions related to fashion, well-being, nutrition, finance and hypnotherapy. Email your queries to friday@gulfnews.com.