Visual Diagnosis: The Case of the Balding Preschooler

Somya Abubucker; Bernard A. Cohen

doi:10.1542/pir.2016-0143

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Somya Abubucker, MD*
Bernard A. Cohen, MD^†

^*Fourth-year medical student and
^†Department of Dermatology, Johns Hopkins School of Medicine, Baltimore, MD

AUTHOR DISCLOSURE
Drs Abubucker and Cohen have disclosed no financial relationships relevant to this article. Dr Abubucker is currently an Internal Medicine resident at the University of Hawaii. This commentary does not contain a discussion of an unapproved/investigative use of a commercial product/device.

Presentation

An anxious mother brings her 4-year-old daughter for evaluation of hair loss that started several weeks ago and for which she was prescribed clobetasol cream at an urgent care center. The child denies itching, pain, or burning sensation. She wears her hair loose and has never had braids or hairstyling treatments. The mother denies any chronic medical problems, recent stressors, or infections. They have a stable home life and follow a healthy diet, and they do not own pets. On repeated questioning, the mother recalls that the child occasionally “plays with her hair.” Family history is positive for a maternal uncle with alopecia areata.

On examination, the child is not anxious. There is a vaguely defined annular patch of hair thinning on the left parietal and occipital scalp (Fig). The scalp skin is normal, without erythema, scales, pustules, or scarring. Eyebrows and eyelashes are intact, and the nail examination results are normal. There is no lymphadenopathy. The hair pull test, in which gentle traction is applied to approximately 50 hairs in the affected area, is negative, ie, fewer than 10% of the pulled hair comes out. Trichoscopy (in which the scalp is examined under a dermascope) is significant for multiple broken hairs that differ in length and shape.

Figure.

Annular patch of hair thinning on the left parietal and occipital scalp, with normal underlying skin.

Diagnosis

Based on findings from history, physical examination, and trichoscopy, a diagnosis of early-onset trichotillomania (TTM), or hair-pulling disorder, is made.