A 14-year-old previously healthy child was referred to the paediatrician by the gynecologist as she had unexplained hair loss on the left side of forehead for two-week duration. She did not have hair loss at any other sites of her body initially. In addition, parents also reported that she had poor sleep at night and also had witnessed abnormal fast breathing from time to time for two months. Her school performance was above average. Family history revealed that her parents were elderly and overprotective but had no similar illness or any other psychiatric illnesses in the family. The patient reported that parents had never allowed this child to have friends or share her problems with friends. Except during school hours, she had no association with her friends. As there was the pandemic of COVID-19, she did not attend school and was missing her school friends.
Physical examination revealed that she is active, pink, and well-grown. There was oval-shaped patch of hair loss on the left forehead (Figure 1). No other hair loss was noted. All other systems examination was normal. The dermatologist suspected the possibility that hair had likely been shaved rather than pulled (trichotillomania) or lost spontaneously. The dermoscopy examination revealed uniform loss of hair with all the hair follicular openings filled with black hair shafts (Figure 2). Furthermore, there was no erythema, tenderness, ulcers, or scaring, and it was confirmed that hair loss was caused by shaving with a blade upon careful history taking. The hair-pull test was negative. Her parents were advised about the nature of her problem, but parents were not convinced at all initially. She was referred to the psychiatrist for further assessment. While waiting for psychological assessment in one-week time, her mother again reported that there was hair loss in the pubic region and hand on the next day (Figure 3). These patches of hair loss were also confirmed to be secondary to shaving rather than pulling of her hairs. The child denied the act of shaving. However, parents were convinced this time and were advised to observe the child as to whether she had any shaving razors or been using her father's shaving razor. Subsequently, the mother could find a razor in her bed room.
The psychiatrist further assessed her and found that she had clinical features of obsessive-compulsive disorder and anxiety behaviour. The final diagnosis was made as trichotemnomania secondary to obsessive-compulsive disorder following multidisciplinary assessment. She was started on sertraline at a dose of 50 mg/day and behaviour modification counselling.
After 3 months of treatment, the medication could be tailed off. Currently, she has been under follow-up at the child guidance clinic and off all medications. As school had been restarted following control of COVID-19 outbreak in the country, she now has an opportunity to make new friends. Her hyperventilation and sleep disorder have also resolved.