Trichotillomania Triggered by Vitamin D Deficiency and Resolving Dramatically With Vitamin D Therapy İsmail Akaltun, MD Abstract: Trichotillomania (TTM) is a disorder characterized by the indi- vidual pulling out his hair in a repetitive manner, resulting in significant hair loss, a feeling of tension before the hair pulling, and pleasure during it. Our understanding of the neurobiological basis of TTM is limited. How- ever, the condition in all likelihood involves multiple pathways and a com- plex interaction between various genetic, psychological, and social factors. Vitamin D deficiency is thought to be linked to rickets in children and to a range of different diseases in adults, including osteoporosis, osteomalacia, cardiovascular diseases, cancer, dermatological diseases, and psychiatric disorders. We report a case of a 4-year-old girl with TTM triggered by vi- tamin D deficiency resolving dramatically with vitamin D therapy. Key Words: trichotillomania, vitamin D deficiency (Clin Neuropharm 2019;42: 20–22) T richotillomania (TTM) is continuously pulling out one's own hair, which results in hair loss, multiple attempts to reduce or stop the hair pulling, clinically significant impairment in daily functioning (eg, social gatherings, work), the hair pulling is not associated with another medical condition, and it cannot be ex- plained by another mental disorder. 1 Several studies have reported onset of TTM in childhood or adolescence. Pulling of the scalp hair is most frequently observed in cases of TTM, whereas pulling the hair from other regions, such as the eyebrows, eyelashes, beard-mustache, axilla, and inguinal region, is less common. 2,3 Although there is no consensus on the cause of TTM, various eti- ological models have been proposed based on different theoretical perspectives. These models are based on psychoanalytical, bio- logical, and behavioral causes. In terms of biological causes, sero- tonin has been regarded as the neurotransmitter with the greatest involvement in TTM, although the most recent studies support the idea that dopamine plays a potent role in the pathophysiology of the disease. 4 Vitamin D is one of the hormones whose importance to growth and a healthy skeleton from birth to death has been known for the longest. The principal function of vitamin D is to establish the requisite calcium and phosphorus levels for growing bone tis- sue in children and for bone regeneration and mineralization in adults. 5 Its principal function is the anabolic activation of calcium and bone metabolism, and because its effects have become better understood in recent years, vitamin D has become recognized as one of the most important metabolic factors in the body. Vitamin D deficiency is thought to be linked to rickets in children and to a range of different diseases in adults, including osteoporosis, osteo- malacia, cardiovascular diseases, cancer, dermatological diseases, and psychiatric disorders. 6–8 We report a case of TTM resulting from vitamin D deficiency in a 4-year-old girl. CASE A 4-year-old girl was brought to our polyclinic by her mother because of hair pulling and eating the pulled-out hair. According to her mother, the patient had begun pulling out the hair on the right side of her head 4 months ago and had subsequently begun eating that hair. The patient had presented to the pediatric poly- clinic because of these symptoms 3 weeks ago. After examination and tests in the pediatric polyclinic, her vitamin D level was low (2 ng/mL), whereas all results of the other tests were normal. The pediatrician, therefore, diagnosed vitamin D deficiency. The patient was started on vitamin D therapy (50,000 IU/wk) and re- ferred to the child psychiatry unit. Her mother reported that she had made an appointment and presented to our polyclinic. Again according to the mother, the patient's hair pulling and eating be- havior decreased after starting vitamin D therapy, significantly so in the last few days. Psychiatric examination results revealed a female patient appearing her stated age, with normal psychomotor activity, open to communication, making eye contact, able to form sentences of four to 5 words, and exhibiting age-appropriate development. Sig- nificant hair loss, 7 to 8 cm in diameter, was observed in the right frontotemporal region (Fig. 1), and TTM was diagnosed based on Diagnostic and Statistical Manual of Mental Disorders 5 diagnos- tic criteria. Vitamin D levels investigated because of the decrease in the patient's hair-pulling behavior after vitamin D therapy were seen to have increased to 15 ng/mL. Because of the significant de- crease in TTM, we advised that the patient continue to receive vita- min D therapy, with a control visit 3 weeks subsequently. The patient was brought back for this control visit after 3 weeks, at which we learned that the hair-pulling behavior had ceased en- tirely. The patient's vitamin D level had increased to 35 ng/mL, within normal thresholds. DISCUSSION This report describes a 4-year-old girl diagnosed with TTM resulting from vitamin D deficiency. Scalp hair pulling is the most commonly reported symptom in cases of TTM 2,3 and was also present in our patient. Age at onset of TTM is generally between 11 and 15 years. 2,9 Age at onset of the type commencing in early childhood is 18 months. 10 Our understanding of the neurobiologi- cal basis of TTM is limited. However, the condition in all likelihood involves multiple pathways and a complex interaction between var- ious genetic, psychological, and social factors. Changes in reward processing and impulse control with the neurotransmitters serotonin and dopamine, as well as γ-aminobutyric acid, have been impli- cated. 11 Various publications supporting this theory have suggested that medications such as selective serotonin reuptake inhibitors and antipsychotics are effective in the treatment of TTM and that the fa- cilitating effect on neurotransmission of the psychostimulants on dopamine and serotonin that are generally used leads to compulsive behavior such as hair pulling. 12 Gaziantep Dr. Ersin Arslan Training and Research Hospital, Department of Child and Adolescent Psychiatry, Gaziantep, Turkey. Address correspondence and reprint requests to İsmail Akaltun, MD, Gaziantep Dr. Ersin Arslan Training and Research Hospital, Department of Child and Adolescent Psychiatry, Eyüpoğlu Mahallesi, Hürriyet Cd, No. 40, 27010 Şahinbey/Gaziantep, Turkey; E‐mail: drmahirx@hotmail.com Conflicts of Interest and Source of Funding: The authors have no conflicts of interest to declare. Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved. DOI: 10.1097/WNF.0000000000000317 CASE REPORT 20 www.clinicalneuropharm.com Clinical Neuropharmacology • Volume 42, Number 1, January/February 2019 Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved.