The case of the balding preschooler

A common cause of focal nonscarring alopecia in children is trichotillomania (TTM), a pediatric-onset obsessive-compulsive and related disorder. Although it is useful to differentiate between the early-onset TTM that tends to be more automatic and self-limited and the later-onset more compulsive and persistent variant, currently TTM is not formally subtyped. The diagnosis of TTM is clinical, with the key elements being a history that is positive for hair manipulation, physical examination that shows patches of incomplete alopecia with irregular borders, and trichoscopy demonstrating broken hairs on a normal scalp. Early-onset TTM responds well to simple behavior interventions, and later-onset TTM is best managed with behavior and pharmacologic therapy.