Alopecia (kids)

• Common causes
  • Tinea capitis
  • Alopeica areata
  • Trauma secondary to
    • Traction (often frontal)
    • Trichotillomania
  • Telogen effluvium – 3 months after stressful event
• Crucial to differentiate hair shedding(normal to shed between 50 and 100 hairs a day) and hair breakage

 

Tinea capitis presenting with a solitary circular area of hair loss. Note there is a short stubble of broken hairs and the skin is inflamed.

Tinea capitis presenting with a solitary circular area of hair loss. Note there is a short stubble of broken hairs and the skin is inflamed.

Tinea capitis presenting with a solitary circular area of hair loss. Note there is a short stubble of broken hairs and the skin is inflamed.

Traction alopecia caused by repeatedly pulling the hair tightly back into a pony tail over many months.

Trichotillomania producing an area of diffuse thinning. Within the area there are numerous broken hairs. The borders are angular.

History

• Duration and rate of hair loss
  • The duration and rate of hair loss helps differentiate congenital (from a young age) and acquired (due to an inciting factor or behaviour).
  • This also determines acute, chronic or transient conditions.
• Location of hair loss  
  • Determine whether the alopecia is focal, diffuse or patterned. Determine, in conjunction with physical examination, whether other hair-bearing body areas are involved.
• Extent of hair loss
  • A degree of hair shedding is normal, with normal hair loss of 50–150 hairs per day.
  • The use of a hair shedding assessment chart quantifies hair shedding and allows for objective assessment of improvement.
  • Determine whether patients or parents have noticed reduction in ponytail density, although this may only be noticeable after 30% decrease in density.
• Associated symptoms  
  • The presence of associated symptoms, including pain, tenderness, pruritus and burning sensation, are associated with certain diagnoses.
  • Symptoms may be present due to concomitant diseases (eg seborrhoeic dermatitis).
• Differentiation of hair loss versus hair breakage
  • Determining true hair shedding versus hair breakage helps differentiate causes of alopecia from hair shaft disorders or traumatic causes of alopecia.
  • Enquire about the presence of pain when removing hairs (painless extraction of hairs from the scalp is characteristic of loose anagen hair syndrome).
• Hair care behaviour
  • use of hair care products and grooming behaviour is important for diagnosing traction alopecia or hair care that damages the hair shaft (eg use of chemicals).
• Medical and family history
  • past medical history and family history of alopecia (often undiagnosed) may assist diagnosis. In adolescent females, enquire about menarche.
  • A diagnosis of telogen effluvium is often made when an inciting factor is identified (eg medical illnesses, stress, poor diet, medications).

Examine

• Erythema
• Pustules, papules
• Erosions, excoriations
• Lack of pinpoint openings – suggests a scarring alopecia
• Kerion – fungal abscess – painful, boggy mass
• Examine hair shafts for length, calibre, fragility
• Hair pull test
  • Pull 50 hairs if > 6 — increased shedding

Management

• The psychological effects of hair loss in children can be profound, leading to social isolation, low self-esteem, depression and humiliation.
• Consider referral to a child and adolescent psychologist or psychiatrist if appropriate

Tinea capitis 

• Scaly patches, black dots of broken hair follicles, pruritis
• Enlarge centrifugally
• Needs systemic therapy – oral Griseofulvin (20–25 mg/kg/day for six to 12 weeks)
• (topical antifungal treatment has inadequate penetration into the hair follicles)
• differential diagnosis:
  • Alopecia areata and trichotillomania
    • cause patchy alopecia but are not scaly
  • Seborrhoeic dermatitis, atopic dermatitis, and scalp psoriasis
    • may mimic non-inflammatory tinea capitis, but the scale is usually more diffuse
  • Discoid lupus erythematosus and lichen planopilaris
    • cause scarring alopecia
  • Bacterial scalp folliculitis, impetigo, pyoderma, and pyogenic abscess
    • may resemble inflammatory tinea capitis.
• Family members and close contacts should be examined for tinea capitis and should be treated simultaneously if detected
  • Use anti-fungal shampoo for 1 month, avoid sharing equipment

 

painful nodule with pus, and scarring alopecia

honeycomb destruction of the hair shaft

Alopecia areata

• autoimmune form of nonscarring hair loss defined as being in childhood if the onset is by 10 years of age, or adolescence if between 11 and 20 years
• age <10y strongly associated with
  • Atopic dermatitis (approximately 33%)
  • lupus erythematosus
• teenage years associated with
  • psoriasis
  • rheumatoid arthritis

• Symptoms
  • Pathcy, reticular, diffuse or total
  • multiple circular patches on any hair-bearing body site, including eyebrows and eyelashes
  • Nail changes seen in almost 50%
    • pitting and trachyonychia
• Treatment
  • Potent topical glucocorticoids
  • Intralesional glucocorticoids – low tolerability as a result of pain and anxiety during injections
  • Topical minoxidil
  • Topical immunotherapy
  • systemic glucocorticoids
    • may induce hair growth
    • most often relapse on cessation of treatment

Traction alopecia

• may be reversible if identified and if the hairstyle or behaviour is modified
• Prolonged traction on the hair may lead to irreversible scarring.
• Childhood trichotillomania
  • is often a benign inadvertent behaviour that children may outgrow
  • Counselling the patient and parents about the behaviour and modifications can occasionally be successful.
• Adolescent trichotillomania
  • more difficult and may represent underlying psychological distress.
  • often more secretive with behaviours
  • Psychological therapy and counselling may identify the underlying problem and modify behaviour
  • SSRI may be effective in treating obsessive-compulsive disorder.

Telogen effluvium

• reactive and self-limiting condition
• Rx
  • reassurance – temporary and regrowth is likely
  • avoidance of triggers
  • efficacy of topical minoxidil in telogen effluvium is unclear.
    • Theoretically, minoxidil should hasten resolution of hair growth by prolonging anagen and stimulating telogen hairs to re-enter anagen. However, it is not considered first-line therapy.