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Artigo de Reviso / Review Article

Tricoses compulsivas* Compulsive trichoses*

Jos Marcos Pereira 1
Resumo: Por sua importncia esttica, os cabelos freqentemente so alvo de interferncias sociais, como o caso de penteados e tinturas bizarras, e por vezes de auto-agresses. Os atos auto-agressivos mais freqentes so: tricotilomania, tricotemnomania, tricofagia, tricoteiromania, pseudoalopecia da coadura, tricocriptomania, tricorrexomania e plica neuroptica. Neste artigo o autor discute detalhadamente as caractersticas clnicas e propeduticas de cada doena, dando nfase aos aspectos psiquitricos dos pacientes. Palavras-chave: alopecia; cabelo; tricotilomania. Abstract: Due to its aesthetic importance, our hair is often a target of social manifestations, as in the case of bizarre hairstyling and hair dyes and sometimes even self-aggression. The most frequent acts of self-aggression are: trichotillomania, trichotemnomania, trichophagy, trichoteiromania, scratch ing-pseudoalopecia, trichocryptomania, trichorrexomania and neuropathic plica. In this article, the author discusses in detail the clinical characteristics and propedeutics of each disease, with empha sis on the psychiatric aspect of the patients. Key-words: alopecia; hair; trichotillomania INTRODUO Em todas as culturas e em todas as pocas os cabelos so venerados. Muitos trabalhos tm mostrado os danos psicossociais que uma pessoa sofre ao perder os cabelos. Um estudo curioso foi feito por Maffei e cols.,1 que compararam o comportamento emocional de pacientes com alopecia androgentica com o da populao com cabelos e constataram que na amostra com cabelos, 10,3% tinham algum distrbio psiquitrico, tais como parania, comportamento anti-social, obsesso, agressividade, sadismo, depresso, e outros mais. Em pacientes com alopecia androgentica, esses ndices chegaram a 76,3%. O cabelo, sem dvida alguma, o ornamento mais relevante para o ser humano. bvio que, por sua importncia esttica, passa a ser alvo fcil para manifestaes culturais, tais como cortes, penteados e coloraes bizarras, dreadlocks, black power, etc., e, no raro, comportamentos auto-agressivos, as chamadas tricoses compulsivas. A tricose compulsiva mais conhecida na dermatologia a tricotilomania, porm outras menos citadas devem ser lembradas, como tricotemnomania, tricofagia, tricoteiromania, pseudoalopecia da coadura, tricocriptoINTRODUCTION In all cultures and throughout all the ages the hair has been highly regarded. Many works have described the psychological and social trauma that a person suffers upon losing his/her hair. An interesting study was done by Maffei and cols.,1 that compared the emotional behavior of patients with androgenic alopecia with that of the population with normal hair. They reported that in the sampling with normal hair, 10.3% had some psychiatric disturbance, such as para noia, antisocial behavior, obsession, aggressiveness, sadism, and depression, among others. In patients with androgenic alopecia, the level of disturbance reached 76.3%. The hair, without any doubt, is the most significant ornament for the human being. It is clear that, due to its aesthetic importance, hair becomes the most obvious means of cultural expression, such as with haircuts, hair styles and bizarre colorations, such as for example, dreadlocks and black power, etc. The hair is also the target for self-aggres sive behaviors, or the so-called compulsive trichoses. The best known compulsive trichosis in dermatology is trichotil lomania, however there are others less well known that should be kept in mind, such as trichotemnomania, tri chophagy, trichoteiromania, scratching- pseudoalopecia,

Recebido em 21.10.2002. / Received on October 21, 2002. Aprovado pelo Conselho Consultivo e aceito para publicao em 04.07.2003. / Approved by the Consultive Council and accepted for publication on July 04, 2002. * Trabalho realizado na clnica privada: Centro Dermatolgico de Guarulhos. / Work done at private clinic Centro Dermatolgico de Guarulhos
1

Ex-professor instrutor de dermatologia da Faculdade de Medicina da Santa Casa de So Paulo. / Ex-professor of Dermatology at the Faculdade de Medicina da Santa Casa de Sao Paulo

2004 by Anais Brasileiros de Dermatologia

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mania, tricorrexomania e plica neuroptica, cada uma com caractersticas prprias. Tricotilomania o ato compulsivo de extrair os cabelos, embora plos de qualquer regio do corpo tambm possam estar envolvidos no processo. A abordagem de um paciente com tricotilomania requer cautela e deve ser feita sob os pontos de vista psiquitrico e dermatolgico. 1. Aspectos psiquitricos Ato compulsivo distrbio psicopatolgico caracterizado por impulso repetitivo e incontrolvel para realizar uma determinada ao.2 As caractersticas clnicas de um ato compulsivo seriam: falha na tentativa de resistir ao impulso; tentao para atos perigosos para si mesmo ou outros; aumento na tenso ou excitao imediatamente antes do ato; gratificao ou prazer logo aps o ato. Dos mais variados impulsos, quatro so os mais freqentes, a saber: jogo compulsivo (por exemplo, cassino), cleptomania, tricotilomania e compra compulsiva.2 Estudos psiquitricos tm criado critrios para o diagnstico da tricotilomania. Segundo o Diagnostic and Statistical Manual of Mental Disorders (DSM-IV),2,3 a tricotilomania seria uma desordem compulsiva e requer os seguintes critrios para diagnstico: 1) trao recorrente sobre os cabelos, ocasionando uma alopecia perceptvel; 2) aumento no senso de tenso imediatamente antes do ato de trao dos cabelos ou ao tentar resistir ao impulso; 3) prazer, gratificao ou alvio quando o cabelo tracionado e conseqentemente extrado; 4) a doena no explicada apenas pela existncia de doena mental. Obviamente, esses critrios da DSM-IV, exceto o primeiro, so avaliaes psiquitricas, que no levam a um diagnstico definitivo Quanto ao primeiro item, dermatologicamente muito vago, uma vez que a tricotilomania apresenta exuberncia clnica muito grande, que pode enganar o dermatologista mais experiente; alm disso, quando a tricotilomania assume uma forma mais ou menos difusa, a rarefao s percebida aps perda de 30% dos cabelos.3 Quando a tricotilomania ocorre aps a adolescncia mais provvel que exista uma psicopatia ou desordem que cause ansiedade. 3 Mulheres so muito mais acometidas do que homens. Curiosamente muitas vezes os pacientes no se preocupam com a aparncia por vezes grosseira de seus cabelos ( la belle indiffrence), o que se constitui em forte indcio para diagnstico. Muitos deles admitem que realmente extraem os cabelos, porm a maioria nega terminantemente qualquer manipulao dos cabelos, dificultando uma abordagem teraputica.4 A tricotilomania no adulto mais grave do que na criana, em quem, muitas vezes, o quadro se resolve espontaneamente com o passar dos anos.5 Alguns autores calculam que s nos EUA dois a oito milhes de pessoas podem ter tricotilomania, sendo 90% mulheres, devendo seus aspectos psicossociais ser devidamente analisados.6
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trichocryptomania, trichorrexomania and neuropathic plica, each of these with its own characteristics. Trichotillomania Trichotillomania is the compulsive action of pulling out the hair, and may involve hair of any area of the body. In attending a patient with trichotillomania, great caution is required, since this should be done considering the psychi atric as well as the dermatological point of view. 1. Psychiatric aspects Compulsive action is a psychopathic disturbance char acterized by a repetitive and uncontrollable impulse to do a particular act.2 The clinical characteristics of a compulsive action may be defined as: a failure in the attempt to resist the impulse; a temptation to inflict dangerous acts against oneself or others; an increase in tension or excitement immediately before the action; and a gratification or pleasure soon after the action. Of the wide variety of impulses, four are the most fre quent: compulsive gambling (for instance in a casino), klepto mania, trichotillomania and compulsive shopping.2 Psychiatric studies have created criteria for the diagnosis of trichotilloma nia. According to the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV),2,3 trichotillomania should be con sidered a compulsive disorder and requires the following crite ria for diagnosis: 1) recurrent traction of the hair, causing a perceptible alopecia; 2) an increase of a sense of tension imme diately before the action of hair pulling or when trying to resist the impulse; 3) pleasure, gratification or relief when the hair is pulled and consequently extracted; and 4) mental illness should not be considered the only explanation for the existence of this disease. Obviously, these criteria of the DSM-IV, except for the first, are psychiatric evaluations that do not lead to a definitive diagnosis. As for the first item, it is quite vague dermatologi cally, since trichotillomania when presented in the clinic is only one of a very wide range of clinical possibilities, thus even the most experienced dermatologist may be deceived. Besides this, when the trichotillomania assumes a form more or less diffuse, the rarefaction is only noticeable after a loss of 30% of the hair.3 When the trichotillomania occurs after adolescence it is more probable that there exists a psychopathic disorder that causes anxiety.3 Women are much more affected than men. Surprisingly, many times these patients do not worry about the sometimes unkempt appearance of their hair (la belle indiffrence ). This constitutes a strong indication for the diagnosis of this condition. Many patients openly admit that they pull their hair, however most categorically deny any manipulation of their hair, thus hindering a therapeutic approach.4 Trichotillomania in adults is more serious than in children, amongst whom, the situation often resolves spontaneously with the passing of time.5 Some authors estimate that in the USA alone two to eight million persons may have trichotillomania, of these 90% are women who should have their psychosocial aspects properly analysed.6

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Enos e col.7 criaram guias para diagnstico, medida da intensidade e conduta na tricotilomania. 2. Aspectos dermatolgicos A tricotilomania pode ocorrer em qualquer rea pilosa do corpo, como barba, clios, plos pbicos, etc.,8 porm, neste artigo enfoca-se apenas a tricotilomania no couro cabeludo. A tricotilomania prevalece em 0,6% dos estudantes. Tem sido mostrada incidncia de 3,4% em mulheres e 1,5% em homens. Muitas vezes a tricotilomania passa despercebida. Em geral 40% dos casos no so diagnosticados, e 58% dos pacientes no so tratados.2 Estudos em populaes fechadas mostram que, quando a tricotilomania pesquisada ativamente, ou seja, sem que haja queixa ou procura do mdico pelo paciente, sua incidncia muito grande.9 Do ponto de vista dermatolgico, a tricotilomania muito rica em sinais propeduticos. O quadro eventualmente precipitado ou agravado por uma patologia no couro cabeludo, como eczema, neurodermite, dermatofitose ou at mesmo alopecia areata. Pode ser acompanhado de tricofagia,10 e por vezes os cabelos so encontrados dentro da boca do paciente ou acumulados no estmago ou intestino, formando o clssico tricobezoar. Geralmente a agresso aos cabelos ocorre quando o paciente est assistindo televiso, estudando, falando ao telefone, etc., e intensificada quando associada a uma situao estressante, como por exemplo preparao para uma prova. Nem sempre a extrao do plo imediata. Muitas vezes o paciente fica durante horas torcendo os cabelos entre os dedos ou manipulando de uma forma qualquer, para depois extra-los, o que, ocasionalmente, pode ser feito com pina. 3,11 A extrao dos cabelos angenos mais difcil e dolorosa, motivo pelo qual os cabelos telgenos so primeiramente arrancados. 11 A tricotilomania pode alternar perodos de exacerbao e de acalmia.8 Anamnese Dificilmente o paciente, adulto ou criana, quer consultar o mdico por apresentar tricotilomania. Em geral, apesar da aparncia bizarra de seus cabelos, ele no d importncia. Na maioria dos casos o paciente vai ao consultrio com acompanhante, que quem tem o maior interesse pela doena. Normalmente o paciente j passou por outros mdicos e, assim como o acompanhante, no aceita e no admite a hiptese de uma tricotilomania. Apesar de toda cautela para abordar o assunto, grande parte dos pacientes no mais retorna aps confirmao do diagnstico. Clnica extremamente varivel a clnica da tricotilomania, que, em geral, acomete mltiplas reas nas regies temporoparietais, sendo a leso raramente nica. No existe um padro de alopecia. O quadro pode ser exuberante e bizarro
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Enos and col.7 created guides for diagnosis, for meas urement of intensity and for the management of trichotillomania. 2.Dermatological aspects Trichotillomania may occur in any pilose area of the body, such as the beard, eyelashes, pubic hair, etc.,8 howev er this article focuses only on trichotillomania of the scalp. Trichotillomania has a prevalence of 0.6% among students, with a reported incidence of 3.4% in women and 1.5% in men. Many times trichotillomania passes unno ticed. In general, 40% of these cases are not diagnosed, and 58% of the patients are not treated. 2 Studies in closed populations show that, when tri chotillomania is actively investigated, or that is, going beyond counting specific complaints or of patients seeking medical help, its incidence is found to be much greater.9 From the dermatological point of view, trichotillo mania is very rich in propedeutical signs. The situation is occasionally triggered or worsened by a pathology in the scalp, such as eczema, neurodermatitis, dermatophytosis or even alopecia areata. It may be followed by trichophagy,10 and at times hair may be found inside the patient's mouth or accumulated in the stomach or intestine, forming the clas sic trichobezoar. Usually aggression to the hair occurs when the patient is watching television, studying, talking on the phone, etc., and is intensified when associated with a stress ful situation, for example when preparing for an examina tion. The extraction of the hair is not always immediate. Often the patient spends hours in twisting the hairs with the fingers or manipulating them in some way and only later actually extracting them. This is occasionally done with tweezers.3,11 The extraction of anagenous hairs is more dif ficult and painful, for this reason telogenous hairs are usu ally pulled out first.11 Trichotillomania may have alternat ing periods of exacerbation and relative calm.8 Anamnesis Apatient with trichotillomania, adult or child, rarely wants to consult a physician. Generally, it is not considered important in spite of the often bizarre appearance of the hair. In most cases the patient goes to the clinic with a com panion who has taken a greater interest in the disease. Usually the patient has already been seen by other doctors and consequently neither the patient nor the companion want to accept or admit the hypothesis of a trichotillomania. In spite of great tact on the part of the physician in approaching the subject, the great majority of patients never return after confirmation of the diagnosis. Clinical examination The clinical presentation of trichotillomania is extremely variable, in that in general, it may involve any of several areas in the temporoparietal region, a single lesion is rare. A standard pattern for alopecia does not exist. The

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ou at ser to discreto, a ponto de passar despercebido. Dificilmente existe uma rea com franca alopecia, ou seja, com ausncia total de cabelos. Na maioria das vezes existe sua rarefao e observam-se muitos cabelos partidos e outros tantos rebrotando. Algumas vezes, pela manipulao constante, os cabelos ficam encaracolados irregularmente, assumindo a aparncia da sndrome dos cabelos encaracolados, kinking sindrome, ou mesmo sndrome dos cabelos impenteveis. Outras, podemos encontrar escoriaes ou pequenos ferimentos no couro cabeludo e, eventualmente, at uma placa de neurodermite localizada na regio alopcica. Dermatoscopia Na rea afetada existem cabelos de vrios tipos: observam-se fios terminais normais; alguns em flmula, mostrando que so cabelos "nascendo"; muitos de vrios tamanhos e com extremidade em pincel, caracterizando um rompimento; e alguns "encaracolados". Muitos stios esto vazios, e alguns com impregnaes enegrecidas, que so restos de hastes (tricomalcia). O tradicional cabelo em ponto de exclamao no patognomnico da alopecia areata. Na tricotilomania tambm podemos encontrar cabelos muito parecidos com os peldicos. Na alopecia areata o cabelo em ponto de exclamao, tem a extremidade distal em pincel, como no cabelo quebrado na tricorrexis nodosa. J na tricotilomania a extremidade distal cortada a pique, ou seja, lisa e arredondada.12 Tambm pela dermatoscopia comum serem observados tricoptilose, pili torti e tricorrexis nodosa. Teste da trao suave Como sua maioria est na fase angena, os cabelos no se desprendem com esse teste, que se demonstra, portanto, negativo; porm, como existe leso da haste, pode haver quebra do fio, e os cabelos que se soltam, na verdade so pedaos da haste, levando a um resultado falso positivo.13 Nesses casos fundamental a microscopia ptica comum para analisar as extremidades dos fios assim obtidos. Teste do puxo 13 Feito por trao intensa sobre os cabelos, teste til, pois, estando os fios em geral quebradios, a obteno de fragmentos mostra a fragilidade dos cabelos. Teste do atrito Consiste em atritar com o dedo indicador um chumao de cabelos colocado no centro da palma da outra mo.13 Pelas constantes leses da haste, ao se realizar o teste do atrito, observam-se pedaos de cabelos na palma, caracterizando leso na haste. Tricograma O tricograma na tricotilomania pode ser bastante caracterstico.13 Como os cabelos telgenos so primeiramente extrados por ter menos adeso ao folculo e sua
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picture may be radical and bizarre or even so discreet as to the point of passing unnoticed. Rarely will an area be observed with complete alopecia, that is, with total absence of hair. Usually there is a thinning with many broken hairs and many others growing again. Sometimes, because of the constant manipulation, the hairs are curled irregularly, assuming the appearance of the kinking syndrome, or even the syndrome of unmanageable hair. In some cases excori ations or small wounds may be found in the scalp. Eventually these may even form a plaque of neurodermati tis localized in the area of alopecia. Dermatoscopy In the affected area, hairs of several types may be observed: shafts with normal ends; some in flammule, showing that they are "sprouting" hairs; many of several sizes with extremities in a brush shape, characterizing a breaking off; and some that are curled. Many follicles are empty, and some present darkened impregnations, which are the remains of stems (trichomalacia). The classic excla mation mark hair is not pathognomonic of alopecia areata. In trichotillomania, hair quite similar to that of the excla mation mark hair may also be found. In alopecia areata, exclamation mark hair forms a brush at the distal extremi ty, as in the split hairs of trichorrexis nodosa. However, in trichotillomania the distal extremity is cut off cleanly, or that is the ends are smooth and rounded.12 Also in the dermatoscopy it is common for trichop tilosis, pili torti and trichorrexis nodosa to be observed. The Gentle Traction Test SSince most of the hairs are in the anagen phase, they do not come loose easily with this test, thereby demonstrating a negative result. However, as there may be a lesion of the stem, the hair may break and come loose, leading to a false positive result as they are actually pieces of the stem.13 In these cases it is fundamental to use a simple optical microscope to analyze the extremities of the hair shafts thus obtained. The Hair Pull Test13 This test is done by an intense traction on the hairs. It is a useful test because if the shafts in general are brittle, the obtaining of fragments demonstrates the fragility of the hair. The Attrition Test The attrition test consists of rubbing with the index fin ger a wad of hair placed in the center of the palm of the other hand.13 Due to the constant lesions of the hair shafts, on per forming the attrition test, broken pieces of hair are observed in the palm, thereby characterizing lesions of the stems. Trichogram The trichogram in trichotillomania can be quite char acteristic.13 Since the telogenous hairs are the most easily extracted as they have less adhesion to the follicles and their

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extrao ser menos dolorosa, restam no couro cabeludo os cabelos angenos, podendo o tricograma chegar a 100% deles.11 Alm disso, toda reposio capilar angena, o que contribui para o aumento dos cabelos angenos. Anlise dos cabelos eliminados espontaneamente Quando o paciente extrai os cabelos, tem trs opes para os mesmos: 1) com-los (tricofagia); 2) escond-los ou livrar-se deles, por exemplo, jogando-os no lixo, lavatrio, sanitrio etc.; 3) simplesmente deix-los carem, onde quer que esteja. Atentando para essas possibilidades, conveniente que a coleta na tricotilomania seja feita de duas maneiras. A primeira, a mais importante e confivel, seria a coleta feita pelo acompanhante, geralmente um parente, a quem se pede que procure e recolha os cabelos nos ambientes em que vive o paciente. Deve-se ficar atento para cabelos no cho, na mesa onde o paciente estuda, no banheiro, na fronha do travesseiro, etc. importante ter o cuidado de no deixar que o paciente saiba da coleta, pois este pode deixar de extrair momentaneamente os cabelos ou simplesmente escond-los. J a segunda forma de coleta feita pelo prprio paciente, que, em geral, no mostra muito interesse em cooperar com o mdico, trazendo-lhe quase sempre quantidade de cabelos coletados muito pequena. Quando se faz a anlise dos cabelos, em ambas as coletas, a presena de cabelos angenos, catgenos ou de telgenos com saco epitelial mostra que os cabelos foram extrados por trao, o que confirma a tricotilomania.13 A presena de cabelos partidos sugestiva, porm no diagnstica. Estudo da pelugem Ao examinar um paciente com tricotilomania, o estudo da pelugem pode esclarecer algumas dvidas. Tatase de pequenos plos, geralmente com poucos milmetros de comprimento, observados com o auxlio de um carto de papel, colocado perpendicularmente ao couro cabeludo.13 Uma amostra deles removida com um porta-agulhas e observada microscopia ptica comum. Quando o paciente extrai um fio de cabelo em sua fase angena, trs possibilidades podem acontecer: o cabelo quebra junto matriz, mas logo continuar a crescer; o cabelo fragmenta-se dentro do canal folicular e, nesse caso, poder formar a tricomalcia; e, finalmente, o cabelo quebra a poucos centmetros da superfcie do couro cabeludo. Nas trs possibilidades a pelugem encontrada angena e com extremidade distal em estilhao. Quando o cabelo extrado telgeno, dificilmente quebra, pois sua adeso ao folculo baixa. Sua reposio ser por meio de um plo angeno, que ter como caracterstica sua extremidade distal afilada em flmula. Esses conceitos so importantes, pois, se o paciente tiver uma doena associada tricotilomania, como, por exemplo, uma alopecia androgentica, ele ter uma pelugem predominantemente telgena.
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extraction is less painful, thus the anagen hairs are left in the scalp, thus the trichogram can reach 100% anagenous hairs.11 Besides this, every capillary replacement is anage nous, which contributes to the increase in anagenous hair. Analysis of hair eliminated spontaneously When the patients extract their hair, they have three options as to what to do with it: 1) eat the hair (trichophagy); 2) hide or dispose of it, for instance, in the garbage, flush it down the toilet, etc.; and 3) simply let it fall to the ground, wherever they are. Considering these possibilities, there are two convenient ways to make the collection of samples in a case of trichotillomania. Firstly, the most important and reli able method is a collection done by a companion of the patient, usually a relative, who is asked to find and collect the hair in the environment in which the patient lives. Careful attention is required to collect hair on the ground, on the desk where the patient studies, in the bathroom, on the pillowcase, etc. It is important that care be taken to not let the patient know about the collection, because his or her reaction might be to temporarily stop extracting the hair or simply to hide it. The second form of collection is done by the patients them selves. Generally though, these patients do not show much interest in cooperating with the doctor, almost always bring ing in very small amounts of collected hair. When the hair is analyzed from either means of collec tion, the presence of anagenous, catagenous or telogenous hairs with epithelial sacs shows that the hairs were extracted by traction, which confirms trichotillomania.13 The presence of broken hair is suggestive, but does not confirm the diagnosis. Study of the pelage When examining a patient with trichotillomania, a study of the pelage may clarify some aspects. These are fine hairs, usually only a few millimeters in length, observed with the aid of a paper card held perpendicular to the scalp.13 A sample of them is removed with tweezers and observed under a simple optical microscope. When the patient extracts a hair shaft in its anagen phase, three possibilities may occur: the hair breaks off near the matrix, in which case it will soon continue to grow; fragmentation of the hair occurs inside the follicular channel, which may cause the formation of a trichomala cia; and finally, the hair breaks off a few centimeters from the surface of the scalp. In all three possibilities, the pelage to be found is anagenous and with splintering of the distal extremity. When the extracted hair is telogenous, it rarely breaks as its adhesion to the follicle is weak. Its replace ment will be with an anagenous hair that will have as its characteristic a thin distal extremity in flammule. These concepts are important, because if the patient has a disease associated with trichotillomania, such as, for instance, an androgenic alopecia, there will be predominantly teloge nous pelage.

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Um plo peldico no deixa de ser uma pelugem, e sua haste bem caracterstica, sendo seu bulbo em geral telgeno, embora em raros casos tambm possa ser angeno. Teste da luz fluorescente um teste simples e mostra se realmente o paciente manipula o couro cabeludo. Junto rea alterada do couro cabeludo, coloca-se tinta fluorescente, do tipo das que so usadas em canetas marcadoras de texto. No dia seguinte a mo do paciente examinada com lmpada de Wood.13 A fluorescncia em sua mo mostra que o paciente manipulou os cabelos. Em muitos casos esse teste tem valor principalmente para convencer o acompanhante de que existe a manipulao dos cabelos. Janela de observao Uma pequena rea de cabelos cortada junto ao couro cabeludo e isolada com fita adesiva.13 Trata-se de recurso muito til, e talvez a melhor indicao para esse tipo de teste seja mostrar ao paciente e acompanhantes que os cabelos esto crescendo normalmente. Histopatologia A histopatologia importante para confirmar o diagnstico14 ou, pelo menos, para afastar outras doenas. Classicamente so encontrados vrios canais foliculares vazios, alguns folculos com infundbulo dilatado e com rolhas crneas. A maioria dos folculos esto na fase catgena ou angena inicial, poucos so telgenos e chama ateno a inexistncia de processos inflamatrios perifoliculares. Alguns folculos esto destrudos com hemorragia perifolicular, restos pigmentares junto ao istmo do folculo e a caracterstica tricomalcia, que so pedaos de plos dentro do folculo piloso. TRICOFAGIA Ato compulsivo de engolir os cabelos. Pacientes com cabelos longos costumam colocar na boca chumaos de cabelos que ficam mastigando, podendo engolir alguns pedaos. Outra forma consiste em o paciente arrancar os cabelos, caracterizando uma tricotilomania, para depois lev-los boca. Sempre que se apresentar um quadro clnico de tricotilomania, deve-se aventar a possibilidade de o paciente estar engolindo os cabelos, podendo levar a um tricobezoar.15 Ao examinar um paciente com tricotilomania no se deve esquecer de examinar sua boca, pois podem ser encontrados pedaos de cabelos entre seus dentes e mesmo aderidos mucosa. Pelo menos teoricamente, qualquer outra tricose compulsiva, como tricotemnomania, tricoteiromania, pseudoalopecia da coadura, tricocriptomania e tricorrexomania, pode levar a uma tricofagia, que, por sua vez, pode levar formao de um tricobezoar, tambm chamado de sndrome de Rapunzel. 15 Trata-se de uma massa de cabelos
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A exclamation mark hair is still part of the pelage, and its shaft is very characteristic since its bulb is general ly telogenous, although in rare cases it may be anagenous. The Fluorescent Light Test This simple test shows whether or not the patient actually manipulates the scalp. Close to the altered area of the scalp, fluorescent ink of the type used in text marking pens is applied. The following day the patient's hand is examined with a Wood lamp.13 Fluorescence on the hands shows that the patient had manipulated the hair. In many cases the value of this test is mainly to con vince the companion of the patient that manipulation of the hair is actually taking place. Observation Window A small area of hair is cut close to the scalp and iso lated with adhesive tape.13 This test is a very useful resource, and perhaps the best indication for this type of test is to demonstrate to the patient and companions that the hair is growing normally. Histopathology Histopathology is important for confirming the diag nosis14 or, at least, for ruling out other diseases. Classically, several empty follicular channels will be found, as well as some follicles with dilated infundibula with corneous plugs. Most of the follicles will be in the catagenous phase or ini tial anagenous, few will be telogenous. The complete lack of perifollicular processes will be notable. Some follicles are destroyed by perifollicular hemorrhage, by pigmentary remains close to the isthmus of the follicle and by the char acteristic trichomalacia caused by pieces of hair within the pilose follicle. TRICHOPHAGY Trichophagy is the compulsive action of swallowing hair. Patients with long hair, who may be in the habit of put ting wads of hair in the mouth and chewing, could be swal lowing some of the pieces. Another form consists of the patient pulling out the hair, characterized as trichotilloma nia and thereupon transferring it into the mouth. Whenever faced with a clinical picture of trichotillo mania, the possibility should always be considered that the patient may be swallowing hair, and that this could lead to a trichobezoar.15 When examining a patient with trichotillo mania, an examination of the mouth should not be over looked because fragments of hair might be found between the teeth or adhering to the mucous membrane. At least theoretically, any other compulsive tri chosis, such as trichotemnomania, trichoteiromania, scratching-pseudoalopecia, trichocryptomania and trichor rexomania, may lead to a trichophagy, which in turn may result in the formation of a trichobezoar, also known as Rapunzel's syndrome.15 This is defined as a mass of hair that

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que se forma no estmago e, mais raramente, no intestino delgado,16 resultante da ingesto de cabelos. Geralmente os pacientes apresentam quadro de tricotilomania, embora existam casos de formao de tricobezoar sem que o paciente apresente alteraes no couro cabeludo. Na maioria das vezes, 90%, ocorre em meninas com cabelos longos.16 Normalmente so crianas com perda de peso e manifestaes gastrointestinais imprecisas. Clinicamente podem ser observados vmito e nusea em 64% dos pacientes, clica abdominal em 70%, alteraes dos hbitos intestinais em 32%, massa epigstrica palpvel em 88%, e outras alteraes gastrointestinais. Se no houver diagnstico precoce com tratamento, retirada por endoscopia e, em ltimo caso, cirurgia, pode haver necrose gstrica, hematmese, perfurao intestinal com peritonite, podendo o ndice de mortalidade chegar a 50%.16 A radiografia e a ultra-sonografia sugerem uma massa gstrica, porm o diagnstico firmado pela endoscopia. A maioria dos casos de tricobezoar est associada a um retardo mental. 17 TRICOTEMNOMANIA Termo criado por Braun-Falco e col.,18 em 1968, para descrever um homem de 69 anos de idade que apresentava reas nas quais os cabelos estavam tonsurados a poucos milmetros da superfcie do couro cabeludo. O exame desses cabelos mostrava que suas extremidades distais apresentavam um corte a pique, ou seja, feito com objeto cortante. Meiers,19 em 1971, publica um caso idntico ao de Braun-Falco, e, em 1990, Orfanos e cols .20 publicam outro caso semelhante aos demais. Em todos os pacientes descritos, os cabelos eram cortados praticamente junto ao couro cabeludo, com tesoura ou lmina, 4 estando os cabelos curtos e com extremidades distais cortadas a pique. Na tricotemnomania no existe tricotilomania, ou seja, o paciente no arranca os cabelos, mas corta-os com algum instrumento. Obviamente, exames como tricograma, anatomopatolgico, densidade capilar estaro dentro dos limites da normalidade. O diagnstico feito com a dermatoscopia ou com a microscopia ptica comum, que permitem observar cabelos pequenos e cortados a pique. Ao contrrio do tricotilomania, a tricotemnomania s ocorre em adultos idosos, e todos os casos descritos so em pacientes psicopatas. PSEUDOALOPECIA DA COADURA Runne,21 em 2000, descreveu uma mulher com 70 anos que apresentava trs reas alopcicas no couro cabeludo com dimetros variveis de seis a 8cm nas regies temporal e parietal, e na nuca. Ao dermatoscpio notavam-se alguns fios de cabelos quebradios, que davam rea um aspecto aveludado. Na periferia da leso o tricograma era normal, porm os fios no centro da leso apresentavam triAn bras Dermatol, Rio de Janeiro, 79(5):609-618, set./out. 2004.

is formed in the stomach or, more rarely, in the small intes tine,16 resulting from the ingestion of hair. Usually the patients present a profile of trichotillomania, although cases of trichobezoar formation have been reported in which the patient did not present alterations in the scalp. Most of the cases (90%) occurs among girls with long hair.16 Usually these patients are children with weight loss and imprecise gastrointestinal manifestations. Clinically, vomiting and nausea can be observed in 64% of the patients, abdominal cramps in 70%, alterations of the intes tinal habits in 32%, palpable epigastric mass in 88%, as well as other gastrointestinal alterations. Without early diagnosis and treatment, consisting of either removal by endoscopy or as a last resort surgery, it can lead to gastric necrosis, hematemesis or intestinal perforation with peri tonitis. The mortality rate can reach 50% .16 Diagnosis by xray and ultrasound scan may suggest a gastric mass, but endoscopy provides confirmation of the diagnosis. Most of the cases of trichobezoar are associated with mentally retarded persons.17 TRICHOTEMNOMANIA The term trichotemnomania was created by BraunFalco and col.,18 in 1968, to describe the case of a 69-yearold man who presented areas in which the hairs were cut short a few millimeters from the surface of the scalp. The examination of these hairs showed that their distal extrem ities presented a clean cut, or in other words, were severed with a sharp object. Meiers,19 (1971) published a report of an identical case to that of Braun-Falco, and, in 1990, Orfanos and cols.20 reported another case similar to the others. In all the described patients, the hair was cut almost at the surface of the scalp, with scissors or a razor,4 the hair thus being short and the distal extremities were cut off cleanly. There is no trichotillomania in trichotemnomania, that is, the patient does not pull out the hair but cuts it off with some instrument. Obviously, the results of anatomico pathological exams, trichograms and capillary density will be within the normal limits. The diagnosis is made through dermatoscopy or with a simple optical microscope, which allows the observation of very short hairs that are cut off cleanly. Unlike trichotillomania, trichotemnomania only occurs in senior adults, and all of the described cases were psychotic patients. SCRATCHING-PSEUDOALOPECIA Runne,21 (2000) described a 70-year-old woman that presented three areas of alopecia on the scalp with diame ters varying from 6 cm to 8 cm in the temporal and parietal regions, and on the nape of the neck. Under the dermato scope some strands of brittle hair were observed. These gave the area a velvety aspect. In the periphery of the lesion the trichogram was normal, however the hair shafts in the

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coptilose, tricorrexis nodosa, fraturas incompletas e dobras. A histopatologia mostrou intensa acantose. Todo dermatologista est familiarizado com essa situao. Em qualquer regio do corpo em que exista atrito freqente, pode haver quebra dos plos e mesmo alopecia. Exemplo tpico a perda dos plos na regio tibial dos alfaiates, conhecida como alopecia dos alfaiates, que ocorre pelo fato de esses profissionais cruzarem as pernas para costurar. Tambm comum observar plos quebrados, dando a impresso de tonsura, em qualquer dermatose prurigionosa, como lquen plano, dermatite atpica, placa de neurodermite etc. Obviamente, qualquer dessas condies pode ocorrer no couro cabeludo. Runne21 caracterizou a coadura compulsiva no couro cabeludo como pseudoalopecia da coadura, mas, na opinio dos autores, esse quadro corresponde escoriao psicognica descrita por Arnold e cols.,22 e Touraine.27 TRICOTEIROMANIA Termo criado por Freysschmidt e cols.,23 em 2001, para descrever uma mulher com 61 anos que apresentava, h vrios anos, reas no couro cabeludo nas quais os cabelos estavam partidos a dois centmetros da superfcie. A paciente queixava de intenso prurido na regio, motivo pelo qual ela coava muito. Alguns cabelos foram coletados com pina e, ao serem examinados microscopia ptica comum, observavam-se cabelos com cerca de dois centmetros de tamanho e extremidades distais estilhaadas em forma de pincel. A superfcie da pele do couro cabeludo era eritematosa e descamativa, conseqente ao ato de coar. O exame anatomopatolgico mostrou acantose, ortohiperceratose, paraceratose focal e microvesiculao intraepidrmica. O tricograma desses cabelos estava normal. Na opinio dos autores, os termos tricoteiromania e pseudoalopecia da coadura representam uma mesma entidade clnica. Ambas so causadas pelo ato de atritar o couro cabeludo e tm como caracterstica a presena de pequenos cabelos no couro cabeludo com extremidade distal em forma de pincel, ou seja, em estilhao, e a pele com achados de espessamento epidrmico reacional decorrente do atrito. Sabouraud,24 em 1913, descreveu quatro casos, cujos pacientes apresentavam os cabelos tonsurados a poucos centmetros do couro cabeludo, e chamou a tricose de tricoclasia tonsurante. Posteriormente, Jeanselme e col.,25 e Touraine e col.26 descreveram casos semelhantes ao de Sabouraud. Sanderson e col.,24 em 1970, publicaram oito casos que apresentavam grandes reas com cabelos cortados a poucos centmetros do couro cabeludo e chamou esse quadro de tricotilomania tonsurante. Em todos esses casos os autores no descrevem as caractersticas dos cabelos remanescentes, se so angenos ou telgenos, e nem a forma pela qual foram tonsurados. Portanto, clinicamente podem corresponder a tricotemnomania, tricoteiromania, tricocriptomania ou tricorrexomania.
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center of the lesion presented trichoptilosis, trichorrexis nodosa and incomplete fractures and folds. Histopathology demonstrated intense acanthosis. Every dermatologist is familiar with this situation. In any area of the body where there is frequent attrition, there may be breakage of the hairs and even alopecia. A typical example is the loss of the hair in the tibial area experienced by tailors, known as tailors' alopecia. This occurs because workers in this profession tend to cross their legs when they are sewing. It is also common to observe broken hair, giving the impression of having been shaved, in any pruriginous dermatosis, such as lichen planus, atopic dermatitis, plaque of neurodermatitis, etc. Obviously, any of these conditions may occur in the scalp. Runne21 characterized the compulsive scratching of the scalp as scratching-pseudoalopecia. But in the opinion of the authors, this condition corresponds to the psychogenic excoriation described by Arnold and cols.,22 and Touraine.27 TRICHOTEIROMANIA The term trichoteiromania was created by Freysschmidt and cols.,23 in 2001, to describe a syndrome in a 61-year-old woman who, over a period of several years, had presented areas in the scalp in which the hair was bro ken off at about two centimeters from the surface. The patient complained of intense itching in the area, which lead her to scratch a great deal. Some hairs were collected with tweezers and when they were examined under a simple optical microscope, the hairs were observed to be about two centimeters in length with distal extremities split into a brush form. The surface of the skin of the scalp was erythematose and scaly as a consequence of the scratching. Anatomicopathological exam revealed acanthosis, ortho-hyperkeratosis, focal parakeratosis and intraepidermic microvesiculation. The trichogram of these hairs was normal. In the authors' opinion, the terms trichoteiromania and scratching-pseudoalopecia represent the same clinical entity. Both are caused by the action of attrition in the scalp and have as a common characteristic the presence of small hairs on the scalp with the distal extremities split into brush form. The skin reveals an epidermic thickening due to the attrition. Sabouraud,24 (1913) described four cases of patients who presented hair shortened to a few centimeters from the scalp, he denominated this condition as trichosis of tonsure trichoclasia. Later, Jeanselme and col.,25 and Touraine and col.26 described cases similar to those of Sabouraud. Sanderson and col.,24 in 1970, published a report of eight cases that presented large areas where the hair was cut off only a few centimeters from the scalp. Sanderson called this condition tonsure trichotillomania. In none of these cases the authors described the characteristics of the remaining hairs, if they were anagenous or telogenous, nor the means by which they were cut off. Therefore, clinically they could correspond to trichotemnomania, trichoteiromania, tri chocryptomania or trichorrexomania.

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TRICOCRIPTOMANIA OU TRICORREXOMANIA Os termos tricocriptomania28 e tricorrexomania28 so sinnimos e correspondem a um ato compulsivo de cortar os cabelos com as unhas. O paciente pode cortar os cabelos em qualquer nvel, tanto junto ao couro cabeludo, como a vrios centmetros da superfcie da pele. Normalmente no existe uma rea alopcica, mas sim fios cortados em vrios tamanhos, dando m qualidade ao penteado. Os cabelos que sofreram o processo de tricocriptomania ou tricorrexomania, mas que ainda esto presos no couro cabeludo, apresentam em sua extremidade distal a aparncia de pincel. A tricocriptomania pode fazer parte da tricotilomania, ou seja, alm de o paciente arrancar os cabelos, ele pode quebrar os cabelos com as unhas. PLICA NEUROPTICA Le Page, 29 em 1884, apresentou no Departamento de Dermatologia do Museu Real do Colgio de Cirurgies da Inglaterra o caso de uma jovem branca, com 17 anos de idade, com cabelos muito emaranhados, levando formao de uma massa endurecida. Como a jovem sofresse de problemas psiquitricos, o autor chamou a tricose de "plica neuroptica". Aps essa primeira descrio, outros casos j foram mencionados na literatura.30-33 Savil e col.34 utilizaram a expresso "plica neuroptica" quando o emaranhado de cabelos estava acompanhado por problemas psiquitricos. A plica neuroptica deve fazer diagnstico diferencial com compactao aguda dos cabelos, fenmeno eletrosttico que ocorre nos cabelos durante a lavagem.35 COMENTRIOS A caracterizao das tricoses compulsivas no to simples quanto parece. Segundo Toit e cols.,36 nem toda extrao de cabelos compulsiva; esses autores chamaram os pacientes que extraem os cabelos de hair-pullers, que poderiam ou no apresentar tricotilomania, segundo avaliao psiquitrica. A abordagem do paciente com tricose compulsiva um pouco embaraosa para o dermatologista, uma vez que o paciente e mesmo o acompanhante no admitem uma possvel auto-agresso. Um bom domnio da propedutica tricolgica fundamental para um diagnstico preciso. Como j visto, muitas vezes as manifestaes so descritas sob o ponto de vista clnico, porm sem nenhuma nfase s caractersticas dos cabelos, o que dificulta a compreenso da etiopatogenia da doena. Existe uma denominao especfica para cada tipo de agresso aos cabelos. Tm sido observado pacientes, geralmente jovens, com cabelos longos, que simplesmente cortam seus cabelos com os dentes, porm sem os engolir; o autor acredita que no h uma nomenclatura especfica para esses casos e por isso denominaram esse quadro "tricodontoclasia". Eventualmente, pacientes com psicopatias graves
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TRICHOCRYPTOMANIA OR TRICHORREXOMANIA The terms trichocryptomania28 and trichorrexoma 28 nia are synonymous and correspond to a compulsive action of cutting the hair with the nails. The patient may cut the hair at any level, close to the scalp or several centime ters from the surface of the skin. Usually an area of alope cia does not exist, but rather there are strands of hair cut in various lengths, giving a poor quality to the hairstyle. The hairs that suffer from the process of trichocryptomania or trichorrexomania, but are still attached to the scalp, present a brush appearance in their distal extremity. Trichocryptomania may sometimes be part of the tri chotillomania problem, in that, in addition to the patient pulling the hair, he may be breaking the hair with his nails. NEUROPATHIC PLICA In 1884, Le Page29 presented in the Department of Dermatology of the Royal Museum of the School of Surgeons of England, the case of a young woman, 17 years of age, with very entangled hair and which was starting to form into a hardened mass. Since the youth suffered from psychiatric problems, the author called the trichosis: "neu ropathic plica". After that first description, other cases have been mentioned in the literature. 30-33 Savil and col.34 used the expression "neuropathic plica" when the matting of hair was accompanied by psy chiatric problems. Neuropathic plica should be diagnosed differentially from acute compacting of the hair, an electro static phenomenon, that occurs in the hair during sham pooing.35 COMMENTS The characterization of compulsive trichoses is not as simple as it seems. According to Toit and cols.,36 not all extraction of hair is compulsive; those authors called the patients that extract the hair as "hair-pullers", whether or not they presented trichotillomania, according to a psychi atric evaluation. The management of a patient with compulsive tri chosis is somewhat embarrassing for the dermatologist, especially if the patient and even the companion do not admit the possibility of self-aggression. A good knowledge of elementary trichology is fundamental for a precise diag nosis. As already seen, many times the manifestations are described from a clinical point of view, but without any emphasis on the characteristics of the hair. This hinders the understanding of the etiopathology of the disease. There is a specific classification for each type of aggression to the hair. Patients have been observed, usual ly young with long hair, who simply cut their hair with their teeth, however without swallowing. The author believes that there is as yet no specific nomenclature for these cases and have denominated this condition: "trichodontoclasia." Sometimes patients that are seriously psychotic may present profiles that are practically unclassifiable. There may

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podem apresentar quadros praticamente inclassificveis. Pode haver uma mistura de todos os quadros citados, muitas vezes com maior gravidade. O paciente, em algumas ocasies, arranca com violncia grande quantidade de cabelos ao mesmo tempo ou pode at neles atear fogo. Acreditam tambm que s o dermatologista no suficiente para resolver uma tricose compulsiva, visto que ela faz parte da sintomatologia de uma psicopatia, e, sendo assim, um profissional dessa rea tambm deve ser consultado. q REFERNCIAS / REFERENCES
1. Maffei C, Fossati A, Rinaldi F, Riva E. Personality disorders and psychopathologic symptoms in patients with androgenetic alopecia. Arch Dermatol. 1994; 130:686-872. 2. Lejoyeux M, Mc Loughlin M, Ad J. Epidemiology of behavioral dependence: literature review and results of original studies. Eur Psychiatry. 2000; 15:129-34. 3. Sinclair RD, Banfield CC, Dawber RPR. Nonscarring traumatic alopecia. In: Sinclair RD, Banfield CC, Dawber RPR Handbook of diseases of the hair and scalp. USA: Blackwell Science Ltd.; 1999. p.85-94. 4. Elliott AJ, Fuqua WR. Acceptability of treatment for trichotillomania. Effects of age severity. Behav Modif. 2002;26:378-399. 5. Oranje AP, Peereboom-Wynia JDR, Raeymaecker DMJ. Trichotillomania in childhood. J Am Acad Dermatol. 1986;15:614-9. 6. Casati J, Toner BB, Yu B. Psychosocial issues for women with trichotillomania. Compr Psychiatry. 2000; 41:344-51. 7. Enos S, Plante T. Trichotillomania. An overview and guide to understanding. J Psychosoc Nurs Ment Health Serv. 2001; 39:10-8. 8. Hautmann G, Hercogova J, Lotti T. Trichotillomania. J Am Acad Dermatol. 2002;46:807-21. 9. Diefenbach GJ, Reitman D, Williamson DA. Trichotillomania: a challenge to research and practice. Clin Psychol Rev. 2000; 20:289-309. 10. Sharma NL, Sharma RC, Mahajan VK, Sharma RC, Chauhan D, Sharma AK. Trichotillomania and trichophagia leading to trichobezoar. J Dermatol. 2000; 27:24-6. 11. Steck WD. The clinical evaluation of pathologic hair loss, with a diagnostic sign in trichotillomania. Cutis. 1979; 24:293-301 12. Ihm CW, Han JH. Diagnostic value of exclamation mark hairs. Dermatology. 1993; 186:99-102. 13. Pereira JM. Propedutica das Doenas dos Cabelos e do Couro Cabeludo. Brasil: Editora Atheneu; 2001. p. 25-233. 14. Walsh KH, McDougle CJ. Trichotillomania. Presentation, etiology, diagnosis and therapy. Am J Clin Dermatol. 2001;2:327-33. 15. Kaspar A, Deeg KH, Schmidt K, Meister R. Rapunzel syndrome a rare form of intestinal trichobezoars. Klin Pediatr. 1999; 211:420-22 16. Sood AK, Bahi L, Kaushal RK, Sharma VK, Grover N. Childhood trichobezoar. Indian J Pediatr. 2000; 67:390-91. 17. Schulte-Markwort M, Bachman M, Riedesser P. Trichobezoar in a 16 year old girl. Case report and review of literature. Nervenarzt. 2000; 71:584-7. 18. Braun-Falco O, Vogel PG. Trichotemnomanie - Eine besondere Hautmanifestation eines hirnorganischen Psychosyndrons. Hautarzt. 1968; 19:551-3. 19. Meiers HG. Zur weiteren kenntnis der Trichotemnomanie. Hautarzt. 1971; 22:335-7. 20. Orfanos CE, Imcke E. Hair and hair cosmetics. In: Orfanos
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be a combination of some or all of the aforementioned con ditions, many times with even greater gravity. The patient, on some occasions, may violently pull out a large amount of hair at one time, or may even set his or her hair on fire. It is considered that the dermatologist alone is insuf ficient to resolve the problem of a compulsive trichosis because the disease is linked to the symptomatology of a psychopathy, and thus, a professional in the field of psy chology should also be consulted. q

CE, Happle R. Hair and hair diseases. Springer-Verlag. Berlin. 1990. p. 887-925. 21. Runne U. Chronische Pseudo-alopezie durch stndiges Kratzen(Kratz-Pseudoalopezie). Z Hautkr. 2000; 75:444-5. 22. Arnold LM, Auchenbach MB, McElrou SL. Psychogenic excoriation. Clinical features, proposed diagnostic criteria, epidemiology and approaches to treatment. CNS Drugs. 2001;15:351-9. 23. Freyschmidt-Paul P, Hoffmann R, Happle R. Trichoteiromania. Eur J Dermatol. 2001; 11:369-71. 24. Sanderson KV, Hall-Smith P. Tonsure trichotillomania. Br J Derm. 1970; 82:343-50. 25. Jeanselme M, Bloch M. Trichoclasie idiopathique. Bull Soc Fr Derm Syph. 1923; 30:79-82. 26. Touraine A, Gallerand L. Trichoclasie idiopathique. Bull Soc Fr Derm Syph. 1947; 54:18-21. 27. Touraine LM. Auchenbach MB, McElrou SL. Psychogenic excoriation. Clinical features, proposed diagnostic criteria, epidemiology and aproaches to treatment. CNS Drugs. 2001;15:351-9. 28. Thomas CL. Dicionrio Mdico Enciclopdico Taber. Brasil: Editora Manole Ltda.; 2000. p. 1754-5. 29. Le Page JF. On neuropathic plica. Br Med J. 1884; 1:160. 30. Simpson MH, Mullins JF. Plica Neuropathica. Arch Dermatol. 1969; 100:457-8. 31. Hajini GH, Ahmad QM, Ahmad M. Plica Neuropathica. Indian J Dermatol Venereol Lepr. 1982; 48:221-2. 32. Khare AK. Plica Neuropathica. Indian J Dermatol Venereol Lepr. 1985; 51:178-9. 33. Sarkar R, Kaur S, Thami GP, Kanwar AJ. Plica Neuropathica. Matting of hair. Dermatology. 2000; 201:184-5. 34. Savil A, Warren C. Defects of hair shafts. In. Savil A, Warren C. The hair and scalp. London: Edward Arnold Publishers Ltd.; 1962. p. 246-56. 35. Pereira JM. Compactao aguda dos cabelos. An Bras Dermatol. 2002;77:355-64. 36. Toit PL, Kradenburg J, Niehaus DJ, Stein DJ. Characteristics and phenomenology fo hair-pulling: an exploration of subtypes. Compr Psychiatry. 2001;42:247-56.

ENDEREO PARA CORRESPONDNCIA : / M AILING ADDRESS: Dr. Jos Marcos Pereira Rua Slvio Rodini, 611 apto 101 02241-000 So Paulo SP Brasil Email: [email protected] Site: www.jmarcosderm.med.br Tel/fax (11) 6452-8727