Trichopsychodermatology: trichotillomania and trichophagia leading to Rapunzel syndrome

Introduction
The Rapunzel syndrome occurs when the trichobezoar (hair ball) extends beyond the small intestine and sometimes even into the colon, producing long, tail-like hair extensions.

Aim: To present cases of trichobezoars, an extremely rare human intestinal disease caused by the ingestion of hair (trichophagia).

Material and methods
In this retrospective study, we assessed the medical records of two patients diagnosed with Rapunzel syndrome admitted to Academic Clinical Hospital No. 2 in Rzeszow, Poland.

Results
The first patient was a 15-year-old girl. The abdominal ultrasound examination revealed an abnormal, non-compressible structure with the approximate dimensions of 12 × 11 cm in the epigastrium, with a strong shadow obscuring the view. Gastroscopy was performed and a tumour sample was taken for histopathological examination, which confirmed the diagnosis of a trichobezoar. The patient’s mother did not agree to her daughter’s psychiatric treatment. The second patient was a 15-year-old girl who reported to the Emergency Room in critical condition due to dehydration and long-term emesis with symptoms of cachexia. Ileotomy with the removal of two trichobezoars with a diameter of about 5 cm and 7 cm was performed. The patient was discharged for treatment at the Mental Health Clinic for trichotillomania.

Conclusions
Trichobezoars give non-specific symptoms that may imitate other diseases for example tumours. Psychotherapy is the recommended treatment and follow-up visits are important in preventing relapses.