Trichotillomania vs Alopecia: How to Tell the Difference

If you’ve been told that you or your child has “alopecia”, or you’re wondering what caused a patch of missing hair, this guide is for you. Trichotillomania vs alopecia is one of the most common mix-ups in hair loss, and it matters, because the two need very different kinds of help.

Below: how each one looks, how doctors tell them apart, whether you can have both, and who to see first, plus a section for parents who suspect pulling after an alopecia diagnosis.

Is trichotillomania a type of alopecia?

Not really. “Alopecia” is simply the medical word for hair loss. When people say “alopecia”, they usually mean alopecia areata, one specific condition. Trichotillomania is a different condition with a different cause.

• Alopecia areata is an autoimmune condition. The immune system, which normally fights germs, attacks the hair follicles (the tiny pockets in the skin that hairs grow from) by mistake, and the hair falls out.
• Trichotillomania is a body-focused repetitive behaviour (BFRB). BFRBs are conditions where people repeatedly pull, pick or bite at their hair, skin or nails. The hair loss comes from pulling, not from a problem in the follicles.

Neither condition is anyone’s fault. Trich is not a bad habit, attention-seeking or self-harm, and alopecia areata isn’t caused by anything a person did.

The label matters because the help is different. Alopecia areata is treated by doctors, sometimes with medicines that calm the immune system. Trich is helped most by therapy that works on the pulling itself, such as Habit Reversal Training (HRT), which teaches you to notice pulling and do something else with your hands. Our guide to Habit Reversal Training explains how it works. For the full picture of trich, see our complete guide to trichotillomania.

What does each one look like?

Alopecia areata usually causes smooth, round or oval bald patches with clear edges. Trich usually causes patches with uneven edges that feel stubbly, because the hairs inside have broken off at different lengths. These are typical patterns, not rules, so only a doctor can say for sure.

Smooth skin with exclamation mark hairs around the edge is a classic sign of alopecia areata. A stubbly patch that keeps changing shape points more towards pulling. A red, scaly or itchy scalp may mean an infection instead (see below).

Our guide to trichotillomania symptoms describes the signs of pulling in more detail.

How do doctors tell them apart?

Most of the time a doctor can tell by looking at the hair and scalp and asking a few questions. The UK’s NHS says a GP can often work out the cause of hair loss just by looking. If it isn’t clear, a dermatologist (a doctor who treats skin, hair and nails) has a few extra checks.

1. Questions. When the hair loss started, whether the area itches, and whether hair loss or autoimmune conditions run in the family. A doctor may gently ask whether you touch or pull at your hair. Doctors have heard it before, and answering openly speeds everything up.
2. A hair pull test. The doctor holds a small bunch of about 40 to 60 hairs and tugs gently. In alopecia areata, more than 1 in 10 of those hairs often slide out easily near an active patch. In trich, the test is usually negative.
3. Trichoscopy. The doctor looks at the scalp through a dermatoscope, a handheld magnifier with a built-in light. It’s quick and painless. In alopecia areata they look for exclamation mark hairs and tiny yellow and black dots in the follicle openings. In trich they look for hairs snapped at different heights, split ends, V-shaped stubs, tightly curled stubs and a fine powdery residue called hair powder.
4. A special light. Some doctors shine a Wood’s lamp (a handheld ultraviolet light) on the scalp to rule out a fungal infection.
5. A small skin sample (biopsy), only if still unsure. Under a microscope, alopecia areata shows immune cells crowded around the hair roots. Trich shows damaged and broken hairs and follicles plugged with debris and pigment, with little sign of an immune attack.

Trichoscopy works well. In a 2014 study of 370 people with patchy hair loss, all 44 people with trich had irregularly broken hairs, and more than half had V-shaped stubs. A 2021 review of the research found that hook-shaped, V-shaped and curled hairs almost never appear in other hair conditions, while plain broken hairs and black dots also show up elsewhere. So doctors look for a combination of signs.

What about traction alopecia and other look-alikes?

Traction alopecia is hair loss from hairstyles that pull tightly for a long time, such as tight ponytails, buns, braids, cornrows, weaves and extensions. It comes from styling, not an urge to pull. It mostly affects the front and sides of the hairline, often leaving a “fringe sign”: a thin rim of hair along the very edge. Loosening hairstyles helps stop it getting worse, but years of tension can damage follicles for good, so it’s worth acting early.

Other causes a doctor will think about:

• Scalp ringworm (tinea capitis), a fungal infection that can make the scalp scaly and itchy and cause patchy hair loss. It spreads through shared combs, towels and bedding, and usually needs prescription antifungal tablets and shampoo.
• Shedding after illness, stress, weight loss or low iron, which is often temporary and grows back once the cause is dealt with.
• Pattern hair loss, which tends to run in families and thins hair gradually.

Our complete guide also covers other conditions that can look like trich.

Can you have trichotillomania and alopecia areata at the same time?

Yes, though it seems to be rare. Doctors have published a small number of cases, mostly in children.

It can happen two ways. An itchy alopecia areata patch can lead to scratching that turns into pulling. Or pulling at new growth in an alopecia areata patch can keep it bare for longer. In one reported case, a 6-year-old boy’s patch had lasted two years. Under magnification, doctors saw exclamation mark hairs alongside marks from scratching and small spots of bleeding, and careful questions revealed he was also pulling.

This is worth knowing if alopecia areata treatment isn’t working, or a patch stays bare when hair should be regrowing. Short, stubbly regrowth is a common trigger for pulling, whatever caused the hair loss. Our guide to whether hair grows back after trichotillomania explains what regrowth looks like and how long it takes.

My child was diagnosed with alopecia, but I think they pull. What now?

Go back to the doctor and share what you’ve noticed. The two are among the most common causes of patchy hair loss in children, and trich is easy to miss because children often pull in private or without realising. One published case describes a 12-year-old girl first diagnosed with alopecia areata whose hair loss turned out to be from pulling.

Things that help:

• Describe what you’ve seen, such as a hand in their hair while watching TV or falling asleep, or patches that feel stubbly or change shape. Ask whether the scalp has been checked with a dermatoscope.
• Stay calm and curious, not accusing. Asking “Are you pulling your hair out?” in a worried or cross voice often leads to more hiding. Children can’t stop just because they’re told to, so never tell them off or punish pulling.
• Tell your child it isn’t their fault. It has a name, lots of people have it, and people know how to help.
• In toddlers and preschoolers, pulling is often self-soothing and often stops on its own.

Our guide on what to say to a child who pulls their hair has words that help. Our guide on when to take your child to a doctor about hair pulling explains what to expect at the appointment. For a fuller walkthrough, start with The Parent’s Guide to Trichotillomania: understanding what your child is going through.

Who should I see?

Start with your GP or family doctor, who can check the hair loss and refer you to a dermatologist if the cause isn’t clear. The NHS advises seeing a GP before going to a commercial hair clinic. After that, it depends on the cause:

• Alopecia areata, traction alopecia or an infection: your doctor or a dermatologist will guide treatment.
• Trichotillomania: trich is often diagnosed by skin doctors, but it’s a mental health condition, and help comes from someone who understands hair pulling, such as a psychologist, therapist, counsellor or other practitioner. You don’t need a skin doctor’s diagnosis to start.
• Both: it’s fine, and often best, to see both kinds of professional at the same time.

When should I get help?

See a doctor about any hair loss that worries you, and get support for pulling if it’s causing you distress, taking up your time, or you’ve tried to stop and can’t. You don’t need to wait until it’s “bad enough”.

Many doctors and therapists have never worked with someone who pulls. Everyone in our directory has told us they understand trichotillomania and already help people who pull, in person or online. You can search the directory. Our guide to finding someone who understands trich explains what to ask on a first call.

Hair loss of any kind can be hard to live with. If you’re feeling very low or hopeless, please talk to someone today.

In an emergency, call 111 or go to your nearest emergency department.

• Need to Talk? (free call or text) — 1737 (1737.org.nz)
• Lifeline Aotearoa — 0800 543 354
• Youthline — 0800 376 633

Questions people ask

Sources

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2. Kaczorowska, A., Rudnicka, L., Stefanato, C.M., Waskiel-Burnat, A., Warszawik-Hendzel, O., Olszewska, M. & Rakowska, A. (2021). Diagnostic accuracy of trichoscopy in trichotillomania: a systematic review. Acta Dermato-Venereologica, 101(10), adv00565.
3. Trüeb, R.M. & Cavegn, B. (1996). Trichotillomania in connection with alopecia areata. Cutis, 58(1), 67–70.
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5. Pinto, A.C., Andrade, T.C., Brito, F.F., Silva, G.V., Cavalcante, M.L. & Martelli, A.C. (2017). Trichotillomania: a case report with clinical and dermatoscopic differential diagnosis with alopecia areata. Anais Brasileiros de Dermatologia, 92(1), 118–120.
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11. NHS. Ringworm.