Sir,

A 58-year-old gentleman presented to the eye casualty complaining of reduction in vision in his right eye. He had been diagnosed with right trigeminal nerve (ophthalmic branch) herpetic zoster by his general practitioner 1 month ago, and at that time he had completed an oral course of acyclovir. History was otherwise unremarkable.

Acuity was 6/18 in the right eye and 6/5 in the left. His right-sided trigeminal shingles rash was now only just visible. His right cornea had reduced sensation and there was a rapid tear break-up time on this side. The corneal epithelium was intact but irregularly heaped. Ocular examination was otherwise unremarkable.

A diagnosis of post-herpetic, neurotrophic corneal epitheliopathy was made. Regular lubricants were applied and a lower punctual plug was inserted. Within 6 weeks the corneal epithelium was healthy and vision returned to 6/5.

The gentleman had also reported post-herpetic neuralgia, which in this case had an interesting manifestation. He had found relief (and almost gratification) from this trigeminal neuralgia by recurrently pulling his right eyebrow. As a result, he had substantial unilateral eyebrow loss (see Figure 1).

Figure 1
figure 1

Loss of the right eyebrow (trichotillomania following herpetic neuralgia).

Full size image

There are over 30 reported causes for eyebrow loss,1 one of which is trichotillomania (TTM). TTM is defined as the compulsion to pull out one's own hair. TTM is an impulse control disorder wherein hair is pulled out by the patient, typically from the scalp but also from the eyebrows and eyelashes.2 TTM is often found to co-exist with mood and anxiety disorders and is classified by the Diagnostic and Statistical Manual of Mental Disorders.3

This gentleman had no associated psychiatric disorder, but he had developed a marked and persistent impulse to repeatedly pull his right eyebrow, resulting in a cosmetically undesirable consequence of unilateral eyebrow loss. This significantly affected his quality of life and he became keen for treatment. Treatment for TTM includes various drugs, and also forms of cognitive behavioural therapy, such as habit-reversal training.2 This patient's neuralgia is now controlled with gabapentin.

To the author's knowledge, this is the first case reporting eyebrow loss due to TTM following herpetic neuralgia.