Friar tuck sign in trichotillomania

A 40-year-old female presented with hair loss from the scalp for 2 years. She initially denied but subsequently conceded that she pulled her hair whenever stressed. Examination revealed noncicatricial alopecia with broken hair of varying lengths involving the frontal scalp, mid-scalp, and crown with sparing of margins [Figure 1a and b]. Trichoscopy showed broken hair of different lengths, black dots, follicular hemorrhages, and vellus hair [Figure 2]. Based on above findings, a diagnosis of trichotillomania was made.

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Figure 1:

(a) Patch of incomplete alopecia involving the frontal scalp, mid-scalp, and crown with a rim of sparing on the periphery. (b) Tonsure pattern with sparing of the lower occiput.

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Figure 2:

Trichoscopy showing black dots, broken hair of different lengths, vellus hair, and follicular hemorrhages (Dermlite DL4, ×10).

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Trichotillomania is a form of alopecia caused by the irresistible compulsive pulling of one’s own hair. It presents as a bizarre-shaped patch of incomplete alopecia with broken hair of varied lengths.^[1] In severe cases, pulling of hair in or beyond the vertex results in a typical tonsure pattern which remarkably involves the crown with a rim of sparing at the periphery.^[2] The sparing of hair at the periphery may be explained by a lower pain threshold at the scalp margins. This peculiar pattern of alopecia is called the “Friar Tuck sign” as it resembles the tonsure haircut of Friar Tuck, the legendary character in the folklore of Robin Hood.^[3] Friar tuck sign in trichotillomania is rare and should be differentiated from other non-scarring alopecias such as alopecia areata and tinea capitis. The mainstay of treatment is behavior modification therapy. Pharmacotherapy may be required for the treatment of underlying psychopathology.