“It's her hair,” the mother said as she brought in her fourteen-year-old daughter. What we saw were two stripes of bald skin running across the girl's scalp. Present for two years, they crossed forming a perfect crucifix pattern. It looked as if one had run a hair clipper from the forehead posteriorly to the nape of the neck, and then clipped a 3/4 inch band transversely to form a precise cross. The margins were straight as an arrow, so geometric that we realized it was nothing nature could produce. It had to be the patient.

She was pulling her hair out. It was not the total loss of alopecia areata with its round patterns of totally bald skin. A pluck test showed that her hairs had excellent root strength, and a twist test proved the hairs were not fragile and could not be broken easily. The very short stubble present in the bare areas suggested to us that she would pull the hairs out as soon as they were long enough to grasp with her fingers. Her skin was perfectly normal, and the other doctors she had seen for this problem had found her to be in excellent health on physical and laboratory examinations.

We made the diagnosis of trichotillomania, i.e., hair loss due to the patient pulling out her own hair. It was a nonverbal cry for help. We usually see it in children brought in with the complaint of thinning hair.