Trichodynia is a scalp condition characterized by abnormal burning, stinging, or crawling sensations in the scalp. These sensations often occur without visible signs of inflammation or skin disease. Trichodynia is frequently associated with hair loss, particularly telogen effluvium or androgenetic alopecia, making it a condition that spans both dermatological and neurological domains. It tends to affect younger to middle-aged adults and is more commonly reported in women than in men. The condition has a strong link to psychiatric disorders such as anxiety, depression, and obsessive-compulsive disorder (OCD), suggesting that both medical and psychological evaluation are essential for effective management.

How common is Trichodynia?

Trichodynia, being a subjective feeling, often goes under-reported or dismissed due to a lack of physical findings. Therefore, we don’t exactly know how common it is. But we can get an estimate through the prevalence of associated conditions. In a study involving patients with various hair disorders, more than a quarter also had trichodynia.Askin, O., Gok, A. M., & Serdaroglu, S. (2021). Presence of Trichodynia Symptoms in Hair Diseases and Related Factors. Skin appendage disorders, 7(1), 18–20. https://doi.org/10.1159/000511739 According to another study, it’s twice as common in women than in men.¹

We don’t have specific data regarding prevalence in the US, but as a related condition, androgenetic alopecia affects half of the middle-aged men here.²
A few other studies show that 44% of the French and 35.77% of the Chinese population have trichodynia. ³ ⁴

What happens in Trichodynia?

Several mechanisms might be going on in the background of trichodynia. In biopsies of patients experiencing trichodynia, scientists observed elevated levels of substance P⁵ and mast cells. Substance P is a neuropeptide that dilates your blood vessels, recruits immune cells, and makes your scalp more sensitive to pain. Mast cells release mediators of inflammation that irritate nerves and contribute to scalp tenderness. This led them to believe these chemicals might be producing trichodynia.

Another proposed mechanism is the hypersensitivity of the trigeminal nerve pathways and central sensitization, which produce and amplify these burning sensations. Apart from this, due to a strong association between trichodynia and psychiatric disorders, there might be an underlying dysfunction of the CNS-skin axis, altering pain perception secondary to emotional stress.⁶

Symptoms of Trichodynia

The symptoms of Trichodynia often include abnormal sensations on the scalp, such as:

Burning, itching, stinging, or crawling
Pain or soreness while combing hair
A feeling of tightness
In 1996, when Trichodynia was first described, patients described it as a feeling of ‘your hair bent in the wrong direction’⁷

You may have these symptoms restricted to your temples, crown, or the occipital area of your scalp, or you may feel them all over it.
As trichodynia usually coexists with other dermatological and psychological conditions, you may also have:

Gradual thinning of your hair
Excessive hair loss
Spot baldness
An urge to pull your hair
Stress episodes
Anxiety spells
Depression

What causes Trichodynia?

Bald Spot on a boy's head — Allopecia areata or Spot Baldness (Image Courtesy: Wikimedia Commons, under Public Domain)

While the exact causes of trichodynia haven’t yet been established, epidemiologists frequently find the following conditions associated with it.

Telogen effluvium: It’s a reversible dermatological condition characterized by rapid hair loss following any stressful event or trauma.
Androgenetic alopecia: This condition refers to patterned hair loss in individuals with a genetic predisposition to it.
Alopecia areata, or spot baldness, is an autoimmune condition in which our immune system mistakenly attacks hair follicles, causing circular or ‘spot’ hair loss.
Scarring alopecia: It’s a type of permanent hair loss, secondary to scarring.
Trichotillomania: This condition is primarily a psychiatric issue, in which you have an irresistible urge to pull out your hair.
Chemotherapy-induced alopecia: According to an observational cohort study, 87% of the patients on chemotherapy experienced hair loss.⁸
COVID-19: In an Indian study done on COVID-19 patients, around a quarter of the patients with hair loss had trichodynia too.⁹

Additionally, scientists observe a link between trichodynia and psychiatric morbidities such as:

Depression
Anxiety
Obsessive-Compulsive Disorder
Somatoform Disorders, such as chronic pain syndrome

These illnesses may cause, worsen, or trigger trichodynia by altering your perception of pain or making your scalp more sensitive to it.

How to diagnose Trichodynia?

Trichodynia is a diagnosis of exclusion. Doctors clinically diagnose it based on patient-reported symptoms, after they have successfully ruled out other conditions that may mimic or overlap with it.

Clinical Evaluation:

Your doctor will begin with a thorough history to understand the nature, duration, and progression of your symptoms. He will then proceed to the following dermatological examinations to rule out the differentials and confirm trichodynia:

Hair Pull Test

It’s a simple test done to determine the presence and severity of active hair shedding.¹⁰ In this test, the doctor grasps sections of your hair and gently tugs on them. He then observes the number of hairs that come out easily. Some 6 or more indicates active hair loss, helping in diagnosing telogen effluvium or alopecia areata that may coexist with trichodynia.

Trichodynia — Trichoscopy (Image courtesy: Wikimedia Commons, under Public Domain)

Trichoscopy (Scalp Dermoscopy)

It’s a non-invasive technique that allows for a magnified observation of the hair shafts, follicular openings, and scalp skin. Doctors use it to diagnose and categorize hair loss. In case of pure trichodynia, this test reveals a normal scalp appearance.

Scalp Biopsy

It’s an invasive procedure done in cases of diagnostic uncertainty or suspicion of scarring or inflammatory alopecia. A biopsy identifies the presence of mast cells, perifollicular fibrosis, or inflammatory infiltrates. Doctors use it to differentiate between primary scalp diseases and pain disorders such as trichodynia.

Blood Tests:

Your doctor may ask for your serum levels of vitamin B12, zinc, iron folate, vitamin E, vitamin D, and thyroid profile to rule out nutritional deficiencies.

Psychiatric Assessment:

Since trichodynia often co-exists with psychiatric conditions, psychiatric assessment should be carried out as an essential part of the trichodynia workup.

Patients should be evaluated for depression, anxiety, OCD, and somatoform disorders. For this purpose, doctors should use validated questionnaires or refer patients to mental health professionals where required. Note that it’s important to identify mental health conditions early, as they do influence the intensity of symptoms and the approach to treatment.

Hormonal Profile:

Additionally, doctors should evaluate female patients for peri and postmenopausal symptoms too, and ask for a hormonal profile, as several studies point out an association between menopause and trichodynia.

Can Trichodynia be treated?

Currently, there are no official treatment guidelines for trichodynia. But there are several therapies that patients benefit from, such as pharmacotherapy, hair loss treatments, psychotherapy, and home remedies.

Doctors usually adopt a step-wise approach–start with conservative measures such as scalp care, then introduce topical agents, and finally systemic therapies if necessary.¹¹

Step 1: Scalp Care & Home Remedies for Trichodynia

These include:

Identify and avoid potential scalp irritants such as chemical treatments, exfoliants, and hair straighteners from your daily routine. Better replace them with non-irritating shampoos and cleaners–preferably amphoteric or soft anionic surfactants, and always fragrance-free.
Keep your scalp hydrated with products that contain glycerin, hyaluronic acid, natural oils, and ceramides.
Stick to mild, pH-balanced hair care products with anti-inflammatory or soothing ingredients. Look for labels like “pH-balanced,” “for sensitive scalp,” or “dermatologist recommended”, when choosing a hair-care product.
If commercial options don’t suit you, consider compounding pharmacies. For example, as per Guerra-Tapia et al, one formulation that has shown promising results included a transparent gel with sodium hyaluronate 0.1–0.5%, glycerin 5%, hydroxypropyl methylcellulose 1.5%, and purified water.¹²
Staying stress-free is super-important. Practice stress-reducing techniques like meditation, mindfulness, yoga, and cognitive-behavioral therapy (CBT)
You might benefit from gentle scalp massages. They boost blood flow and reduce discomfort.
Tight hairstyles often worsen symptoms through mechanical irritation. Avoid them.
Cool compressors also provide temporary relief from the burning/tingling sensations. Take a clean, damp, cold compress. Apply it to the affected area for 10-15 minutes. Don’t directly put ice packs onto your scalp–they may cause cold burns.

Step 2: Topical Treatments

These are often used as first-line pharmacological options, especially when symptoms are localized or mild to moderate. They may be combined with scalp care for enhanced results.

Topical Corticosteroids: These are particularly useful in cases of inflammatory scalp conditions. Doctors advise topical steroids for localized inflammation, whereas systemic steroids are reserved for unresponsive cases or when there is extensive inflammation present.
Capsaicin Cream (0.025–1%): It inhibits the TRPV1 receptors on sensory neurons, desensitizing them to chronic pain and itch. If advising this cream, it is important to counsel the patient regarding the initial burning sensation it may cause upon application.
Pimecrolimus Cream: It’s a calcineurin inhibitor having a mechanism of action similar to that of capsaicin cream. Doctors advise it as an alternative to steroids when their use is contraindicated.
Cannabinoids: Scientists are currently exploring topical CBD as a potential treatment for trichodynia. This drug resolves neurogenic inflammation by interfering with the endocannabinoid system.

Step 3: Systemic Treatments

These are typically reserved for moderate to severe trichodynia, especially when there’s an emotional or neuropathic component, or when topical therapies fail.

Antidepressants: Low-dose tricyclic antidepressants such as amitriptyline are usually the first-line agents for trichodynia in patients reporting significant emotional symptoms alongside scalp pain. They help with neuropathic pain and also alleviate associated depression or anxiety.
Neuromodulators: These are used in patients who don’t find relief from conventional therapies. They help reduce nerve excitability and sensitivity, especially when there is a neuropathic component to trichodynia. The commonly prescribed neuromodulators are gabapentin (starting at 300 mg once every night) and pregabalin (starting at 75 mg twice daily)
Propranolol: It’s a beta blocker that doctors advise in patients who have anxiety-related trichodynia. Patients have benefited from it at even low doses such as 10 mg a day.
Systemic Corticosteroids: Reserved for extensive or treatment-resistant inflammation, these should be used cautiously and under specialist supervision.
Botulinum Toxin A injections: These aren’t FDA-approved yet. Their primary mechanism of action is inhibiting the release of neuropeptides that cause scalp sensitivity, but we need more evidence to establish their efficacy and safety.¹³
Naltrexone: It’s another off-label option prescribed in doses of 1-5 mg/day. Owing to its analgesic and anti-inflammatory effects, it may reduce symptoms with fewer side effects as compared to other options.

Treating Underlying Psychiatric Conditions

Patients report improvement of their symptoms with treatment of underlying psychiatric conditions. Therefore, it’s important to:

Screen patients for psychiatric disorders such as anxiety, depression, obsessive-compulsive disorder, and somatoform disorders.
Start their treatment with pharmacotherapy such as SSRIs, TCAs, or anxiolytics, as per the underlying disorder.
Couple pharmacotherapy with Cognitive Behavioural Therapy and other psychotherapies to further improve outcomes.

Managing Associated Hair Loss Disorders

Your doctor might advise any of the following hair loss treatments to manage associated hair loss conditions like telogen effluvium, androgenetic alopecia, or alopecia areata:

Topical Minoxidil: It’s a vasodilator that acts by enhancing blood flow to the scalp. Better perfusion means more nutrients to the hair follicles, keeping them in the growth phase longer. Known by the brand name Rogaine, it comes in a solution or foam form that you can directly apply to your scalp.
Platelet-Rich Plasma (PRP Therapy): It’s another hair loss treatment in which doctors use your blood to stimulate your hair growth. Doctors extract your blood, concentrate the platelets, and then inject this platelet-rich plasma into your scalp. Alongside hair growth, the resultant improved blood circulation and tissue healing help reduce scalp sensitivity too.
Oral Finasteride: As a 5-alpha reductase inhibitor, Finasteride blocks the enzyme that converts Testosterone to Dihydrotestosterone. Lower levels of DHT help arrest hair loss and promote hair regrowth in patients with male pattern baldness.

These therapies not only help control hair loss but also alleviate trichodynia by stabilizing scalp health.

Patient Counselling & Lifestyle Advice

Apart from the aforementioned treatment options, patient education is of utmost importance:

Doctors should reassure their patients about the benign nature of trichodynia.
Help them understand that while the condition is distressing, it’s not life-threatening at all and is manageable with appropriate care.
Emphasize how combining medical treatment with lifestyle modifications promises optimal results and long-term relief.
Suggest maintaining a diary to track symptoms, triggers, and efficacy of respective treatments. This would empower them with knowledge of their condition and aid in tailoring personalized management strategies.
Patients often tend to switch products frequently or misuse medications in pursuit of quick relief. Warn them against the harms of self-diagnosis. Explain how overusing medications without medical supervision can mask underlying issues and irritate the scalp further.

Is there a link between Trichodynia & Menopause?

Yes, scientists observed that more women report hair disorders and trichodynia after they have had their menopause. This led them to believe there must be a link between the two. Estrogen and progesterone–the female hormones–also have a role in maintaining the scalp barrier function and healthy hair growth. After menopause, as levels of these hormones decline, your scalp may become more sensitive, potentially triggering trichodynia.¹⁴

Additionally, since the anti-inflammatory and neuroprotective role of estrogen is no longer there, women may also have an elevated perception of pain, making their scalp more susceptible to burning, tingling, and other abnormal sensations.
Scientists also propose that since hair loss and hair thinning during menopause cause emotional distress, it may activate the stress-related pathways and exacerbate trichodynia.¹⁵

It’s due to these reasons that doctors need to consider the hormonal profile and evaluate for concurrent menopausal symptoms or hormone-related changes when investigating trichodynia in female patients.

Prognosis of Trichodynia

The prognosis of trichodynia depends upon multiple factors, such as the nature of the underlying disorder and patient compliance.

When there’s a clear and reversible trigger, like telogen effluvium, patients usually respond well, and the symptoms improve over time. But when the cause is unclear or involves multiple factors, the results tend to be less predictable, and recovery can take longer.
Consistency matters a lot. Patients who religiously follow both medication and lifestyle advice tend to have better outcomes.
Managing any underlying psychiatric issues, such as anxiety or depression, is also a major part of treatment. If these conditions are left unaddressed, trichodynia can linger or come back.
Even after things get better, flare-ups can still happen, especially during stressful periods or if the original trigger returns.

Conclusion

Trichodynia is a multifactorial scalp pain condition that often coexists with hair loss disorders and psychiatric comorbidities. It affects women more than men. Diagnosing trichodynia involves a careful clinical evaluation, along with a thorough psychiatric assessment and hormonal profile (where required). Treatment follows a tier-based approach, starting with conservative measures and moving on to topical and systemic treatments. Since every person is different and recovery can take time, counseling and ongoing patient support remain critical components of care to navigate the often challenging path to recovery.

Refrences

1
Mohammed Abu El-HamdSoha AboeldahabTrichodynia: An Update on Definition, Etiopathogenesis, Diagnosis, and Treatment.J Skin Stem Cell.2022;9(1):e122659.https://doi.org/10.5812/jssc.122659.
2
Rhodes, T., Girman, C. J., Savin, R. C., Kaufman, K. D., Guo, S., Lilly, F. R., Siervogel, R. M., & Chumlea, W. C. (1998). Prevalence of male pattern hair loss in 18-49 year old men. Dermatologic surgery : official publication for American Society for Dermatologic Surgery [et al.], 24(12), 1330–1332.
3
Rebora, A., Semino, M. T., & Guarrera, M. (1996). Trichodynia. Dermatology (Basel, Switzerland), 192(3), 292–293. ; Guichard, A., Ma, L., Tan, Y., Yuan, C., Wang, H., Lihoreau, T., Humbert, P., & Wang, X. (2016). What if scalp flora was involved in sensitive scalp onset?. International journal of cosmetic science, 38(4), 429–430.
4
Ma, L., Guichard, A., Cheng, Y., Li, J., Qin, O., Wang, X., Liu, W., & Tan, Y. (2019). Sensitive scalp is associated with excessive sebum and perturbed microbiome. Journal of cosmetic dermatology, 18(3), 922–928.
5
Xerfan, E. M. S., Andersen, M. L., Facina, A. S., Tufik, S., & Tomimori, J. (2021). The role of sleep in telogen effluvium and trichodynia: A commentary in the context of the current pandemic. Journal of cosmetic dermatology, 20(4), 1088–1090.
6
Rodriguez-Tamez, G., Imbernon-Moya, A., Saceda-Corralo, D., & Vano-Galvan, S. (2024). Dermatology Update on the Challenging Trichodynia. Actualización de la tricodinia, un reto para los dermatólogos. Actas dermo-sifiliograficas, S0001-7310(24)00717-8. Advance online publication.
7
Rebora, A., Semino, M. T., & Guarrera, M. (1996). Trichodynia. Dermatology (Basel, Switzerland), 192(3), 292–293.
8
Kanti, V., Nuwayhid, R., Lindner, J., Hillmann, K., Bangemann, N., Kleine-Tebbe, A., Blume-Peytavi, U., & Garcia Bartels, N. (2016). Evaluation of trichodynia (hair pain) during chemotherapy or tamoxifen treatment in breast cancer patients. Journal of the European Academy of Dermatology and Venereology : JEADV, 30(1), 112–118.
9
Wadhwa, D., Monga, A., Kumar, N., Khullar, G., Karmakar, S., & Khunger, N. (2023). A Cross-Sectional Study on Post-Coronavirus Disease (COVID-19) Hair Loss at a Tertiary Care Hospital. Dermatology practical & conceptual, 13(4), e2023263.
10
Willimann, B., & Trüeb, R. M. (2002). Hair pain (trichodynia): frequency and relationship to hair loss and patient gender. Dermatology (Basel, Switzerland), 205(4), 374–377.
11
Souza, E. N., Anzai, A., Costa Fechine, C. O., Sakai Valente, N. Y., & Romiti, R. (2023). Sensitive Scalp and Trichodynia: Epidemiology, Etiopathogenesis, Diagnosis, and Management. Skin appendage disorders, 9(6), 407–415.
12
C.M. Willis, S. Shaw, O. De Lacharrière, M. Baverel, L. Reiche, R. Jourdain, P. Bastien, J.D. Wilkinson, Sensitive skin: an epidemiological study, British Journal of Dermatology, Volume 145, Issue 2, 1 August 2001, Pages 258–263,
13
Alhomida, F. A., Alkhezzi, S., Alshammari, R., Alasmari, B. S., AlDosari, D. A., AlNasser, M., Almesfer, A., & AlSaadan, S. (2024). Successful Treatment of Refractory Trichodynia With Onabotulinumtoxin-A. Cureus, 16(3), e57009.
14
Kamp, E., Ashraf, M., Musbahi, E., & DeGiovanni, C. (2022). Menopause, skin and common dermatoses. Part 1: hair disorders. Clinical and experimental dermatology, 47(12), 2110–2116.
15
Duarte, G. V., Trigo, A. C., & Paim de Oliveira, M.deF. (2016). Skin disorders during menopause. Cutis, 97(2), E16–E23.

Trichodynia: Understanding Why Your Scalp Hurts

In this Article [hide]