Corkscrew Hairs in Trichoscopy of Trichotillomania

Dear Sir, A woman in her twenties presented with progressive vertex hair thinning for 6 months, without associated symptoms. She denied receiving heat or chemical hair treatments, hair-pulling, extensions, or frictional habits. She reported untreated anxiety episodes over the past year and had a known history of iron deficiency anemia. Examination showed diffuse alopecia over the vertex and frontoparietal regions with relative sparing of the remaining scalp [Figure 1]. Hair pull and tug tests were negative. Dermoscopy (DermLite DL4, 10×, polarized) revealed multiple irregularly broken hairs of varying lengths, along with a few irregularly coiled and corkscrew-like hairs. Additional findings revealed flame hairs, trichoptilosis, and hair casts [Figure 2]. The card test demonstrated irregular longitudinal twisting with distal trichoptilosis [Figure 3]. Potassium hydroxide mount of hair shafts showed no fungal elements. The differential diagnoses considered included tinea capitis, trichotillomania (TTM), and traction alopecia.Figure 1: Diffuse non-scarring alopecia involving the frontoparietal regionFigure 2: (A) Dermoscopy (Dermlite DL4, 10× magnification, polarized mode) reveals multiple broken hair shafts (yellow arrow) with distal trichoptilosis (green arrow), along with flame hair (red arrow), hair casts and peppering (light green arrow), and a few irregular corkscrew hairs (black arrow). (B): Dermoscopy (Dermlite DL4, 10×, polarized mode) reveals numerous corkscrew hairs in tinea capitisFigure 3: Card test reveals the presence of twisting of hair shafts along the long axis with distal fraying and trichoptilosis.Histopathology from the vertex scalp showed distorted, triangular hair shafts with trichomalacia, pigment casts, intrafollicular hemorrhage, and polytrichia [Figure 4A, B]. PAS staining at multiple levels was negative for fungal elements, effectively ruling out tinea capitis.Figure 4: (A) Histology (hematoxylin and eosin, scanner magnification) reveals the presence of multiple broken triangular hair shafts with pigment casts (black arrow) and empty follicular units (red arrow) without any inflammatory infiltrate. (B): Histology (hematoxylin and eosin, ×40 magnification) shows trichomalacia with broken hair shafts (black solid arrow) without any inflammatory infiltrateBased on the clinical, dermoscopic, and histopathological features, a diagnosis of TTM was established. The patient was counseled and referred for psychiatric evaluation. She was initiated on habit reversal therapy (HRT) and iron supplementation but was subsequently lost to follow-up. TTM (Greek: thrix—hair, tillein—to pull, mania—madness) is a psychodermatological disorder defined by recurrent hair-pulling that results in noticeable alopecia. It occurs in two patterns: a self-limiting childhood form resembling other benign repetitive habits (e.g., nail-biting and thumb-sucking) and a chronic adult form, more common in females and often associated with depression or anxiety. The DSM-5 classifies TTM as obsessive–compulsive and related disorders. Hair is usually plucked in an irregular pattern, most often from the frontoparietal scalp, producing uneven, broken, and twisted shafts that may mimic a “Friar Tuck” pattern. Pulling may be automatic or focused, and some individuals exhibit trichophagia, which can lead to trichobezoar formation.[1] Dermoscopy plays a key role in distinguishing TTM from other forms of non-scarring alopecia, such as alopecia areata, tinea capitis, and traction alopecia. Trichoscopic features commonly associated with TTM include trichoptilosis, the V-sign, hook hairs, flame hairs, coiled hairs, tulip hairs, hair powder, black dots, and broken hairs.[2,3] Alopecia areata shows yellow dots, black dots, exclamation-mark, and cadaverized hairs. Tinea capitis features corkscrew, comma, zig-zag, and Morse-code hairs with black dots and scaling. Traction alopecia presents with hair casts, broken hairs, black dots, and reduced follicular density. Although corkscrew hairs are classically associated with tinea capitis (particularly endothrix infections), they may appear in TTM as irregular and sparse forms accompanied by other traction-related features [Table 1].[4,5]Table 1: Difference in corkscrew hairs between tinea capitis and trichotillomaniaRepetitive mechanical trauma such as tugging, twisting, and pulling weakens the hair shaft and can produce these atypical corkscrew morphologies. Corkscrew hairs may also occur in scurvy, alongside follicular hyperkeratosis and perifollicular hemorrhage.[6] Histopathology of TTM typically demonstrates irregularly broken shafts with pigment casts, intrafollicular hemorrhage (“hamburger sign”), trichomalacia, increased catagen/telogen ratio, and follicular dropout. Early traction alopecia, which may show triangular or irregular follicles and a reduced terminal:vellus ratio without inflammation, can histologically overlap with TTM.[7,8] Management focuses on identifying and addressing the underlying psychiatric comorbidities. Cognitive behavioral therapy and HRT have demonstrated effectiveness in numerous cases. For refractory or severe presentations, pharmacologic interventions including clomipramine, olanzapine, and N-acetylcysteine may be considered.[1] We report this novel dermoscopic observation of corkscrew hairs in TTM to aid in the early recognition and diagnosis of the condition, enabling timely intervention. Acknowledgments None. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest