Case Presentation: A 60-year-old woman with history of trichotillomania and multiple psychiatric comorbidities presented with a full-thickness parietal scalp wound measuring 6.0 x 3.0 cm, with exposed calvarium. She reported persistent hair pulling behavior as the underlying cause. Previous attempts at surgical closure failed due to ongoing self-trauma from trichotillomania. On exam, the wound appeared clean without erythema, purulence or fluctuance, and she remained afebrile without leukocytosis. Magnetic resonance imaging of her skull revealed enhancement of the exposed calvarium concerning for osteomyelitis. Plastic surgery, Neurosurgery, and Infectious Disease were consulted. Due to high likelihood of treatment failure and re-injury, all teams agreed that both pursuance of bone biopsy to guide antimicrobial therapy and attempts at surgical reconstruction would be futile without stabilization of her trichotillomania. Psychiatry was engaged and identified severe trichotillomania superimposed on major depressive and generalized anxiety disorders. Her psychiatric medication regimen was optimized and within 48 hours, her levels of depressed mood, anxiety, and hair pulling behaviors decreased significantly. An intensive outpatient plan emphasizing habit-reversal therapy and local wound care was formulated. Incorporating the power of telehealth, a joint decision was made between primary medicine and infectious disease teams to discharge the patient with a 2-week course of doxycycline and levofloxacin. Should her trichotillomania continue to improve, she will be considered for antimicrobial extension and definitive surgical management.
Discussion: This case highlights the complex interplay that ensues when severe, uncontrolled psychiatric disorders result in medical complications such as full-thickness scalp defects complicated by calvarial osteomyelitis. Akin to how offloading pressure is often a cornerstone in the medical and surgical success of chronic sacral osteomyelitis management, psychiatric stabilization to reduce pressure from trichotillomania behaviors on patient’s wound beds is paramount. Once psychiatric stabilization is achieved, appropriate antimicrobial therapy and surgical planning can begin. Achieving these steps in timely fashion is critical to patient outcomes given the significant morbidity associated with untreated calvarial osteomyelitis, with complications including progression to chronic infection, bone necrosis, extradural abscess formation, and potentially life-threatening central nervous system complications such as meningitis. As the most effective treatment for trichotillomania centers around intensive behavior therapy, especially habit-reversal therapy, the growing availability of virtual telehealth visits provides access for patients who previously faced significant barriers to care. Identifying shame as a frequent barrier to seeking care and utilizing telehealth interventions that offer treatment in safe, one-to-one settings can ultimately improve patient outcomes and reduce the risk of relapse following wound reconstruction.
Conclusions: In cases of severe skin defects from trichotillomania, successful management requires coordination across specialties with prioritization of psychiatric stabilization and meticulous wound care. Once underlying psychiatric conditions are optimized, patients may become candidates for definitive medical and surgical management of chronic osteomyelitis.