the term was used by hallopeau in 1889 and is derived from the greek ; thrix - hair , tillein - pull out and mania - madness . scalp is the most common site for pulling hair although other hair bearing areas may be involved . in less severe forms diagnosis is mainly by history and clinical examination , nevertheless , sometimes it is very difficult to differentiate it from other causes of noncicatricial alopecia . trichoscopy , dermoscopy hair and scalp , is a noninvasive technique for differential diagnosis of various hair and scalp diseases . here authors evaluated trichoscopic patterns in ttm and authors believe that these patterns are specific to ttm , which can aide in early diagnosis of this chronic condition . this study was carried out on 10 patients attending department of dermatology in a tertiary hospital attached to s. nijalingappa medical college at bagalkot , south india between january 2014 and july 2014 . ten patients with clinical features of ttm were subjected for a complete history and dermatological examination . demographic data such as age and gender and clinical variables in terms of site of lesions and disease duration were documented . dermlite 3 dermoscope ( 10 magnifications ) with both polarized and nonpolarized lights was employed in the study . sony camera ( digital , 14 mega pixels ) was attached to save the images . initially , ultrasound gel was applied either on the faceplate of dermoscopy or on the skin lesions and then lesions were observed through the eyepiece of dermoscopy . although polarized dermoscopy was employed , ultrasound gel was applied for clarity of images and to lessen distortions associated with light . this study was carried out on 10 patients attending department of dermatology in a tertiary hospital attached to s. nijalingappa medical college at bagalkot , south india between january 2014 and july 2014 . ten patients with clinical features of ttm were subjected for a complete history and dermatological examination . demographic data such as age and gender and clinical variables in terms of site of lesions and disease duration were documented . dermlite 3 dermoscope ( 10 magnifications ) with both polarized and nonpolarized lights was employed in the study . however , only polarized light version was used in our study . sony camera ( digital , 14 mega pixels ) was attached to save the images . initially , ultrasound gel was applied either on the faceplate of dermoscopy or on the skin lesions and then lesions were observed through the eyepiece of dermoscopy . although polarized dermoscopy was employed , ultrasound gel was applied for clarity of images and to lessen distortions associated with light . mean age of the patients was 34 years ( minimum age 13 years and maximum age 55 years ) . mean duration of disease was 19 months ( minimum 2 months and maximum 36 months ) . most common symptom was patchy loss of hair over the scalp ( 100% ) especially in the frontal area [ figure 1 ] and one patient ( 10% ) had tonsure pattern of hair loss . four patients agreed to knowingly pulling of hair , and one patient ( 10% ) gave a history of eating them ( trichophagia ) . the most common trichoscopic pattern observed in all patients was decreased hair density and hairs broken at different lengths ( 100% ) [ figure 2 ] . excoriations are also seen on the forehead trichoscopy showing decreased hair density , trichoptilosis ( yellow arrows ) , tulip hairs ( red arrows ) and perifollicular whitish areas ( red stars ) short hair with trichoptilosis (  split ends  ) [ figures 25 ] , irregular coiled hairs [ figure 3 ] and upright re - growing hairs were demonstrated in 8 patients ( 80% ) each . the novel diagnostic signs like black dots and flame hair [ figure 4 ] , v - sign [ figure 3 ] , follicular hemorrhages [ figure 5 ] were observed in 3 patients ( 30% ) each . tulip hair and hair powder [ figure 6 ] patterns were observed in 1 ( 10% ) patient each . all patients ( 100% ) had the noninflammatory alopecia with follicles having distorted and collapsed inner root sheath [ figure 7 ] in histopathology . trichoscopy showing coiled hairs ( red arrows ) and v - hairs or v - sign ( yellow arrows ) trichoscopy showing flame hairs ( red arrows ) and black dots ( yellow arrows ) trichoscopy showing decreased hair density , follicular hemorrhage ( black arrow ) and trichoptilosis ( red arrows ) trichoscopy showing tulip hairs ( red arrows ) and hair powder ( yellow arrows ) histopathology showing diffuse , noninflammatory alopecia , missing hair shafts ( black stars ) and inward collapse of outer root sheath ( black arrows ) . few unaffected follicles are also seen ( yellow arrows ) ( h and e , 4 ) histopathology showing an irregular , deformed and pigmented shaft characteristic of trichomalacia ( h and e , 40 ) trichotillomania is a chronic impulse control disorder characterized by repetitive hair pulling resulting in alopecia . in young children , it is usually a habit that resolves spontaneously or with minimal treatment . in older age groups , adolescents and adults , seen predominantly in females and evidence of some form of psychological or behavioral stress is often apparent . the favorite site is the easily reached fronto - parietal region of the scalp followed by eyelashes , eyebrows , pubic hair , body hair and facial hair . this results in patchy loss of hair , often in a bizarre or angular pattern , in which the hairs are twisted and broken at various distances from the clinically normal scalp . a hairball , trichobezoar , is a rare accompaniment of ttm in those who also eat the plucked hair ( trichophagia ) . in our study , most of the patients belonged to adolescent , and middle age group and most of them were females . all of them presented with patchy hair loss over the scalp , none of the patients gave a history of hair loss in other areas . only one patient had a history of eating of pulled hairs , but there were no signs and symptoms of trichobezoar in her . the diagnosis of ttm is often difficult as other hair loss diseases appear similar in clinical manifestations . this difficulty is encountered especially with alopecia areata ( aa ) . as ttm often coexists with aa trichoscopy is a novel diagnostic technique , both simple and noninvasive , can be used as a handy bed side tool for diagnosing common hair and scalp disorder . several common trichoscopy features of ttm were identified . decreased hair density , hairs broken at different lengths , short hairs with trichoptilosis ( " split ends " ) are described in the literature as diagnostic of ttm . authors observed these findings in all the patients , and this is due to irregular and repetitive pulling of hairs leading to damage to the cuticle . irregular coiled hairs and upright re - growing hairs are also reported to be seen in ttm . in this study , these findings were demonstrated in 80% of patients . coiled hair results from hair shaft fracture and coiling of the remaining proximal part which is fixed to the scalp . black dots are believed to be remnants of hair shafts arising from tapering hairs , broken hairs , and bent hairs . in a study conducted by shim et al . rakowska et al . observed that black dots tend to be uniform in size and shape in aa , whereas in ttm and tinea capitis they are variable in diameter and round , oval , irregular in shape . it presents as a red dot corresponding to follicular ostia capped or stuffed with the blood clot and suggests a history of traumatic forced plucking . recently , flame hairs , v - sign , tulip hairs , and hair powder are described , and authors claim these signs are specific only for ttm . flame hairs are semi - transparent , wavy and cone - shaped hair residues , which develop as a result of severe mechanical hair pulling and shredding . v - sign is created when two or more hairs emerge from one follicular ostium , which are pulled simultaneously and break at the same length above scalp surface . when hair shafts are almost totally damaged by mechanical manipulation , only a sprinkled hair residue is visible . this finding is referred to as  hair powder .  in the present study , these trichoscopic patterns were demonstrated in variable frequency . in aa , the common trichoscopic findings are yellow dots , uniform black dots , broken hair , trichoptilosis , upright re - growing hair , and vellus hair . as some of the trichoscopic features are overlapping in ttm and aa , histopathology plays a corroborative role in definitive diagnosis . the histopathological features of ttm include empty follicles , incomplete disrupted follicular anatomy , trichomalacia , and pigment casts without significant inflammation . collapsed inner root sheath and missing hair shaft indicate the extraction of the hair follicle due to forcible hair pulling . partially extracted and distorted root sheath material with fragments of pigment can be identified as the germinative follicular epithelium may produce abnormally formed , diminished and distorted hair shaft with irregular pigmentation as a result of trauma . a new trichoscopic pattern was observed by the authors in one patient , in the form of perifollicular whitish areas [ figure 2 ] . authors believe these whitish areas represent hyperkeratosis that is due to perifollicular damage as a result of repeated hair pulling trichotillomania is often chronic and difficult to treat . patients may attempt to disguise the condition due to its social implications . hence trichoscopy , being a noninvasive and in vivo diagnostic technique , can be utilized in this condition as it plays a vital role in the diagnosis of this condition by demonstrating specific trichoscopic patterns . further studies on trichoscopic patterns correlating with duration of disease and histopathology of ttm are suggested .
introduction : trichotillomania ( ttm ) is characterized by patchy alopecia of hair bearing areas . this is because of compulsive urge to pull the hair . 
 scalp is the most common site for pulling hair . 
 usually , patients may have only small areas of baldness , in severe forms , tonsure pattern of baldness is observed . 
 diagnosis is by history and clinical examination . 
 however , it is difficult to differentiate from other causes of noncicatricial alopecia . here , authors observed trichoscopic patterns and evaluated their importance in the diagnosis of ttm.materials and methods : this study was conducted in s. nijalingappa medical college , bagalkot , from january 2014 to july 2014 . 
 ten patients with clinically suspected ttm were included in the study . 
 informed consent was taken and ethical clearance was obtained . 
 dermlite3 dermoscope was used with sony camera attachment to save the images . 
 histopathological examination was conducted in all the patients to confirm the diagnosis.results:ten patients were included in the study . 
 mean age of the patients was 34 years . 
 most common symptom was patchy loss of hair in the frontal area ( 100% ) . 
 common trichoscopic feature was decreased hair density and broken hairs . 
 trichoptilosis ( split ends ) and irregular coiled hairs were seen in 80% patients . 
 novel diagnostic signs like black dots , flame hair , v - sign , follicular hemorrhages , were seen in 30% each . 
 tulip hair and hair powder were observed in 10% of patients . 
 all patients had the noninflammatory alopecia with distorted and collapsed inner root sheath in histopathology.conclusion:trichotillomania is often chronic and difficult to treat . hence 
 , early diagnosis and treatment is necessary . 
 authors believe that the trichoscopy plays a vital role in the diagnosis of this condition by demonstrating specific trichoscopic patterns .