A Case of Late-Onset Trichotillomania with Coexisting Dysthymiaand Substance Use

Trichotillomania is a compulsive disorder characterized by recurrent hair-pulling, typically beginning in adolescence and showing a marked female predominance. Late-onset cases are rare and frequently associated with psychiatric comorbidity. We report a 62-year-old woman referred from dermatology with a two-year history of scalp itching and repetitive hair-pulling that began shortly after she realized she had used expired hair dye. Despite multiple dermatological consultations, no organic pathology was identified. Psychiatric evaluation revealed a three-year history of persistent low mood, worsening over the preceding two months, along with relapse of alcohol use 20 days prior to presentation after 25 years of abstinence. Psychosocial stressors were significant, and biological and social functioning were impaired. Examination showed patchy alopecia, while dermatoscopy demonstrated broken hairs and perifollicular hemorrhage. Mental status examination revealed agitation, preoccupation with scalp discomfort, and depressive cognitions. She was diagnosed with dysthymia, a current moderate depressive episode with somatic syndrome, and trichotillomania; alcohol use did not meet criteria for dependence. Laboratory investigations and brain MRI were normal. Treatment with escitalopram, short-term anxiolytics, and behavioral interventions resulted in an approximately 25% reduction in symptom severity at six-week follow-up. This case underscores the importance of recognizing psychiatric morbidity underlying persistent dermatological complaints and highlights the need for a multidisciplinary approach in lateonset trichotillomania.