Alopecia

A 4 year old African American girl comes to your office with the complaint that her hair is falling out.

 

How would you approach this problem?

Important questions to ask in the history

1. How long has hair loss been going on?
2. Are there any associated symptoms/illnesses?
3. How does the child usually wear hair?
4. Has the child been observed pulling hair out?
5. Does the child take any medications and/or are there any exposures to toxins?
6. Are any other children losing hair? Any children in the house with ringworm?
7. Is this the first time this has occurred?
8. Is the hair loss associated with fibrosis and scar tissue        replacement?

Differential Diagnosis

• Alopecia Areata – Thought to be secondary to autoimmune lymphocyte-mediated injury to hair follicle.  Patient typically develops discrete areas of hair loss.  There is no scalp inflammation.  40% of patients will also have pitting of nails.  Subtypes include alopecia totalis (loss of all scalp hair) and alopecia universalis (loss of all body and scalp hair).

Alopecia areata seen on the back of the scalp
https://en.wikipedia.org/wiki/Alopecia_areata

• Telogen Effluvium – Very common type of alopecia, 2nd only to male-pattern baldness.  Characterized by reversible, diffuse loss of mature, terminal hairs 2-3 months following an acutely stressful event (eg, illness, trauma, surgery).  Hair loss continues for 3-4 months before hair regrowth occurs.  Thought to be due to excessive number of hair follicles in telogen phase (resting phase). 

https://en.wikipedia.org/wiki/Hair_loss

• Traumatic alopecia – Hair loss secondary to mechanical traction, chemical trauma, or trichotillomania.
  • Traction Alopecia – Often results from chronic traction on hair from styling practices (hair braids, curlers, constant rubbing).  Hair loss is most prominent in areas of greatest tension.
    permanent-traction-alopecia/
     
  • Chemical Trauma – Often due to styling practices (lye-containing chemicals, hot oils).
  • Trichotillomania – Secondary to pulling or twisting of hair.  Manifests in bizarre, irregular patches of hair loss and by hairs that have been broken off at different lengths.  May be associated with anxiety.  There may be eyelash/eyebrow involvement.

A pattern of incomplete hair loss on the scalp of a person with trichotillomania
https://en.wikipedia.org/wiki/Trichotillomania

• Tinea Capitis – Fungal infection of the hair. There is patchy hair loss and infected areas are extremely scaly.  Pustules may also be present.  Occipital and posterior cervical lymphadenopathy are commonly present, as well as a large red nodule (kerion) at the site of infection.  Diagnosed with KOH prep showing hyphae.  Hairs may fluoresce under Woods light.

https://en.wikipedia.org/wiki/Tinea_capitis

• Endocrinopathies
  1. Diabetes
  2. Hypothyroidism
  3. Hypopituitarism
• Nutritional disorders
  1. Hypervitaminosis A
  2. Zinc deficiency (eg, Acrodermatitis enteropathica)
  3. Iron deficiency
  4. Marasmus
  5. Gluten enteropathy
  6. Anorexia nervosa
• Medications
  1. Heparin
  2. Warfarin
  3. Chemotherapy
  4. Cyclophosphamide
• Seborrhoeic dermatitis – Due to inflammation of the scalp.  Will usually see associated waxy scales on face and/or neck.
• Scarring hair loss – This is typically permanent and can be caused by a variety of etiologies such as folliculitis, lichen planopilaris, discoid lupus erythematosus, and tumors.    

During physical exam, be sure to:

1. Observe child's hairstyle
2. Take note of distribution of hair loss
3. Take note of evidence of inflammation and scaling
4. Check nails
5. Check entire body for hair loss

Treatment – Depends on underlying etiology

1. Alopecia Areata – Treatment usually not necessary as hair often regrows within one year.  However, steroids and/or minoxidil may augment hair growth.  Offer psychological counseling and reassurance.
2. Telogen Effluvium – Reassurance is usually sufficient as this is a self-limited and reversible process.  However, rule out other potential causes of hair loss.
3. Traumatic Alopecia – Stop precipitating trauma (if mechanical or chemical).  If hair loss is caused by trichotillomania, management includes behavior modification.  Also, search for potential stressor. Consider oils that make hair difficult to pull out or cognitive behavioral therapy if initial management does not work. 
4. Tinea Capitis – Systemic oral antifungal medication (eg, griseofulvin) for 6-8 weeks.  Also, selenium sulfide shampoo (2.5% or 5%) can decrease infectivity or spread.
5. Endocrinopathies – Treat underlying etiology
6. Nutritional disorders – Treat underlying etiology
7. Medications – Stop causative medication if medically feasible
8. Seborrhoeic dermatitis – Increase frequency and duration of shampooing.  Also, use shampoos with salicylic acid, tar, selenium, sulfur, or zinc.
9. Scarring Hair Loss – Treat underlying etiology

References

1. Atton AV and Tunnenessen WW. Alopecia in Children. The most common causes. Pediatrics in Review 1990;12(1):25-30.
2. Bolduc C, et al. Alopecia Areata. Emedicine. 2009.
3. Goldstein BG, Goldstein AO. Nonscarring hair loss. UpToDate. 2010.
4. Hughes ECW. Telogen Effluvium. Emedicine. 2009.
5. Leung A. Hair Loss in Children. J Royal Soc Health 1998;113(5).
6. Mukherjee N, et al. Treatment of Alopecia Areata In Children.  Pediatric Annals  2009;39(7):388-95.
7. Rietschel RL. A Simplified Approach to the Diagnosis of      Alopecia. Dermatologic Clinics 1996;14(4):691-5.
8. Saperstein HW, Brown LJ. Dermatology. In: Brown LJ, Miller LT,  eds. Pediatrics. Board Review Series. Baltimore:
9. Lippincott      Williams & Williams; 2005, p. 533-48.
10. Seldon S. Seborrheic Dermatitis. Emedicine. 2009.
11. Vasiloudes.  Bald Spots: Remember the big three.  Contemporary  Pediatrics 1997.
12. Yong-Kwang.  Trichotillomania in Childhood.  Case Series and Review.  Pediatrics e494, May 2005
13. Gilhar A. et al. Alopecia Areata.  NEJM April 19,2012