Hair loss in children is not uncommon, it differs from the normal physiological hair loss in newborns and is an abnormal hair loss condition. Some are developmental defects caused by the complete absence or thinning of hair, called congenital baldness, often with a family history of genetic inheritance, most hair is thin and fine, or normal hair at birth, soon to fall out and not grow, or extremely slow growth, sometimes accompanied by abnormalities of nails, teeth, etc., diagnosis and treatment is very difficult. The common hair loss in childhood is acquired alopecia, and there are many kinds of it, mostly due to shock, anxiety, fear or nutritional imbalance, thus causing disorders in the immune endocrine system of the body, resulting in hair loss, the most common being baldness, and in severe cases, total baldness or even universal baldness can occur. In addition, there are also micronutrient deficiencies, such as iron deficiency and calcium deficiency; fungal infections, such as various kinds of ringworm; abnormal thyroid function, and even syphilis, which can also lead to hair loss. Dermatological manifestations of hair-pulling fetish There are some children who have no family history, no specific triggers for acquired hair loss, and all kinds of laboratory tests are normal, but still keep losing hair, especially in a specific area of the head. This is the time to pay special attention to whether the child has the habit of pulling his or her own hair, and to whether there are hair breaks on the child’s desk, bedside, and other places where he or she often stays alone. If this is present, you need to be aware of a specific type of hair loss – plucking fetish. The disease can often develop in young children and at least in early childhood, and can last long into adulthood, with the prevalence in children being seven times higher than in adults. It can develop in both men and women, with a higher proportion of women, 5 to 10 times more often than men. Patients consciously or unconsciously pluck out their hair, eyebrows, eyelashes, beard, axillary hair or pubic hair to form non-scarring alopecia. Hair loss is the main symptom reported by patients or their families. The most common areas of hair loss are the frontal and temporal areas, which are easily accessible by hand, followed by the occipital area and the top of the head, and the areas where hair is plucked vary greatly from patient to patient, but the areas where hair is plucked are generally fixed in the same patient. Hair plucking is mostly done at night, before napping, when taking a shower, or when the patient thinks it is convenient. Some patients feel nervous before hair extraction and feel relaxed and satisfied after performing the operation. In children, hair plucking can be detected by their parents, but older female patients often deny plucking and cover up the affected area by themselves. A few patients also swallow the plucked hairs, causing gastrointestinal symptoms such as intestinal obstruction, which can be life-threatening in severe cases. Examination of the alopecia area shows that hair loss and hair breakage often exist at the same time, the residual broken hair is of different heights, the broken ends are twisted, and the hair pulling test at the edge of the alopecia area is negative. If the patient denies hair pulling and there is a high clinical suspicion of the disease, hair microscopy can be performed, which can help in diagnosis. Psychological manifestations of hair-pulling fetish Patients with hair-pulling fetish are often accompanied by psychological or psychiatric disorders, such as depression and anxiety, but also compulsive neurosis, ADHD, tic disorder, etc. Many patients have bad habits such as nail chewing, finger sucking, nose pinching, hair curling with fingers, or are introverted, irritable, and prone to crying and fussiness. The Diagnostic and Statistical Manual of Mental Disorders, 4th edition (DSM-IV), developed by the American Psychiatric Association, and the Chinese Classification of Mental Disorders and Diagnostic Criteria, 3rd edition (CCMD-3, 2001), developed by the Psychiatric Branch of the Chinese Medical Association, both classify hair-pulling fetish as “habit and impulse control disorder “. It is manifested by the patient having a strong desire to pluck hair and acting on it, repeatedly pulling out his or her own hair, which results in the absence of hair, and having a sense of tension before the action and relief after the action. Although attempts are made to control this action, they often fail and result in hair loss. This intention is not the result of skin disease or other mental disorders such as delusions or hallucinations. Our psychiatric criteria for the diagnosis of hair plucking fetish are: 1. The striking hair loss is due to the failure of a persistent urge to control hair plucking; 2. The patient complains of a strong desire to pluck hair, accompanied by a feeling of tension before the action and a feeling of relief afterwards; 3. It is not due to a skin disease such as dermatitis, nor is it a reaction to a psychiatric disorder, such as delusions or hallucinations. Treatment and prognosis of plucking fetish The etiology and pathogenesis of plucking fetish is still unclear, biological, psychological and social factors all play a role in the development of the disease, about a quarter of the patients are related to psychological stress factors. Hair pulling often starts in children and adolescents, and the later the onset of the disease, the more chronic the tendency, with symptoms lasting about a year in about a third of patients and up to 20 years in some cases. Early diagnosis and treatment are important, and although taxonomically this disorder is still classified as a child psychiatric disorder, some patients and their families do not readily accept psychiatric treatment, and the majority of patients first go to dermatology for consultation and treatment. Therefore, dermatologists need to strengthen their counseling skills and assume a major role in the treatment of hair pulling fetish. Psychological treatment is effective. Contact is first made with the patient’s relatives to help identify psychological triggers and prevent them. Combine educational guidance with behavioral therapy, instructing patients to play rubber bands if they have the urge to pluck hair, play until it hurts and count the numbers until the urge disappears. Appropriate medication to enhance confidence in treatment and improve anxiety and tension. Correcting bad habits, such as shaving the hair of male patients, is also desirable. Establishing good, harmonious family relationships can relieve long-term mental tension. For pediatric patients, reducing the pressure and demands from parents can help the disease to be relieved. Medication is mostly used for antidepressant tablets, such as tricyclic amitriptyline, and promethazine, doxepin, and chlorpromazine; drugs that inhibit pentraxin reuptake, such as fluoxetine and paroxetine. Treatment under the supervision of a psychiatrist is required.