Trichotillomania is defined by a single word: own. The diagnostic criteria describe recurrent pulling of one's own hair, resulting in visible hair loss and repeated, unsuccessful attempts to stop. A case report published this year describes a 23-month-old girl who did something the definition does not anticipate. She pulled mostly from other people, and she swallowed what she pulled.
The report, by Uğur Tekeoğlu, appears in the Journal of Pediatric Health Care and is written to the CARE guidelines, the reporting standard for clinical case reports. Its title states the two features plainly: early-onset trichotillomania with predominantly other-directed trichophagia.
Two Rare Features Stacked on Each Other
Hair-pulling disorder sits in the DSM-5 among obsessive-compulsive and related conditions, and onset usually occurs in late childhood or adolescence. Cases beginning before age six are classified as very early-onset and are described in the literature as uncommon, with little long-term data to draw on.
A patient not yet two years old sits at the far edge of that already small group. Layered on top is the direction of the behavior. Clinical references note that people with trichotillomania sometimes pull from other people, pets, dolls, or fibrous materials such as carpet, and rare reports describe eating hair gathered from the surrounding environment rather than from one's own scalp. Those are documented as occasional variations. Here, the outward direction was the dominant pattern.
The third element is trichophagia, the eating of pulled hair. Estimates of how many people with trichotillomania do this range widely across published sources, from roughly 5% to about 30%. That spread reflects how the behavior is measured and how reluctant patients are to disclose it, not a settled figure.
The Complication Clinicians Watch For
Human hair cannot be digested. Swallowed repeatedly, strands catch in the folds of the stomach lining, tangle with mucus and food, and compact into a dense mass called a trichobezoar. In its most extreme form, a tail of hair extends from the stomach into the small intestine, a presentation known as Rapunzel syndrome.
The absolute risk is low. The Anxiety and Depression Association of America notes that among people with trichotillomania who swallow hair, roughly 1% develop a trichobezoar requiring surgical removal, and the organization is explicit that the message is awareness rather than alarm.
When it does happen, it is serious, and it can begin very young. A 2015 report in the International Journal of Trichology followed a girl whose symptoms started at age three and who returned more than a decade later with recurrent large trichobezoars, needing surgery both times. Her course, the authors wrote, challenged the prevailing understanding of how the disorder behaves in early childhood.
Why Toddlers Get Missed
Pediatric trichotillomania is under-recognized. A retrospective review of 137 children seen at the Children's Hospital of Philadelphia found an average age at diagnosis of around eight years. More than half carried a psychiatric comorbidity and more than a quarter had a skin disorder, with the pattern differing depending on whether dermatology or behavioral health saw the child first.
In toddlers, the picture is muddier still. Hair twisting and pulling in very young children is often a self-soothing habit associated with falling asleep or distress, and parents and clinicians frequently interpret it as a phase. When patchy hair loss appears, the first stops are typically pediatricians and dermatologists, who must rule out alopecia areata and tinea capitis before hair pulling is even considered.
The stakes of missing it are not only cosmetic. A 2025 study in Pediatric Dermatology drawing on a large US research network found that children with trichotillomania face elevated risks of psychiatric comorbidities, and its authors argued that dermatologists are well placed to route those patients toward behavioral care early.
What Parents Should Take from One Case
This is a single child. A case report demonstrates that a presentation is possible. It says nothing about how common it is, and it is not a basis for diagnosing anyone.
What it usefully flags is a blind spot. A screening question framed as "Is your child pulling out her own hair?" would have returned a no. The behavior here pointed outward, and the hair was going into her mouth.
Signs worth raising with a pediatrician include hair loss in patches, hair found in a young child's hands or mouth, hair pulled from other people or pets, and unexplained abdominal pain, vomiting, poor appetite, or weight loss in a child known to handle hair. A clinician can distinguish a common toddler habit from something that needs evaluation, and the distinction is easier to make early than late.
Key Questions Answered
What is trichotillomania? A disorder classified in the DSM-5 under obsessive-compulsive and related conditions, defined by recurrent hair pulling that causes noticeable hair loss and persists despite attempts to stop.
What made this case unusual? The child was 23 months old, placing her in the very early onset group, and she pulled predominantly from other people rather than herself while also swallowing hair.
What is trichophagia? Eating hair that has been pulled out. Estimates of how many people with trichotillomania do this range from roughly 5% to 30% across published sources.
What is a trichobezoar? A compacted mass of indigestible hair in the stomach. Among people with trichotillomania who swallow hair, roughly 1% develop one requiring surgical removal, according to the Anxiety and Depression Association of America.
What symptoms suggest a hairball has formed? Abdominal pain, nausea or vomiting, feeling full quickly, poor appetite, weight loss, or a palpable abdominal mass. These require medical evaluation.
Is hair twisting in toddlers usually a problem? Often, it is a self-soothing habit that resolves. It warrants a conversation with a pediatrician when it causes visible hair loss, involves other people's hair, or is accompanied by hair ingestion.
