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Trichotillomania — SCE Dermatology MCQ

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HardPsychodermatologyTrichotillomaniaSCE Dermatology

A woman has an irregular non-scarring alopecic patch containing hairs of different lengths. Trichoscopy shows flame hairs, coiled hairs, tulip hairs and the V-sign. She describes mounting tension before pulling and relief afterwards. What is the core first-line intervention?

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Correct answer: D — Cognitive behavioural therapy with structured habit-reversal training

Explanation lettering: D = shown as A · A = shown as B · B = shown as C · E = shown as D · C = shown as E

E is correct. The history and trichoscopic pattern support trichotillomania rather than alopecia areata, tinea capitis or androgenetic alopecia. Habit-reversal training uses awareness of triggers, competing responses and stimulus control and is commonly delivered within cognitive behavioural therapy; comorbid anxiety, depression, obsessive-compulsive symptoms and safeguarding needs should also be assessed. Intralesional corticosteroid treats alopecia areata, terbinafine requires evidence of dermatophyte infection, and finasteride/minoxidil does not address hair-pulling behaviour. Examination should remain non-judgemental, and occlusive or behavioural environmental measures may supplement rather than replace psychological treatment.

Reference: PCDS trichotillosis guidance: https://www.pcds.org.uk/clinical-guidance/trichotillosis-formerly-called-trichotillomania