Trichotillomania

What’s the First Rule of Dermatology?  Hint:  It's not the same as the First Rule of Fight Club.  The First Rule of Dermatology is this: Don’t believe your ears, believe your eyes.  Trichotillomania is the perfect example of a condition where the history misleads you.  Many, if not most trichotillomaniacs will tell you their scalp, eyelashes, eyebrows, nostril or pubic hair (yes, pubic hair) itches or burns, and that’s why they pull, tug, or scratch these spots.  Really, though, it is the same setup as lichen simplex chronicus.  The chronic trauma makes them itch or burn, then they really go to work.  Many of them will not recognize they are the problem and will deny the deed when pressed.  Always believe your eyes.  The clue in this case is a patient with a condition which does not fit any normal inflammatory pattern.  There is regrowth displayed in the middle (where the TTM started) that is too short for the patient to get a good grip on, but centripetally away from the center there is further alopecia.  Be prepared for an argument when you make the diagnosis, either from the patient or the omnipresent mother, who says “I never see Jessica doing anything like that…”   Uh huh.