Modified-Release Methylphenidate-Related Trichotillomania in a Boy with Autism Spectrum Disorder

To the Editor:

Trichotillomania (TTM) is a disorder characterized by recurrent hair pulling, generally from the scalp and/or eyebrows. TTM is usually a chronic condition and leads to functional impairment and discomfort (Woods and Houghton 2014). Stimulants, especially methylphenidate (MPH), are well-accepted treatments for attention-deficit/hyperactivity disorder (ADHD) in children and adolescents. Their common side effects include headache, abdominal pain, nausea, loss of appetite, weight loss, insomnia, anxiety, and nervousness (Narine et al. 2013). In this article, we report the occurrence of an unusual side effect, TTM, with modified-release MPH use in a boy with autism spectrum disorder (ASD).

Case Report

Our patient was an 8-year-old boy who was diagnosed with ASD at age 3 years. He was referred to our clinic with the complaint of hyperactivity, anger bursts, and irritability. Developmental history revealed that he had marked delays in social interaction and speech. There was no physical illness, trauma, medication, obsessive-compulsive disorder, or TTM in history. During the clinical evaluation, we observed his hyperactivity and aggression. He showed little interest in social interaction, had odd stereotypies, and gross deficits in speech and eye contact. As a result of his psychiatric and psychometric examinations (Childhood Autism Rating Scale total score = 45, Turgay Diagnostic and Statistical Manual of Mental Disorders, fourth Edition (DSM-IV) Disruptive Behavior Disorders Rating Scale parent form ADHD total score = 40), he was diagnosed with ASD and ADHD according to Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) and was initiated modified-release MPH 20 mg/day gradually. One month after, the second examination revealed that his symptoms improved partially, but he started to pull his scalp hair in the left temporoparietal region (Fig. 1). Metabolic parameters, common blood, and biochemical tests were normal and dermatology was consulted with no important findings. So, we ceased MPH and his hair pulling stopped after discontinuation of the medication. Two weeks later, we restarted modified-release MPH 10 mg/day to know whether TTM was associated with MPH, and we saw that TTM reemerged within the first week of the medication.

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FIG. 1.

The patient's left temporoparietal region, 1 month after starting MPH. MPH, methylphenidate.

Discussion

We reported a case who developed TTM after initiating MPH and had remission after stopping the medication. The chronological sequence and dramatic response to discontinuation of the medication suggested that MPH was probably responsible for TTM, which was seen in our case. Also, the patient did not have any medical illnesses, trauma, or history of previous TTM.

There are several reports of TTM associated with stimulant use (Martin et al. 1998; Hamalian and Citrome 2010; Narine et al. 2013). Hamalian and Citrome (2010) reported stimulant-induced TTM in an adult with ADHD. Narine et al. (2013) reported a case of dextroamphetamine/amphetamine-induced TTM in a 12-year-old girl with ADHD. To the best of our knowledge, this is the first reported case of modified-release MPH-related TTM in a child with ASD.

Although not clearly identified, serotonergic, dopaminergic, and noradrenergic dysfunctions are implicated in the pathophysiology of TTM (Woods and Houghton 2014). It is known that stimulants have facilitative effects on serotonin, dopamine, and noradrenaline neurotransmission (Hamalian and Citrome 2010). Increased serotonergic, dopaminergic, and/or noradrenergic activity with MPH may be related with the emergence of TTM in our case.

The use of MPH has become widely common in children and adolescent for treating ADHD. Thus, MPH-related TTM should be kept in mind when using this medication. In contrast, further studies are needed to clarify the exact mechanisms of TTM associated with MPH.