'Hair casts' and Treatment for Folliculitis

[Guajiro]

I read other postings on folliculitis, but I didn't see one that addresses it on the scalp.  I am 40 and for at least the last 5 years I have had small isolated bumps on the scalp that are annoying and I scratch them a lot, often times breaking the skin which forms scabs that later I pick at.  My brother told me that I do this in public and I'm not even aware of that I'm scratching.  The bumps come and go in about a week's time.  Whenever a bump is irritating, I tweez hairs from the affected spot and the hairs have a transparent to white opaque sheath around the base.  Occassionaly there is a pustule.  One dermatologist called them "hair casts", told me not to scratch or tweez, and proscribed Nizoral 2% shampoo. I use the Nizoral almost daily and it doesn't help much.  Removing the hair seems to provide relief from the irritation, but obviously I loose hair this way.  I also take Luvox for OCD and depression.  I asked my psychiatrist if tweezing scalp hair as I do means that I have trichotillomania and his opinion is that my hair tweezing is not sufficient to be considered trichotillomania and I should seek a dermatological solution.  Daily I pick my face and look for pimples to pop, though I don't have general acne.  As you mention in one of your responses, this is behavioral.  I think the Luvox helps; however, I am considering treatment with a cognitive-behavioral therapist and/or a "certified hypnotist" in an attempt to modify this counterproductive behavior.  I think the folliculitis feeds into the behaviorial pattern in a vicious cycle.  From a dermatological perspective, is there anything else I can do to prevent or treat the folliculitis and/or hair casts?

[Alan Rockoff, MD]

I'm pretty sure what you (and the dermatologist) are calling "hair casts" are actually the hair bulb itself that you're yanking out.  Hair casts are cylindrical and surround part of the shaft; hair bulbs are at the end.  You only see that you pull a living hair out.  This is indeed trichotillomania (awful name), though textbook pictures of that condition usually show a patch of hair loss, whereas you're pulling hairs out one at a time.



I think your relating the situation to your OCD is very likely correct.  The best approach is to suppress the picking/tweezing behavior.  You are already way ahead of the game by acknowledging that you have a picking problem.  Most patients I see with this kind of issue deny it completely.



Good luck.



Dr. Rockoff