Trichotillomania is described as a recurrent failure to resist impulses to pull out hairs. It is usually associated with obsessive-compulsive disorder and body dismorphic disorder. It is usually confined to one or two sites in the body.

The aim of our work is to describe a case of delusional infestation with secondary trichotillomania and briefly review the theoretical aspects of this clinical presentation.

We searched online databases and reviewed current case reports published, using the keywords “delusional infestation”, “Ekbom syndrome” and “trichotillomania” and compared similarities in the presentation, development and outcome. We present a clinical vignette of a 38-year-old female, with no relevant psychiatric history. The patient developed severe itching that she believed was caused by bugs that lived inside her hair follicles, so she pulled out completely all of her eyebrows, eyelashes, pubic and underarms hairs. She maintained some hair on her head, that she repeatedly pulled out and proceeded to break in order to kill the bugs. She claimed to have absolutely no itchiness in the hairless areas of her body.

The patient was referred to psychiatric consultation and was started on oral antipsychotics but, as the review from literature suggested, the clinical evolution only became satisfactory when an antidepressant (SSRI) was added.

Although, trichotillomania is more commonly seen in clinical practice in association with other psychiatric disorders, it may also present itself as a symptom of delusional activity.

The authors have not supplied their declaration of competing interest.