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Common Causes of Paediatric Alopecia

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Common Causes of Paediatric Alopecia CLINICAL Common causes of paediatric alopecia William Cranwell, Rodney Sinclair HAIR LOSS IN CHILDREN aged 12 years to congenital or acquired conditions. and younger encompasses a number of The most common causes of paediatric common and rare conditions that may be alopecia seen in general practice are This article is the fourth in a series congenital or acquired. Differentiation of listed in Table 1. This article will discuss on paediatric health. Articles in this alopecia due to benign causes from that due the diagnosis and management of these series aim to provide information to serious illness is important for reducing conditions. Scarring alopecia and hair about diagnosis and management of presentations in infants, toddlers and patient and parent distress and offering shaft abnormalities are less common pre-schoolers in general practice. adequate and prompt diagnosis and and require further investigation by a treatment. Hair loss disorders are a large, dermatologist. Background heterogeneous group of conditions that Hair loss in children aged 12 years and have various clinical features, pathological younger is most often due to a benign Epidemiology findings and expected outcomes. or self-limiting condition. This article presents a review of the assessment of Alopecia in children can be Tinea capitis is a common condition to common causes of paediatric alopecia characterised as: which prepubertal children are predisposed and outlines the implications for • disorders of hair loss and aberrant (Figure 1A).3–5 The prevalence of positive general practice. hair growth fungal cultures in children is estimated to hereditary and congenital alopecia be 4–13%.2,6 Objective • The objective of this article is to help • hair shaft abnormalities The point prevalence of alopecia readers systematically assess a child • traumatic alopecia areata is approximately 1 in 1000 people, presenting with alopecia, manage the • infections of the hair.1 with a lifetime risk of approximately 2% most common diseases of paediatric The most common causes of paediatric (Figure 1B).7,8 Most cases occur before age alopecia and identify patients requiring alopecia are tinea capitis, alopecia 30 years. Males and females are affected referral to a dermatologist. areata, trauma secondary to traction or equally. 2 Discussion trichotillomania, and telogen effluvium. The prevalence of traction alopecia and The most common causes of paediatric The diagnosis is generally established trichotillomania is not easily estimated alopecia are largely non-scarring. These through directed patient history, scalp and because of underdiagnosis and secretive include tinea capitis, alopecia areata, hair examination, trichoscopy and basic behaviours. One study of a college student trauma due to traction alopecia or laboratory studies. Additional pathological population estimated a lifetime prevalence trichotillomania, and telogen effluvium. and laboratory investigations may be of trichotillomania of 0.6%.9 Hair loss Scarring alopecia can also occur in required after referral to a dermatologist. secondary to pulling and plucking, but not childhood and requires scalp biopsy and further investigation by a dermatologist. Management of paediatric alopecia satisfying the Diagnostic and Statistical General practitioners should treat clear requires holistic care of the child, Manual of Mental Disorders criteria, was cases of tinea capitis. Referral to a parents and any siblings. The clinical reported in 1.5% of males and 3.4% of dermatologist is necessary in cases manifestation may be subtle or females surveyed.9 when the diagnosis is uncertain, disfiguring and may lead to low self- Acute telogen effluvium may occur at any treatment is failing or there is evidence esteem, depression and social isolation. age, including infants and children.10 A study of scarring alopecia. It is important that parents are given investigating causes of paediatric alopecia clear information about the expected found that 2.7% of children presented with clinical course and prognosis. Referral acute telogen effluvium.11 Chronic telogen to a dermatologist is necessary in effluvium is less common, typically affecting cases when the diagnosis is uncertain, women aged 30–60 years.12 treatment is failing or there is evidence of scarring alopecia. Assessment and diagnosis Causes The ability to differentiate children with easily managed causes of alopecia from The causes of paediatric alopecia include those requiring referral and intensive many common and uncommon conditions management is an important skill for the and syndromes. Alopecia may be due general practitioner. 692 | REPRINTED FROM AJGP VOL. 47, NO. 10, OCTOBER 2018 © The Royal Australian College of General Practitioners 2018 COMMON CAUSES OF PAEDIATRIC ALOPECIA CLINICAL History scales, pustules or papules, erosions and density over the scalp. Identify Children and their parents most often and excoriation. These findings may the pattern of hair loss to narrow the present with complaints of increased be associated with alopecia or signs differential diagnosis. Hair density is hair shedding or patterns of hair loss. of a concomitant scalp disorder (eg best examined by parting the hair with A systematic and thorough history will seborrhoeic dermatitis or folliculitis). combs and measuring the distance aid diagnosis (Table 2). It is crucial to The lack of pinpoint openings (follicular between the parts.13 The hair shafts are differentiate between hair shedding and ostia) on the scalp, associated with examined for length, calibre, fragility hair breakage. pustules and ulceration, suggests and texture. Broken and rough hairs may a scarring alopecia. A kerion is an suggest a disorder of the hair shaft or Examination abscess caused by fungal infection and traumatic alopecia. Assessment of a child with alopecia is characterised by a painful, boggy, Dermoscopy can aid the diagnosis involves examination of the scalp, hair inflammatory mass from which any of alopecia in children. Table 3 outlines and other body sites.13 Examination of remaining hairs can be pulled out typical dermoscopic findings that are the hair and scalp is best performed from painlessly.1 associated with certain conditions.14 above, with adequate lighting. Examine Examination of the hair begins A hair pull test identifies active hair the scalp for evidence of erythema, with visual inspection of distribution shedding and should be performed on Table 1. Common causes of paediatric alopecia Condition Clinical presentation Distribution Tinea capitis Most commonly scaly patches of alopecia or patches Single or multiple scaly patches with alopecia: patches of alopecia with small black dots. enlarge centrifugally over weeks to months. Pruritus is common. Patches of alopecia with black dots: black dots are broken Cervical and occipital lymphadenopathy may be seen hair follicles. in inflammatory cases. Widespread scaling of the scalp with subtle hair loss. Children may be asymptomatic carriers. Kerion: an inflammatory plaque with pustules, crusting and Dermoscopic features include broken hairs, comma hairs sinus drainage.29 Tender and painful. Potential for scarring. and corkscrew hairs. Favus: infection with Trichophyton schoenleinii, perifollicular erythema and cup-shaped yellow crusts.30 May progress to scarring alopecia. Alopecia areata Patchy or confluent hair loss occurring on the scalp or any Patchy alopecia areata: most common form, with oval and hair-bearing area of the body. round patches.1 Typically a circular patch with normal-appearing scalp skin. Reticular alopecia areata: irregular pattern in a net-like Dermoscopic features include exclamation point hairs, fashion (reticular).1 yellow dots and black dots. Ophiasis alopecia areata: band-like pattern of hair loss, Correlation with atopic dermatitis, hypothyroidism, vitiligo. most commonly on the temporal or occipital regions.1 Poor Nail changes (especially pitting and ridging) are common. prognostic feature. Diffuse alopecia areata: generalised reduction in hair density over the entire scalp.1 Alopecia totalis: complete absence of hair on the scalp.1 Alopecia universalis: complete absence of hair on the scalp and the entire body, including eyebrows, eyelashes, underarms and pubic hair.1 Traction alopecia Due to constant tension on the hair due to styling, ponytails, Depends on hair care practice and use of hair products. braiding, use of hair rollers and weaving.1,31 Most commonly presents with frontotemporal hair loss. Fringe sign: retention hair along the frontotemporal hairline. May present with patchy hair loss over the scalp in no Long-standing, may cause scarring when chronic. specific pattern of distribution. Trichotillomania Impulse disorder with compulsion to pull or pluck hair.1,32 Unusual pattern of hair loss, most commonly affecting the More common in girls than boys.1,32 scalp and eyebrows. May present in childhood due to habit or in adolescence as a Patchy and non-confluent. sign of underlying psychological issues.1,32 May spare peripheral hairs (‘Friar Tuck sign’/tonsure pattern). May be associated with other self-harm. Telogen effluvium Occurs approximately three months after an inciting event Diffuse decreased hair density, often characterised by (eg medical illness, stress, medication, nutritional disorder). decreased density of ponytail.1,15 Shedding generally resolves within three to six months, then Increased hair shedding. may take six months for density to improve. Rarely patchy, unless concomitant patchy alopecia
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