**3. Psychosocial effects of scarring alopecia**

suicidal behavior have also been found in the first-degree relatives of patients with trichotillomania compared to healthy individuals [45, 50, 51]. Psychological findings and disorders

**Pediatric trichotillomania Adult trichotillomania First-degree relatives**

**•** Negative mood **•** Substance use

**•** Antisocial personality **•** Avoiding social and sexual intimacy

**•** Antisocial personality

**•** Alcoholism

**•** Drug addiction **•** Suicidal behavior

**•** Anxiety disorder **•** Attention deficithyperactivity disorder

**•** Depression

disorder

**•** Obsessive-compulsive

**•** Decreased professional productivity

**•** Mood and personality

**•** Anxiety disorder

disorders

Although the diagnosis can usually be made with the history and examination, patients may not report their problem due to shame, and fear of being mocked or being labeled as a lunatic. The physician should therefore not approach the behavior in an incriminating or condescend-

A substantial number of patients with normal scalp hair and without any sign of alopecia complain of alopecia at dermatology outpatient departments. This condition is identified as *"imaginary hair loss"* or *"psychogenic pseudoeffluvium"* and can be a symptom of an underlying psychological disease. Depression and anxiety disorders are common in these patients. Problems about marriage and the prevalence of depression are believed to be increased in married female patients thought to be suffering from psychogenic pseudoeffluvium. One must also consider that *"body dysmorphic disorder"* or *"delusion of alopecia,"* which can be included among psychotic disorders, could be present in these patients. Obsessive-compulsive behavior such as looking at the mirror for hours to check the hair can be present in these patients [47, 52]. These patients are among the most grueling cases for dermatologists and

ing manner and should be careful while referring these patients to psychiatry.

should be directed to psychiatrists/psychologists in an appropriate manner.

associated with trichotillomania are summarized in **Table 3**.

**•** Thumb sucking

**•** Nose picking

**•** Masturbation

**•** Bad friendships

**•** School problems

**•** Attention deficithyperactivity disorder

**•** Obsessive-compulsive

**Table 3.** Psychological findings and disorders associated with trichotillomania.

**•** Depression

disorder

Psychological findings **•** Nail biting

246 Hair and Scalp Disorders

Psychological disorders **•** Anxiety disorder

*2.4.2. Psychogenic pseudoeffluvium*

Scarring alopecia is a condition characterized by loss of hair as a result of replacement of the follicular structure by fibrous tissue [53]. Scarring alopecia is more common in women. It develops mainly due to lichen planopilaris, discoid lupus erythematosus, frontal fibrosing alopecia, dissecting cellulitis, folliculitis decalvans, central centrifugal alopecia, tufted folliculitis, perifolliculitis abscedens et suffodiens, and pseudopelade (Brocq) [54]. However, nonfollicular conditions (traumatic, burn-induced, inflammatory, infectious, neoplastic, and genetic conditions) can also affect the scalp and cause secondary scarring alopecia. Whatever the underlying reason, scarring alopecias usually create more psychosocial effect than nonscarring alopecias. Pradhan et al. have recently reported moderate-severe psychosocial stress in almost 75% of their patients with scarring alopecia. Although worry about the outer appearance is more prominent in female patients, the psychological effect of scarring alopecia has been reported to be equally severe in both genders. Aesthetic concerns have been found to be higher in younger patients with these patients feeling older due to scarring alopecia. The condition leads to feeling physically unattractive, loss of confidence, and embarrassment in this age group. However, the duration of the disease has been shown not to be proportional to the psychosocial effect it creates and the psychological stress not to decrease even if the disorder becomes chronic [53]. Although it was thought that individuals who were single would experience more stress with the disorder, no difference was found between married and single subjects. This could be related to the condition being more common in women and women receiving less psychological support from male spouses in a male-dominated world. Patients with more localized scarring alopecia were also found to experience less stress than patients with diffuse scarring alopecia because they can cover these areas with their normal hair [38, 53, 54].

The quality of life of female patients with scarring alopecia was shown to be more affected and consequently anxiety and depression to be more common in a study where female patients with and without scarring were compared [54].

It has also been suggested that patients spend a lot of time and effort to normalize their appearance leading to decreased success in friendship, work, and school life in scarring alopecia with a destructive and progressive course [53].

Early diagnosis with clinicopathological correlation and starting treatment at an early stage is essential to prevent irreversible hair loss in scarring alopecia. Starting psychological support from the early stage is also essential in terms of a holistic treatment approach.
