CASE REPORTS

Trichotemnomania: Obsessive-compulsive habit ofcutting or shaving the hair

Rudolf Happle, MD

Marburg, Germany

A 28-year-old woman presented with a completely hairless scalp. The disorder had started 1 year ago, andat the same time she had developed dysphonia. During the past year, her hair disease had been diagnosedas alopecia areata totalis by many specialists, including several dermatologists. A close inspection of herscalp, however, revealed that no alopecia was present, because all infundibula were filled with a hair shaftthat, on microscopic examination, showed cleanly cut surfaces. A scalp biopsy specimen showedcompletely normal structures. The pubic area was found to be covered with hair stubs of the samelength. Therefore, a diagnosis of trichotemnomania was made. This term is derived from Greek thrix (hair),temnein (to cut), and mania (madness). After a stressful life event, the patient had developed bothpsychogenic dysphonia and the compulsive habit to remove the hair of her scalp, eyebrows, and axillaryand pubic areas by shaving. Trichotemnomania is a distinct obsessive-compulsive disorder that should notbe confused with trichotillomania. The condition should be taken into account when a supposed alopeciaareata looks somewhat unusual. ( J Am Acad Dermatol 2005;52:157-9.)

Every dermatologist knows trichotillomania,the compulsive habit of plucking hair, re-sulting in bizarre bald patches and sometimes

in virtually total hairlessness of the scalp.1 Anotherfactitious disorder characterized by hair loss istrichotemnomania, an obsessive-compulsive habitto cut the hair with scissors or with a razor.2 This hairdisease has so far not been mentioned in US text-booksofdermatology.A typical case ispresentedhere.

CASE REPORTA28-year-oldwomanpresentedwith a completely

hairless scalp. She reported that the disorder hadbegun 1 year ago with small round bald patches onthe right side of her scalp. Later she had also lost hereyebrows and axillary and pubic hair. Approx-imately 1 year ago she had also developed psycho-genic dysphonia that was interpreted by herpsychiatrist as a reactive disorder resulting from thesudden onset of total alopecia.

At a first glance, physical examination showed anentirely bald scalp (Fig 1). The axillary and pubicareas likewise appeared to be hairless. A close

From the Department of Dermatology, Philipp University of

Marburg.

Funding sources: None.

Conflicts of interest: None identified.

Reprint requests: Rudolf Happle, MD, Department of Dermatology,

University of Marburg, Deutschhausstrasse 9, 35033 Marburg,

Germany. E-mail: happle@med.uni-marburg.de.

0190-9622/$30.00

ª 2005 by the American Academy of Dermatology, Inc.

doi:10.1016/j.jaad.2004.07.060

inspection of the scalp, however, showed that allfollicle openings were filled with black hair shafts,none of them being elevated above the skin surface(Fig 2). In fact, the scalp looked like it had beenshaved. The eyebrows and the axillary hair were alsoabsent. An important additional diagnostic clue wasnoted in the pubic area where all of the hair waspresent but only 4-mm long (Fig 3). Obviously, thehair had not been shaved for several days in thisregion. Her nails did not show any pathologicchanges. Scanning microscopic examination of a bi-opsy specimen obtained from the occipital region ofthe scalp showed that the hair stubs had cleanly cutsurfaces. Similar cut surfaces were noted on lightmicroscopic examination of individually pluckedhair stubs. On histopathologic examination regularstructures including normal hair follicles were found.In particular, no inflammatory infiltrates or othersigns of alopecia areata were present.

We made a diagnosis of trichotemnomania andgave the advice that a further psychiatric or psycho-somatic approach should be performed to help thispatient who had developed psychogenic dysphoniaand trichotemnomania after she had been left by herfriend who moved elsewhere for occupationalreasons. The patient could not be followed up fur-ther because she lived far away and had only pres-ented for one consultation.

DISCUSSIONThe term ‘‘trichotemnomania’’ is derived from

the Greek thrix (hair), temnein (to cut), and

157

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158 Case reports

mania (madness).2 The patient had developed thisobsessive-compulsive disorder in an extreme form.Remarkably, however, during 1 year all of theinvolved internal specialists, psychiatrists, and derm-atologists had erroneously diagnosed her hair disor-der as alopecia areata totalis. This misdiagnosis wasencouraged by the patient herself who rather ex-pressively reported that the disease had started withround bald patches on her scalp. We excluded thisdiagnosis because of the presence of hair stubs withcut surfaces as found on microscopic examination.

From checking the Internet it appears thattrichotemnomania is so far a European disorder.There are only two references. In 1968, Braun-Falcoand Vogel2 created the name ‘‘trichotemnomania’’

Fig 1. Completely hairless scalp mimicking alopeciaareata totalis.

Fig 2. Close-up view showing that all follicle openings arefilled with hair. Note subtle signs of shaving trauma.

when describing a patient with this particular form ofobsessive-compulsive behavior. She was cutting herhair with scissors. In 1971, Meiers3 reported anotherpatient who showed hairless areas that looked likethey had been shaved. Up until now, some Europeantextbooks make note of the disorder,4,5 but otherreference books, including all of the presently avail-able US textbooks of dermatology,6-9 fail to mentiontrichotemnomania.

The disorder should not be confused with tri-chotillomania. The compulsive habit of hair pluckingresults in quite different clinical features such astonsural patterns of hairlessness and irregular lengthof hair shafts.1 Moreover, trichotillomania is charac-terized by distinct histopathologic changes1 whereastrichotemnomania shows entirely normal histo-logic structures. Another obsessive-compulsive habitcausing hair loss consists of repeated rubbing, a con-dition called ‘‘trichoteiromania.’’10,11 From a practicalpoint of view, it seems reasonable to distinguishthese 3 factitious disorders characterized by hair loss.Both trichotillomania and trichoteiromania prepon-derantly occur in the female sex.1,10,11 Tricho-temnomania has so far been described exclusivelyin women.

In conclusion, dermatologists should think oftrichotemnomania when a supposed alopecia areatalooks somewhat unusual.

REFERENCES

1. Hautmann G, Hercogova J, Lotti T. Trichotillomania. J Am Acad

Dermatol 2002;46:807-21.

2. Braun-Falco O, Vogel PG. Trichotemnomanie: Eine besondere

Hautmanifestation eines hirnorganischen Psychosyndroms.

Hautarzt 1968;19:551-3.

3. Meiers HG. Zur weiteren Kenntnis der Trichotemnomanie.

Hautarzt 1971;22:335-7.

4. Braun-Falco O, Plewig G, Wolff HH, Burgdorf WHC, editors.

Dermatology. 2nd ed. Berlin: Springer; 2000.

5. Saurat JH, Grosshans E, Laugier P, Lachapelle JM, editors.

Dermatologie et maladies sexuellement transmissibles. 3rd ed.

Paris: Masson; 1999.

6. Freedberg IM, Eisen AZ, Wolf K, Austen KF, Goldsmith LA,

Katz SI, editors. Fitzpatrick’s dermatology in general medicine.

6th ed. New York: McGraw-Hill; 2003.

Fig 3. Pubic area showing hair stubs of same length,providing proof that it has been shaved.

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Case reports 159

7. Odom RB, James WD, Berger TG, editors. Andrew’s diseases of

the skin: clinical dermatology. 9th ed. London and New York:

WB Saunders; 2000.

8. Schachner LA, Hansen RC, Happle R, Krafchik BR, Lucky AW,

Paller AS, et al, editors. Pediatric dermatology. 3rd ed.

Edinburgh: Mosby; 2003.

Subungual neu

Maureen Connolly, MRCPI,a James R. Hickey, MRCP,a

David A. R. de B

Bristol, United

Neurothekeomas are benign tumors probably of nernerve sheath myxomas. They are commonly found onlower limbs. To our knowledge, this is the first casetoe. Histology confirmed a well-circumscribed, multispindle cells in a copious myxoid matrix staining p2005;52:159-62.)

CASE REPORTA 27-year-old woman presented with a 10-year

history of a progressively enlarging and painfulsubungual lesion affecting her right big toe. Theonly potential precipitating factor had been traumaat the age of 9 years when a horse trod on her foot.She was otherwise fit and well.

On examination there was splitting of the nailand a subungual mass (Fig 1, A). Clinically red-ness around the lunula suggested a myxoid cyst.The more recent onset of pain, however, wasunusual for this diagnosis. Excision of the entirenail matrix and nail bed was, therefore, pro-posed.

Under proximal digital ring block the tumor wasexcised down to the bone. Perioperatively a rela-tively large tumor was confirmed with diffusemargins (Fig 1, B). Despite unremarkable radio-graphic examination a scalloped depression of the

From the Departments of Dermatologya and Histopathology,b

Bristol Royal Infirmary.

Funding sources: None.

Conflicts of interest: None identified.

Reprint requests: David A. R. de Berker, MRCP, Bristol Dermatology

Centre, Bristol Royal Infirmary, Marlborough St, Bristol, BS2 8HW,

United Kingdom.

0190-9622/$30.00

ª 2005 by the American Academy of Dermatology, Inc.

doi:10.1016/j.jaad.2004.08.055

9. Bolognia JL, Jorizzo JL, Rapini RP, Horn TD, Mancini AJ,

Mascaro JM, et al, editors. Dermatology. London: Mosby; 2003.

10. Freyschmidt-Paul P, Hoffmann R, Happle R. Trichoteiromania.

Eur J Dermatol 2001;11:369-71.

11. Reich S, Trueb RM. Trichoteiromanie. J Dtsch Dermatol Ges

2003;1:22-8.

rothekeoma

Laszlo Intzedy, MD,b Joya Pawade, FRCPath,b anderker, MRCPa

Kingdom

ve sheath origin and are also known as dermalthe face, arm, or shoulder and less frequently theof a subungual neurothekeoma affecting the biglobulated tumor composed of bland stellate andositive with S100 protein. ( J Am Acad Dermatol

underlying distal phalanx was identified (Fig 1, C).During the subsequent 6 weeks the wound healedby secondary intention.

Macroscopically the tumor was firm and gelati-nous. Histologically, there was an 18-mm diameter,well-circumscribed, multilobulated tumor.

Each lobule was composed of bland spindle-shaped and rounded cells embedded in an abundantmyxoid stroma. Occasional multinucleated cellswere seen. The lobules were separated by prominentconnective tissue septa. Therewas no pleomorphismand no mitotic activity. This pattern suggesteda myxoid form of neurothekeoma (Fig 2). This wasfurther supported by the immunohistochemistry thatshowed the tumor cells to be strongly S100-proteinpositive (Fig 3). Less definitive markers includingepithelial membrane antigen (EMA), CD34, andHMB45 were all negative. The clinical and immuno-histochemical features helping to differentiate thesubtypes of neurothekeoma are summarized inTable I.

Although the tumor extended to the base of thespecimen making the excision incomplete no re-occurrence has occurred during our 18-month fol-low-up (Fig 1, D).

DISCUSSIONHarkin and Reed1 first described this rare benign

tumor in 1969. The original term ‘‘dermal nerve