Early-onset toddler case reveals rare hair-eating disorder with potential serious complications

A 23-month-old girl exhibits atypical hair-pulling and hair-eating behaviours, challenging recognised diagnostic criteria and highlighting risks like trichobezoars in young children.

Trichotillomania is usually defined as a person pulling out their own hair, often repeatedly and despite trying to stop. But a case report published in the Journal of Pediatric Health Care describes a 23-month-old girl whose behaviour did not fit that narrow picture: she mostly pulled hair from other people and swallowed it. According to the report by Uğur Tekeoğlu, the child’s age placed her in the very small group of very early-onset cases, which are uncommon in the medical literature.

Hair-pulling disorder is listed in the DSM-5 among obsessive-compulsive and related conditions. Mayo Clinic describes it as a condition marked by repeated, hard-to-resist urges to pull hair from the scalp, eyebrows or other parts of the body, and MedlinePlus says symptoms often begin before age 17. Merck Manual notes that treatment usually centres on cognitive behavioural therapy, including habit reversal training, with medication sometimes used as well. But in toddlers, the behaviour can be harder to recognise, because hair twirling or pulling is often dismissed as a soothing habit rather than a sign of a disorder.

The other unusual feature in the case was trichophagia, the eating of hair. The report says this is a known but variable companion to trichotillomania, with published estimates ranging widely. That matters because swallowed hair cannot be digested. Over time, it can collect in the stomach and form a trichobezoar, a compact mass that may require surgery. In the most severe cases, a tail of hair extends into the small intestine, a condition known as Rapunzel syndrome.

The risk of that complication is low, but it is not trivial. The Anxiety and Depression Association of America has said that only about 1% of people with trichotillomania who swallow hair develop a trichobezoar requiring surgical removal. Even so, the consequences can be serious, particularly when symptoms begin early in life. A 2015 report in the International Journal of Trichology described a girl whose hair-pulling and hair-eating started at age three and who later needed surgery more than once after recurrent large trichobezoars formed.

Experts say the toddler case also highlights how easily the disorder can be missed. A retrospective study from the Children’s Hospital of Philadelphia found that children with trichotillomania were diagnosed at an average age of about eight, and many had other psychiatric or skin conditions. In very young children, doctors often first consider alopecia areata or ringworm, while parents may assume the behaviour will pass. The lesson from this case, and from the broader literature, is that visible hair loss, hair found in a child’s mouth, or pulling from other people or pets deserves medical attention, especially if the child also has stomach pain, vomiting, poor appetite or weight loss.