Trichotillomania (Hair-Pulling Disorder) 253
Development and Course
Hair pulling may be seen in infants, and this behavior typically resolves during early devel-
opment. Onset of hair pulling in trichotilloman ia most commonly coincides with, or follows
the onset of, puberty. Sites of hair pulling may vary over time. The usual course of trichotillo-
mania is chronic, with some waxing and waning if the disorder is untreated. Symptoms may
possibly worsen in females accompanying horm onal changes (e.g., menstruation, perimeno-
pause). For some individuals, the disorder may come and go for weeks, months, or years at a
time. A minority of individuals remit without su bsequent relapse within a few years of onset. 
Risk and Prognostic Factors
Genetic and physiological. There is evidence for a genetic vulnerability to trichotillo-
mania. The disorder is more common in in dividuals with obsessi ve-compulsive disorder
(OCD) and their first-degree relative s than in the general population. 
Culture-Related Diagnostic Issues 
Trichotillomania appears to manifest similarly across cultures, although there is a paucity
of data from non-Western regions.
Diagnostic Markers
Most individuals with trichotillomania admit to hair pulling; thus, dermatopathological
diagnosis is rarely required. Skin biopsy an d dermoscopy (or trichoscopy) of trichotillo-
mania are able to differentiat e the disorder from other causes of alopecia. In trichotil-
lomania, dermoscopy shows a range of charac teristic features, in cluding decreased hair
density, short vellus hair, and broken hairs with different shaft lengths. 
Functional Consequences of