Trichotillomania due to pica in a 23-month-old patient: Case
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A 23-month-old female with atopic dermatitis and presumed autism spectrum disorder (ASD), presented with patchy hair loss for one week. She had been pulling out the hair of her frontal scalp, despite preventive measures including hair braiding. Upon questioning, the mother reported finding hair in her daughter’s stool.

In addition to trichophagia, the mother also noted the patient’s chewing on non-food items, such as paint chips. The patient had no recent stressors and no other relevant family history. The patient’s pediatrician had recently started an ASD workup for behavioral changes and sensorineural hearing deficiencies. Physical examination revealed multiple alopecic areas with hairs of varying length and linear excoriations on the frontal scalp consistent with trichotillomania. This presentation of trichotillomania was atypical due to the patient’s young age and pica.

Due to pica, a workup for IDA and lead poisoning were pursued. Labs revealed hemoglobin 8.6 g/dL, MCV 56.6 fL, iron 19 mcg/dL, and total iron binding capacity 429 mcg/dL, consistent with IDA. Blood lead levels were 14 mcg/dL (reference range 0-4 mcg/dL), indicating lead poisoning. The patient was started on iron supplements. Lead chelators were deferred as her blood lead level was below 45 mcg/dL.

Lead poisoning is often asymptomatic, making it difficult to diagnose without regular screening and a known history of lead paint ingestion. The occurrence of trichotillomania in an atypically young age prompted search for organic causes. The
elicitation of a history of trichophagia prompted consideration of pica, commonly caused by IDA and commonly a cause of lead poisoning.