Trichotillomania (TTM) is a psychiatric disorder characterized by frequent, recurrent, and irresistible urges to pull hair from one's head, eyebrows, or other areas of the body. Cognitive behavioral therapy and antidepressants have traditionally been used to treat this disorder, but these treatments are not always successful. In recent years, research has emerged that looks at the use of injectable botulinum therapy in TTM patients.

Botulinum toxin blocks nerve signals, which leads to muscle relaxation and decreased activity of nerve endings at the injection site. This can reduce the sensation of itching and tension that provokes people to pull their hair [1, 2].

Engel E.R. and Ham J.A. (2023) described the case of a 30-year-old woman with a long history of TTM who was resistant to cognitive behavioral therapy and medications. The patient also suffered from chronic migraines and was prescribed botulinum therapy for headache relief. The botulinum therapy was successful, and the headaches were significantly reduced. After completing the main course of botulinum therapy, the patient received 45 units of onabotulinumtoxinA intradermally into the scalp, 5 units at each point. The patient reported marked improvement in the signs and symptoms of trichotillomania. Her hair began to regrow at the first follow-up visit 12 weeks after the start of treatment. The effect of the treatment was maintained, and additional hair regrowth was observed for 1 year after treatment, at which point four cycles of treatment had been completed.

Why is this promising?

1. Fewer triggers. Botulinum toxin relieves the sensation of discomfort in the skin, which often causes the habit of pulling hair.
2. Hair Restoration. For patients, this is an aesthetic benefit and a way to boost self-esteem.
3. Long-term effects. Results can persist with repeated treatments [1, 2].

Intradermal injectable botulinum therapy is not yet included in TTM treatment protocols. Nevertheless, the method may be helpful for patients in whom other methods have yet to work [2, 3].

References

1. Ghani H., Podwojniak A., Tan I. . et al.From tugs to treatments: a systematic review on pharmacological interventions for trichotillomania. Clin Exp Dermatol 2024; 49(8): 774–782.
2. Engel E.R., Ham J.A. Amelioration of trichotillomania with onabotulinumtoxinA for chronic migraine. BMJ Case Rep 2023; 16(2): e254006.
3. Trimboli M., Troisi L. Botulinum toxin and psychiatric applications. Pain Medicine, 2021; 22(3): 759–760.