Global Pediatric Health Volume 9: 1–4 © The Author(s) 2022 Article reuse guidelines: sagepub.com/journals-permissions DOI: 10.1177/2333794X221086576 journals.sagepub.com/home/gph Creative Commons Non Commercial CC BY-NC: This article is distributed under the terms of the Creative Commons Attribution-NonCommercial 4.0 License (https://creativecommons.org/licenses/by-nc/4.0/) which permits non-commercial use, reproduction and distribution of the work without further permission provided the original work is attributed as specified on the SAGE and Open Access pages (https://us.sagepub.com/en-us/nam/open-access-at-sage). Case Report Article Summary N-acetylcysteine is a safe and well-tolerated over-the- counter supplement that can be very effective for some pediatric patients with trichotillomania. Introduction Pediatric trichotillomania, or hair pulling disorder, is a habit disorder that can result in alopecia and cause patients significant emotional distress. Although a few treatment options exist, including cognitive behavioral therapy (CBT) and selective serotonin reuptake inhibi- tors (SSRIs), they are not effective for all patients. N-acetylcysteine (NAC), an acetylated formulation of the amino acid L-cysteine, is an over-the-counter sup- plement shown to be effective for obsessive compulsive disorder (OCD) and other habit disorders. 1,2 Even though it is most widely used at higher doses for acet- aminophen toxicity and as a mucolytic, it is also avail- able over-the-counter in a low-dose oral formulation because of its safety, tolerability, and minimal toxicity risk at low doses. 3 NAC is used more commonly for trichotillomania in adults than kids. Multiple case reports and one random- ized controlled trial (RCT) in adults with trichotilloma- nia showed that NAC was effective at reducing hair pulling. 4-6 Despite this evidence, one small RCT for pedi- atric trichotillomania did not find a difference between NAC and placebo, contradicting multiple case reports. 7-9 But this RCT may not be generalizable to all pediatric patients, particularly teenagers. Age correlates with the frequency and severity of hair pulling in pediatric patients and NAC is hypothesized to work by reducing these urges. 4,10 The pediatric RCT of NAC for trichotillomania highlighted the need for age-stratification of pediatric patients in future trials to determine whether teenagers respond differently than younger children. We present a 1086576GPH XX X 10.1177/2333794X221086576Global Pediatric HealthPopova and Mancuso research-article 2022 1 University of Michigan Medical School, Ann Arbor, MI, USA Corresponding Author: Jennifer Mancuso, Department of Dermatology, University of Michigan-Michigan Medicine, 1910 Taubman Center, 1500 E. Medical Center Drive, Ann Arbor, MI 48109-5314, USA. Email: [email protected] Dramatic Improvement of Trichotillomania with 6 Months of Treatment With N-Acetylcysteine Lilia Popova, BS, BA 1 and Jennifer Mancuso, MD 1 Abstract We present a case of a 17-year-old male with recurrent hair twirling resulting in patchy alopecia, who improved dramatically on N-acetylcysteine (NAC). Trichotillomania is characterized by repetitive hair pulling, twisting, or twirling and can vary from a mild habit to an impulse-control disorder. Standard treatment for pediatric trichotillomania includes cognitive behavioral therapy or medical therapy with selective serotonin reuptake inhibitors. NAC is a more recently utilized, safe, and well-tolerated over-the-counter supplement with some evidence of benefit for habitual skin and hair disorders. For this patient, we recommended 600 mg twice daily, increasing to 1200 mg twice daily as tolerated. After 6 months, our patient reported decreased desire to twirl his hair and his hair had almost completely regrown. Pediatricians who see patients with trichotillomania or other habitual disorders can consider treating these patients with NAC given its potential benefits and favorable side effect profile. Keywords Trichotillomania, Hair Pulling, Hair Loss, Habit Disorder Received January 19, 2022. Accepted for publication February 17, 2022.
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