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Introduction
A 12 year old boy presented with two patches of hair loss on his scalp (figure). A clinical and histopathological diagnosis of trichotillomania was made. On follow up after taking a detailed history, the boy revealed that the hair was being pulled by an abusive teacher during tuition after school. I found two more children similarly abused by the teacher. I discuss the importance of this under-recognised pattern of child abuse and its similarity to trichotillomania.
Localised patch of hair loss on the scalp
Child abuse has varied manifestations. Physical abuse of a child often results in identifiable dermatological signs, which can pinpoint the diagnosis. Abuse can closely resemble other dermatoses, however, resulting in diagnostic errors.
Trichotillomania is a condition currently classified as an impulse control disorder, which is characterised by repetitive pulling of one's own hair resulting in alopecia.
Case report
A 12 year old boy was referred by his family physician to the dermatology outpatient department with a complaint of partial hair loss on his scalp that was noticed one week before. On examination, there were two patches of partial alopecia on the temporovertical scalp measuring 2 cm by 2 cm and 3 cm by 3 cm. The hair shafts were broken off at different levels and there was no evidence of scarring. The scalp was not tender or bruised. A hair pull test did not find his hair easy to pluck and hair shaft microscopy was normal. A potassium hydroxide preparation from the lesional skin did not show any fungal elements. A skin biopsy from one of the patches found many empty hair bulbs without any inflammation or scarring. Several catagen hair follicles were also identified.
Based on these clinical and histopathological findings, I diagnosed him as...