Adam Reich1, Karolina Mędrek1, Zygmunt Adamski2 and Jacek C. Szepietowski1
1Department of Dermatology, Venereology and Allergology, Wroclaw Medical University, Ul. Chałubińskiego 1, 50-368 Wrocław, and 2Department of Medical Mycology and Dermatology, Poznan University of Medical Sciences, Poland. E-mail: email@example.com
Accepted October 17, 2012.
Trichodynia is defined as a painful sensation within hair, which becomes more intense when hairs are touched. The pain occurs with no pathological findings, and is usually considered a type of somatoform disorder (1, 2). Trichodynia should be differentiated from scalp dysesthesia, which refers to situation when the symptoms reported by the patient are localized on the scalp skin, while in trichodynia patients indicate that the pain or burning is solely limited to the hair itself. Many patients with trichodynia present other psychiatric symptoms, including depression, obsessive-compulsive or anxiety disorders. The cause of trichodynia is not known, but it is suggested to be of multifactorial origin (2, 3). We describe here a patient who reported itching of the hair instead of pain.
A 57-year-old Caucasian man was admitted to our department with a 30-year history of itching of the scalp hair, eyebrows, moustache and chest hair. The sensation of itch was more intense when hairs were touched. The patient was in good general condition, with no history of hepatitis, allergy, sexually transmitted diseases or any chronic disorders, that might be linked with reported sensations. He did not use any medication. The first symptoms of itching appeared more than 30 years ago and had been diagnosed initially as hypochondriac neurosis. At that time the patient was admitted to the psychiatric ward for insulin shock therapy, and subsequently treated with promethazine, thioridazine, hydroxyzine, psychotherapy, systemic antibiotics and topical steroids with no improvement.
On current admission the patient manifested only androgenic alopecia (stage VA according to Norwood-Hamilton scale). The patient reported itching within the hair of the scalp, eyebrows, moustache and chest. He described it as severe on the Verbal Rating Scale (itch severity according to VAS was 6 points), and reported a marked increase in itch severity when hairs were touched. It is notable that, based on anamnesis, the itching disappeared over time from areas of hair loss. No symptoms of seborrhoeic dermatitis were observed. Routine laboratory examinations (complete blood cell count, kidney and liver function tests, serum glucose and thyroid hormones level, total serum IgE level, stool examination for parasites) did not reveal any abnormalities. In addition, the patient did not demonstrate any significant abnormalities during the psychiatric examination; the anxiety and depression scores according to the Hospital Depression and Anxiety Scale were 9 and 8 points, respectively. Based on the Dermatology Life Quality Index (DLQI) a moderate impact of itch on patient’s quality of life was observed (DLQI scoring 8 points). As no organic cause of itching was found, the patient started therapy with paroxetine, at a dose of up to 30 mg/day; however, no improvement was noted within the 3-month period of treatment. Prior to the psychiatric therapy we tried to treat the patient with antimycotic drugs (itraconazole 100 mg for 8 days in combination with piroxolamine shampoo once daily for 2 months), but no improvement was seen. After failure with paroxetine, gabapentin (300 mg/day) was introduced as a second-choice anti-pruritic therapy, and this treatment resulted in a significant reduction in perceived itch. Currently our patient continues with gabapentin treatment.
The history of this patient seems to be consistent with trichodynia, but instead of pain the patient experienced chronic itch. We propose the use of the term “trichoknesis” for such a condition, as touching the hair provoked a marked increase in itching sensations, which is a very similar phenomenon to alloknesis, in which lightly touching the normal skin near a site of itch can elicit an itch sensation (4). Whether “trichoknesis” is a variant of trichodynia or a distinct type of dysesthesia is not known; both disorders appear to be very rare, and no epidemiological and pathological data exist. However, because our patient was able to clearly name the sensation experienced as itching, and due to the fact that itching was not limited only to hair on the scalp, but was also present within the hair of the eyebrows, moustache and chest, we conclude that “trichoknesis” should be differentiated from trichodynia. Interestingly, Hoss & Segal (5) in their study of 11 patients with scalp dysesthesia observed 2 women who solely reported itching of scalp with no symptoms of pain or burning. Furthermore, these 2 women were less responsive to antidepressive therapy than the rest of the patients with other types of scalp skin sensations. Importantly, our patient did not respond to the antidepressant paroxetine, further indicating that itchy and painful sensations must be considered separately.